Total Hip Replacement: An Evidence-Based Approach Your Guide From Pre-op Through Recovery

TOTAL HIP REPLACEMENT:

Your Guide From Pre-op

Through Recovery

An Evidence-Based Approach

By

Neil Snyder, PT, DPT

To my wife, who continues to be by my side, supporting and loving me for who I am. You are the best part of my life. To my daughters, Jordan and Avery, I have enjoyed watching both of you grow into beautiful women. I love you both very much.

To my Mom and Dad, thank you for giving me the support I needed growing up, sharing your wisdom, and instilling in me the importance of hard work. Both of you encouraged me to pursue my passions and be the best version of myself.

To my colleagues, thank you for your support in writing this book.

A very special thank you to my friends and mentors, Robert Post, PhD and Carl Deirmengian, MD. Your mentoring has positioned me to be successful.

Table of Contents

1 Hip Pain

2 Before Committing to Surgery

3 Preparing for Surgery

4 The Day of Surgery

5 Post-op

6 Hip Precautions

7 Hospital Stay and Preparing for Discharge

8 Unlikely Post-op Stumbling Blocks

9 Early Recovery

10 Aftercare

11 Remainder of Recovery

12 Putting It All Together

References

Index

About the Author

Foreword

As a hip and knee replacement surgeon at the Rothman Orthopedic Institute in Philadelphia for 17 years, I have had the opportunity to care for thousands of patients making the difficult decision of whether or not to have a joint replacement.  My efforts and interest in research, to identify improved methods of caring for patients, led to my work with Neil Snyder, the author of this book.  Our collaboration since the start of my practice has included caring for patients together, conducting research together, and working on committees to optimize a regional joint replacement program.

Dr. Snyder has a quite sophisticated understanding of the breadth of difficulties among patients having a joint replacement, as he is intimately involved in their post-operative care, not only guiding their therapy, but also having prolonged conversations with each patient while administering therapy.  He understands their concerns, anxieties, misconceptions, and pains at a level that positions him perfectly to write this book. Most unique about Dr. Snyder is his clear passion not only in caring for patients, but also in providing care that is based on evidence as opposed to tradition.  His work in research, reviewing literature, and decision-making for our joint replacement program has been substantial.

This book fills a long-standing void in the references available to those embarking on the voyage of a joint replacement.  From the patient’s point of view, information gathering leading up to and through a joint replacement is an incredibly difficult endeavor. The barriers to attain accurate information include 1) misinformation among family and friends,  2) misinformation spread among advertising in health care 3) the complexity of several topics in the field, and 4) the anxiety patients have while trying to remember things explained during a short surgeon visit.  In fact, it is well known in healthcare that patients forget much of what is explained or taught during an office visit.

Dr. Snyder provides a simple, straightforward, and comprehensive review of joint replacement surgery which will greatly enhance the experience of anyone having a joint replacement. In this book, he addresses the most common misperceptions, simplifies the most complex topics, and educates the reader on the most important aspects of having a joint replacement surgery. It is important for the patient to find a surgeon that they feel comfortable with and develop a communicative physician/patient relationship. Hopefully, this book will reinforce that relationship, providing a background and context which can focus those interested in having a joint replacement on the topics that are truly important for the patient’s outcome. 

Carl Deirmengian, MD 

The Rothman Institute

Associate Professor of Orthopaedic Surgery

The Lankenau Institute for Medical Research

Director of Arthritis and Joint Replacement Research

Introduction

I am fortunate to work with a team of healthcare providers devoted to the highest quality of care and advancing the field of total joint replacement. Unfortunately, outdated treatment interventions and myth engrained in all aspects of care before and after surgery still exist.  Patients have legitimate concerns because of what they have heard from previous patients, friends or family members. Some interventions surrounding this surgery are passed down from surgeon to resident and therapist to student based on tradition and routine without any scientific basis. This erroneous information is shared with patients creating additional, unwarranted stress and anxiety making recovery more challenging.

Total Hip Replacement: Your Guide From Pre-op Through Recovery supplies you with evidenced-based research to help you make informed decisions and ask focused questions to optimize your care. It reviews arthritic pain and explores non-pharmacological and pharmacological pain management strategies before committing to surgery. A clear plan is outlined for the weeks and months before surgery, as well as, what to expect the day of surgery and each day until discharge from the hospital. You will learn about the most common, but statistically unlikely post-operative stumbling blocks patients encounter. Also, Total Hip Replacement: Your Guide from Pre-op through Recovery covers the first two weeks post-op until complete recovery by identifying key components to address each week and month post-op as you achieve specific healing milestones. This evidenced-based approach will provide you with the knowledge to customize your recovery, minimize setbacks, and give you the best results possible.

1 Hip Pain

It is a familiar story. Your hip pain has been going on for weeks, months, or even years.  Morning pain and stiffness decreases during the day only to return by the evening. You deal with some, if not all of these symptoms: pain in the groin, thigh, buttocks or radiating pain to the knee. The pain can be sharp, stabbing or a deep, dull-ache. Decreased range of motion, swelling, warmth, cracking or popping noises occur with movement and weightbearing.

Transferring in and out of chairs, walking and climbing stairs are painful.  A cane or walker has become a necessity.  Activities of daily living (ADL) like bathing, dressing, and stepping in and out of the bath tub are labor intensive.  To put on socks and shoes requires twisting and contorting your body, while managing instrumental activities of daily living (IADL) like driving, cooking, housework, laundry, and shopping require modification.

Eventually, you reach your threshold and make an appointment with your primary care physician.  The doctor examines your hip and gives you a prescription for an x-ray and physical therapy.  If you have arthritis, x-rays will show decreased space between the head (ball) of the femur and the acetabulum (socket) where the cartilage was worn away. The head of the femur can lose its rounded appearance and become irregularly shaped. Osteophytes a.k.a. bone spurs may be evident. They develop to compensate for the loss of cartilage and increase the stability of the joint.

On the following pages see x-ray of a healthy, non-arthritic hip. The head (ball) of the femur is round and there is space between the acetabulum (socket). The arthritic hip shows just the opposite, an irregularly shaped head and minimal to no space between the head and the acetabulum.

(healthy, non-arthritic hip)

(arthritic hip)

You attend physical therapy two-to-three times per week. Your therapist instructs you on basic hip exercises to increase strength, flexibility, and maintain the health of the joint.  Several weeks pass with minimal or no improvements and you often find the pain is worse following PT sessions. You follow up with your primary care physician to re-evaluate the hip and express your frustrations. Your doctor recommends you see an orthopedic surgeon for another opinion.

This visit with the surgeon goes as follows. The Doctor reviews your information, physically examines your hip(s), looks at the x-rays, and asks how your hip pain impacts your ability to ambulate, climb stairs, perform transfers and self-care tasks. The surgeon makes it clear. Based on your symptoms and the results from physical therapy, you are a candidate for a hip replacement.

Bad news. No one wants surgery. Thoughts of having surgery ramp up your anxiety and stress making it difficult to think clearly and ask questions.  The surgeon may offer an injection in the hip joint for some temporary relief (I will review the research on injections later on).  You leave the doctor’s office, mind racing. Unanswered questions start popping up in your mind.

Am I ready for this surgery? 

Is there something I can do to delay it? 

If I lose weight will the pain go away? 

What should I do before the procedure? 

Do I need additional tests before surgery? 

What happens during the hospital stay? 

How much pain will I have? 

How long will I be in the hospital? 

How much physical and occupational therapy will I need? 

Will I go to rehab after my hospital stay?

Will I need homecare or outpatient physical therapy?