LIFE WITH A NEW HIP JOINT
CONTENTS:
first 12 weeks / possible problems
pain in the replaced hip joint
stresses on your new total hip
The first 12 weeks
Problems you may encounter after coming home:
- Excessive swelling of your operated leg and foot. It usually develops during the first few weeks after surgery. The collected blood in the tissues around the hip will sink down to the knee and even to the ankle area and the swelling may take a bluish color. Usually, this wound healing disturbance will resolve without special treatment. Use of special stockings will reduce the edema.
Note: excessive swelling in the leg and foot, associated with pain may be a sign of vein clots (deep vein thrombosis). Contact immediately your doctor in that case.
- Chest pain, a cough, or shortness of breath may herald embolism. This is a dangerous complication and should be treated immediately. Contact your doctor immediately.
Oozing, swelling, and redness of the operative wound indicates that blood has collected in the tissues beneath skin. Usually, this wound healing disturbance will resolve without special treatment other than changes of wound dressings.
Note: If there is a large quantity of collected blood, there is a risk that bacteria may infect the collected blood and start postoperative wound infection. Your surgeon will decide how to treat this disturbance of the operative wound healing.
- Intensive pain in the thigh. There is always some pain and edema (swelling) in the thigh during the first days after the operation.
If, however, the thigh becomes much swollen, much tense, very painful with touch during the first two weeks after the operation, this may signal accumulation of large quantities of blood in the soft parts of the thigh. Especially if you are on blood thinners, this may be a case.
This condition is called compartment syndrome. It is caused by collection of blood in the thigh, beneath the unyielding thigh fascia (a strong sheath of connective tissue that envelops the muscles). The pressure in the soft tissues of the thigh increases and causes intensive pain. When a compartment syndrome develops it must be treated quickly. The treatment is by evacuation of the collected blood. Notice your surgeon immediately if you have intensive pain in a swollen thigh.
- Elevated temperature . The temperature is regularly elevated after the operation, but it usually return to normal within 3 - 6 days. If the temperature is still elevated (over 38 C or 100 F) later, it may be a sign of impeding wound infection
Elevated temperature may also herald
the development of ossifications (bone tissue new building) in the thigh muscles; these ossifications will be, however, apparent on a X-ray picture only later (2-6 weeks)
urinary infection. Urinary infection is discovered by simple urine examination
- The operated leg feels too long although measurement shows that both legs are equally long.
Usually, the cause is the passing contracture of muscles and tissues that keep the pelvis slanting to the operated hip side (apparent leg length difference). As the muscle contracture successively disappears, the apparent leg length difference will disappear too. It takes one or two months of training.
Although the surgeons try to get the leg length correct at operation, it is common to be off by 0,5 cm (one quarter of an inch), usually on the longer side. Most people usually adjust to this difference, which is also present in healthy people too.
See also the chapters Other complications of the total hip surgery and Too long leg
Pain in the replaced hip joint
"Before my surgery I have heard Major Surgery over and over to remind me that recovery may be difficult at times. It turns out that this was the best message I ever got. I am 14 months after my hip surgery and still now and then my energy level drops. I don’t fret, I have been through Major Surgery and fatigue is natural as my body rebuilds.
I am still getting a "tight feeling" in the muscles of my leg if I walk a lot. And I still can get pain in my new hip at the end of the day. The surgery, however, has been a blessing to me and to my family too as I was not walking at all before I get my new hip."
Studies demonstrate that even several years after the total hip replacement the patients
are generally satisfied with pain relief - but they
walk more slowly
have reduced muscle strength
have occasional pain in the replaced hip.
do not achieve comparable overall physical health and mobility as people in the general population (Jones, 2001)
Surprisingly many patients ( in some statistics about 25% of all patients) operated on with total hip replacement still have occasional pain of unclear character in the operated hip and thigh area many years after the surgery. This pain is seldom severe, but it occurs often after strenuous physical activity.
The patients operated on with cementless total hip have more often this pain than patients with cemented total hip.
Even thorough examination does not discover any clear reason for the occasional pain, although the surgeons may have some tentative explanation.
This applies also to the occasional "snapping" sensations that are pain-free and that may scare the patients.
In general, your hip should be getting stronger and better each day. If you think you are getting worse instead, contact your surgeon for close examination.
Se also the chapter Other complications of total hip replacement
Noises in the new total hip
clicking, squeaking, and "piston-like"
Many patients feel clicking or squeaking noises in their new total hips. Usually, these sounds are not followed by pain. These sounds usually occur when the patient changes the position in the hip joint. They may irritate the patient. According to some investigators the squeaking noises occur more often in patients with ceramic total hips. (see Stryker website)
The surgeons have two explanations for this sound phenomenon:
First, The clicking noises may be caused by a tendon or scar tissue streak that glides over the protruding portion of the new total hip joint. When you can put your hand (or the surgeon can do it) over the jerking tendon or scar tissue the diagnosis is clear, otherwise it is only a conjecture. When these clickings cause no pain or other problems you should not br bothered.
Second, the clicking noises may be caused by very small "pistoning" movements of the ball components in the polyethylene cup. The patients sometimes also feel small jerks in the total hip with change of the position.
X-ray studies of patients with total hip joints demonstrated that the ball component separates from the center of the cup component during gait.
When the operated on leg swings out during the gait cycle (the hip is not loaded) the ball component moves out of the centre of the cup and comes in contact with the rim of the cup. The ball separates from the cup.
When the leg then comes back in contact with the floor (the leg takes the body's weight) the ball returns to the close contact with the whole cup. The body weight presses the ball in the centre of the cup.
Thus, during the gait cycle the ball component moves from the center of the cup to the outside of the cup and then backs to the centre again like a piston. The "pistoning" movements are small, between 0.8 to 5 millimeters. Studies showed that these "pistoning" movements occur in all conventional total hips where the metallic ball articulates with polyethylene cup (Dennis 2001) and in total hips with ceramic bearing surfaces. The "pistoning" movements were not observed in metal on metal total hips (Komistek 2002).
Picture: "Pistoning" (piston-like) movements of the ball component
Click on the icon for a full size picture
Left side: During stance phase when the operated leg is in contact with the floor, the ball component is in close contact with the inside of the cup component. The body weight pushed the ball into the centre of the ball.
Right side: during the swing phase of the gait, when the leg is swinging in the air, the total hip is not loaded with the body weight. The ball component moves out of the centre of the cup and comes in contact with the peripheral rim side of the polyethylene cup component. The tonus (springiness) of the muscles around the hip pushes the ball upward. The ball is in contact with only the rim of the cup.
When the patient then tramps with full weight on the limb, the ball glides forcibly back to the centre of the cup. Thus, the ball makes piston-like movements out of and back into the centre of the cup during gait.
The pressure during this movements is concentrated to a small area of the cup and the wear in this area increases. The surgeons speak about "stripe wear". The patients may feel "pistoning" movements and hear clicking sounds.
The clicking, pistoning movements may be more pronounced during rising from the chair or negotiating stairs.
It is important to realize that these piston-like movements are very small, only about some millimeters, although the patients feels / hears them very distinctly.
In laboratory these movements and squeaks are observed mainly in ceramic total hips, less in metal on polyethylene total hips, and not in metal-on-metal total hips. Ceramic surfaces are hard, smooth and repulsing water. They thus separate easily.
On the other hand, water (and synovial fluid) adhere to the metallic surfaces, so that between two congruent metallic joint surfaces forms a thin layer of liquid that keeps the surfaces together (coherent forces). That is the theory that should explain why the clicking, pistoning noises were not observed in metal-on-metal total hips.
Simulation of the "pistoning" motion of the ball inside the cup in laboratory produced loud squeaking noises. (Stewart 2003)
What is the practical importance of this small pistoning movement?
First, it explains the clicking noises that many patients are feeling.
Clicking or squeaking in the total hip joint is a common complaint early after total hip replacement. If it is not painful, the surgeons dismiss these symptoms and tell the patient that the clicking or squeaking is caused "by a tendon or by a scar tissue, moving over the new total hip".
Actually, these noises may be rather caused by the pistoning movements of the ball component.
Are these noises and pistoning movement a bad sign? Nothing point to this, if not associated with pain. Moreover, when soft tissues mature and muscle force returns, these noises and movements cease in the majority of patients.
As yet, this is so recent discovery that one may only guess on its importance.
_____________________________________________________
References:
Dennis DA et al. J Biomech 2001; 34: 623-29
Komistek L et al.: J Bone Joint Surg Am 2002; 84-A: 1836 -41
Lombardi AV et al. J Arthroplasty 2000; 15: 702- 9
Stewart TD et al. J Arthroplasty 2003; 18: 726 – 34
Stryker: www.stryker.com/orthopaedics/sites/trident/healthcare/ceramictech.php
Walter WL et al.: J Arthroplasty 2004, 19: 402-13
Revised March 2006
Precautions
Your surgeon and your physical therapist will usually provide you with a list of do’s and don’ts to remember with your new hip. More "strict" precautions apply for the first 6 -12 weeks postoperatively. These precautions vary according to the operation method, prosthesis type, and the surgeon. Ask your surgeon and your physiotherapist for a written list of precautions and when they can be lifted. Be sure to follow all precautions you learned in the hospital.
The precautions are always customized individually. Discuss them always with your surgeon. Ask your PT to show you how to manage the diffrent risk momemnts.
For a general list of precautions CLICK HERE
Stresses on your new hip joint
the 19 muscles or their parts that cross the hip joint move the hip joint by a system of levers. The dynamic effect of these combined forces is that the resultant stresses acting on the hip joint of a moving person are many times higher than the body weight.
Forces acting on the hip joint
Forces acting on the total hip joint during motion are also higher than body weight. Speed increases always the peak forces acting on your total hip joint, the speedier you walk or jog, the more load you are putting on the new total hip joint. The magnitude of these forces depends also on the position of your body.
To have a better perspective on this matter, here follow data from one older study (Paul 1976).
| ACTIVITY |
MAXIMAL JOINT FORCE (multiples of body weight) |
| Slow level walking | 4,9 |
| Fast level walking | 7,6 |
| Up stair | 7,2 |
| Down stair | 7,1 |
| Up ramp | 5,9 |
(Depending on the calculation methods, other studies may show other values for maximal joint forces on the hip joint, but all studies demonstrate that fast walking and stair climbing produces higher joint forces than slow walking)
From this table it follows that:
If you wish to reduce the stresses on your total hip, just slow down your walking speed.
Jumping or stumbling puts up to eight times body weight on your total hip.
Weight bearing
The patients are told by their surgeon if they are allowed to put body weight on the operated total hip (weight bearing as tolerated) or not.
The surgeon usually follows some "common sense" rules when deciding how much body weight the patient shall put on the newly operated on total hip.
If you have a cemented total hip, the fixation of the total hip to your skeleton is strongest at the moment when the operation is finished. From this viewpoint, you may put full weight on your total hip just as you are leaving the operation room.
Remember, however, that there are soft tissues around your total hip that must heal before you can walk without support. The soft tissues were severed at operation and need rest to heal completely; for this purpose you are ordered to use walking aid devices.
If you have an uncemented total hip, its fixation to the skeleton improves with time as new bone grows into its surface. The ingrowth of new bone is a process that takes time (4 -12 weeks), and the ingrowing bone should be protected from undue stresses during this period.
Originally, the surgeons believed that the patient must avoided loading of the cementless hip to achieve good ingrowth of the bone into the surface layer of the total joint prosthesis. Many surgeons do not adhere to this view longer. Here follow some reasons why:
Studies showed that in cementless total hip prostheses bone ingrowth fixation reliably occurs whether or not a partial or full weight-bearing postoperative protocol is followed. (Woolson 2002)
Moreover, studies demonstrated that even patients who were learned the "partial weight bearing" with crutches by their PT still put much more weight on their hips than learned, without knowing it. (Tveit 2001)
See also the chapter Cemented and cementless THR
Stair climbing and chair raising - the dangerous forces
There are some forces that are more dangerous for the fixation of the total hip prosthesis to the skeleton. These forces are called for twisting forces because these forces try to rotate the shaft component of your total hip within the marrow cavity of the femoral bone.
These forces arise when you are climbing stairs or raising from armchairs without arm support. Your body weight then tends to twist the shaft of your total hip prosthesis which is placed inside the thigh bone.
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Twisting forces acting on the total hip during stair climbing (Click on the icon for a full size picture) The twisting forces during chair raising and stair climbing are always higher than the body weight. The body weight tends to rotate the ball of the prosthesis down, the neck of the prosthesis acts as a lever in a crankshaft. The rounded off shaft of the total hip prosthesis is placed in a circular tube-like marrow cavity. This configuration of a rounded off shaft in a circular shaft tube offers less resistance to twisting (rotating) forces. Many surgeons believe that these twisting forces may start the mechanical loosening of the shaft of the total hip prosthesis.
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Use always stairs’ rails when climbing stairs
Use armchairs with real arm support. Use arm support when rising up or sitting down on armchairs.
Use toilet seat raising device, ideally have also rails mounted beside the toilet seat at your home.
Keep your arms strong to spare your total hip!
4Walking aid devices
The tree most commonly used walking aid devices are
crutches (axillary or elbow crutches),
canes (walking sticks),
walkers.
The purpose of using walking aid devices in patients with total hip is to :
diminish the stresses on the total hip,
keep the soft tissues at rest in the postoperative period
help to keep the balance for patient with weak musculature or with balance problems
The surgeon who prescribes your walking aid should take into account your general condition so that the you will get the correct device.
This may include individually adapted / molded handles of crutches for patients with hand deformities and choice of proper length of the crutches.
You should also receive a thorough instruction on proper use of walking aids; the physical therapist usually conducts the teaching and together with a prosthetic technician they adapt the walking aid device to your needs.
As soon as possible switch to walking with cane. Walking with elbow crutches disturbs the activity of the muscles around the hip joint, and you will learn a clumsy walking method.
Some common problems with the use of walking aid devices are:
falling - the crutches slip on slippery surface. Prevention: remove small/ throw rugs, avoid slippery surfaces, equip crutches with pointed nail ends for walk on snowy / icy surfaces if you must.
carpal tunnel syndrome - the damage of the median nerve in the wrist area. Usually caused by keeping the hand bent upward in the wrist for long periods. (Werner 1989)
The patient feels numbing pain in the thumb and in the index and middle finger, he / she may loose sensitivity in the hand and even loose function in the muscles of the thumb.
Prevention: don't use the crutches for long periods, use special wrist braces. If you develop numbness in your hands after using crutches ask your doctor for help.
Numbness and skin excoriations around the axillary region observed in patients the axillary crutches. Prevention : don't use axillary crutches anyway, they produce a clumsy and abnormal method of walking (Charnley)
Skin damage and localized numbness in palm - caused by pressure from the crutch handle. Prevention: switch to cane (walking stick) if possible, otherwise ask your PT for a crutch with individually custom made wide handle. Such crutches distribute loads over a greater surface, producing less local pressure.
References:
Jones CA:. Arch Intern Med, 2001;161:454-60
Kilgus: Clin Orthop, 1991; 269:25-31
Millett PJ et al: J Bone Joint Surg-Am; 2002; 84-A: 236- 49)
Tveit M, Karrhom J: J Rehab Med 2001;33:42-6
Woolson ST, Adler NS: J Arthroplasty 2002; 17: 820-5
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