Why is the operation done?

The hip joint is a ball and socket joint between the top of the thigh bone and the pelvis which lies deep in the groin. It consists of a ball (femoral head) at the top of your thigh bone (femur) and a socket (acetabulum) in your pelvis.

The surfaces of the ball and socket are covered by a smooth, low friction material called articular cartilage, which cushions the bones and lets them move easily. However, this can become damaged. Ligaments and muscles help keep the ball within the socket whilst allowing a large range of movement.

Hip function

The hip joint bears the full weight of your body. In fact, when you walk, the force transmitted through your hip can be up to three times your body weight. As well as transmitting weight, the hip needs to be able to move freely to enable you to function normally. Muscles surrounding the hip such as your buttock (gluteal) and thigh muscles (quads) are also important in keeping your hip strong and preventing a limp.

When the hip becomes arthritic 

As we get older most people will have “wear and tear” arthritis of the hip, although some will have rheumatoid arthritis which also involves other joints. Many factors may contribute to having arthritis; obesity, accidents, vigorous sport or a family history may be important. In osteoarthritis (wear and tear), certain changes occur in the joint. Patients may need a hip replacement due to inflammatory, rheumatoid or osteo-arthritis.

• The smooth cartilage becomes flaky and develops small cracks
• The bone underneath the cartilage becomes denser
• The lining of the joint becomes inflamed and may thicken up

As the arthritis progresses, there may be:

• Severe wear of the cartilage allowing the bones to rub and grate together
• Loss of the joint space
• Formation of bony lumps called osteophytes

These changes may result in pain, loss of movement and loss of muscle power.

The artificial joint

The worn part of your hip joint is replaced with an artificial joint made of surgical quality stainless steel, a metal alloy or ceramic. A plastic (polyethylene) liner is usually used. 
Some can be used with orthopaedic cement; others have a special coating that binds with the bone instead. Your surgeon will help choose the most appropriate type of hip replacement for you.

The combination of metal and plastic means the new joint has low friction, wears very slowly and moves easily with your weight on it.

Why do I need a hip replacement?

• Because you may have pain which at times is severe and disabling which makes it difficult or impossible to carry out normal daily activities
• You cannot walk very far now and may have to use a stick. Stairs can be very difficult

The main reason for recommending a hip replacement is pain or loss of function due to arthritis. The aims of the hip replacement are to relieve the pain from your hip and to enable you to carry out your normal activities more comfortably. 

How is the operation done?

A hip replacement is a major operation and usually takes approximately one hour. The operation will be done under spinal (epidural) anaesthetic or general anaesthetic (where you are put completely to sleep) and the existing hip joint is replaced:

• The upper part of the thigh bone is removed
• The natural hollow in the pelvis, called the acetabulum, is hollowed out further and a plastic cup is fitted into the hollow
• A short, angled stem, with a smooth ball on its upper end to fit into the socket, is secured into the canal of the thigh bone
• The plastic cup and the metal stem may be either press-fit or may be fixed with acrylic cement
• The layers of soft tissue, muscle and skin are stitched and clipped back together

You are usually in hospital for one to two nights. You should be prepared to work hard at the exercises given to you by the therapy staff. Most patients tell us that they are pleased with the result of their hip replacement. Some, however, are less satisfied either because a complication has arisen or their expectations are too high.

Benefits

The aim of a hip replacement is to reduce pain and improve mobility. About 90% of people having hip replacement rate the result themselves as ‘good’ or ‘excellent’. 

Risks

The vast majority of patients make a rapid recovery after hip replacement operations and experience no serious problems. However, it is important you understand that a hip replacement is a major operation and that complications can occur.

General surgical risks

Thromboses and emboli (blood clots)

Blood clots in the leg veins (deep vein thrombosis) and blood clots on the lungs (pulmonary embolus) are a risk associated with joint replacement surgery.

The simplest way of reducing this risk is early mobilisation (exercises and walking).

Whilst in hospital you will also be prescribed blood thinning treatment, usually in the form of injections, to reduce the risk of clot formation.

Patients already receiving anti-coagulant therapy will be assessed and advised accordingly.

Urinary problems

Some patients, particularly those who may have previously experienced difficulty passing water, may sometimes need a catheter to be inserted into the bladder prior to or after the operation. There is a small risk of temporary incontinence; particularly in women, following surgery.

Except in certain circumstances, this should be removed the morning after surgery.

Transfusion

Blood transfusion following hip replacements is rarely needed. If your blood count is very low or if you are showing symptoms of anaemia (low blood count), the team looking after you may recommend a blood transfusion.

Fat embolism

This is rare and is caused by the fat within the bones (marrow) travelling up into your lungs at the time of surgery and causing breathing problems. Although this can be serious it is most commonly treated with extra oxygen therapy.

Superficial infection

You will not be discharged from hospital unless the appearance of the wound is satisfactory. Where possible, the dressing will stay on until the removal of your clips or stitches. After discharge, if you have any concerns about your wound, please call the ward you were discharged from.

Deep infection

A deep infection of the joint most often starts when bacteria gain access to the tissues at the time of surgery and great lengths are taken in theatre to reduce the risks of this happening. Operations are carried out in an ultraclean air theatre and sterile clothing is worn by the surgical team. You will be given preventative antibiotics at the time of surgery.

Despite all the precautions taken, infections can still occur. An early deep infection (within the first six weeks) may rarely occur and this would require a further operation to clean the joint replacement. Occasionally it would be necessary to take out the joint replacement to resolve the infection. It is likely you would require a course of antibiotics.

An infection can occur at any stage in the life of a hip replacement. The reason for this is that any infection in the body can circulate in the blood and settle on the surface of the new hip joint. Once there it forms its own environment, or ‘bio-film’, which makes it difficult to treat with antibiotics alone. Although the symptoms of infection can often be suppressed with antibiotics the only way to eliminate this deep infection is to remove the artificial implant as described above.

Remember infection is a serious complication. If you develop any new redness around the wound or if the wound leaks after leaving hospital, it is important that you call us on , 8am - 2pm.

Bruising

It is common to see bruising around the hip in the days after surgery and, occasionally, this bruising will extend down the leg, sometimes into the foot.

Leg swelling

Leg swelling is a normal response to the operation and will settle week by week as your body absorbs the bruising. You should continue to do the exercises as directed by Physiotherapists for the first 12 weeks after surgery. You should also aim to lie flat for at least 20 minutes once or twice a day. Walking can help reduce the swelling but standing unnecessarily should be avoided. If the swelling increases or if it is accompanied by tenderness in the calf or groin, a temperature or breathing problems you should ask your GP for advice.

Medical problems

Complications such as heart attack, stroke or death can occur after hip replacement as with other forms of major surgery. These complications are rare and the anaesthetist will not allow the operation to proceed if it is felt that the risks are significantly higher than normal. In this circumstance, it may be that you are sent for further tests or treatment prior to surgery being performed.

Specific risks

Implant wear and loosening

On average, more than 90% of hip replacements are still working well after ten years. We only use hip replacements with a proven track record. As with all artificial joints, wear and loosening can occur. If you experience new pain in your replaced hip, this can be a sign of loosening and you should seek advice from your GP or the orthopaedic team. Occasionally, loosening can occur without symptoms but may be seen on x-rays. It is for this reason that we will often follow you up with check x-rays for many years after your surgery, even though your hip may not be causing you any problems. 

If your hip does loosen or become painful, your surgeon may recommend a revision hip replacement. This can be very complicated surgery and, should it be required, the risks and benefits of this would be discussed with you in detail.

Dislocation

Dislocation occurs in a small number of patients undergoing hip replacements. This may require a manipulation under anaesthetic to restore the alignment of the joint.

In order to reduce the risk of dislocation, there are three precautions you must follow. These are movements that are known to put your hip at increased risk of dislocation.

1. You must not flex your hip past 90 degrees. This means you need to be aware of the height of chairs you sit in. It also means that once you are sitting, you must not lean forwards or reach down to the floor. You will be given equipment to help with this.
2. You must not allow your operated leg to cross the mid-line of your body. This means you must not cross your legs or ankles. It also means that you must not move your shoulders a long way over your un-operated side as this will move your mid-line.
3. You must not allow your operated leg to twist excessively in either direction. This means that whenever you are turning with your walking aids you must make small, steady steps rather than twisting.

Fractures

Very rarely, fractures (breaks) of the bone can occur during the course of surgery. These are almost always identified during surgery or on the check x-ray after the surgery. Occasionally, this requires further surgery or the surgeon may simply slow down your activities for several weeks to allow the fracture to heal.

Leg length

The surgeon will try to ensure that your legs are of equal length but cannot guarantee this.

Sometimes a balance has to be struck between leg length and joint stability leaving the leg slightly long or short. Small differences may not cause any problems but if the difference is significant, it can be corrected by using a shoe insert or heel-raise on the appropriate side.

Nerve damage

Very occasionally one of the main nerves that run past the hip can be damaged during the operation. This can cause a footdrop or paralysis of other muscle groups in the leg. Although the nerve often recovers over a period of months the paralysis can persist.

The skin over the outer side of the hip can feel numb for up to 12 months until the nerve fibres recover - this is normal.

Aching in the joint, stiffness, limp etc

Most are delighted with their hip replacement. Some people describe aching or stiffness in the joint or have a limp which does not improve. This is rare and will be investigated thoroughly by the team looking after you.

Ectopic bone or heterotopic ossification (extra bone formation)

The body may form new bone in the tissues around the hip in response to the trauma of the operation. This tends to occur only in the immediate recovery phase and may lead to long-term stiffness of the joint.

Alternatives to surgery

Alternatives to surgery include managing pain through medication or injections or working with a physiotherapist to complete exercises or the use of walking aids.

Reducing the risk of infection in hospital

What can you do to help?

• Keeping your hands and body clean is important when you are in hospital. Take personal toiletries and specific skin care preparations if appropriate
• Taking a container of moist anti-bacterial hand wipes with you will ensure you always have some available when you need to clean your hands, for example immediately before you eat a meal
• Ensure you always wash your hands after using the toilet and if you use a commode do not be afraid to ask for a bowl of water if the nurse does not offer one
• Hospital staff can help protect you by washing their hands, or by cleaning them with special alcohol rub or gel. If a member of staff needs to examine you or perform a procedure, e.g. change your dressing, do not be afraid to ask if they have first washed their hands or used an alcohol rub or gel
• Try to keep the top of your locker and bed table reasonably free from clutter. Too many things left on top make it more difficult for the cleaning staff to clean your locker and bed table properly
• Inform a nurse if your dressing becomes wet or loose
• If you visit the bathroom or toilet, and you are concerned that it does not look clean report this immediately to the nurse in charge of the ward. Request it be cleaned before you use it, and use an alternative in the meantime
• Your bed area should be cleaned regularly. If you or your visitors see something that has been missed during cleaning report it to the nurse in charge and request it is cleaned
• Always wear something on your feet when walking around the hospital
• Ask your visitors to wash their hands on arrival to the Ward
• If your visitors are feeling unwell, or have had diarrhoea or vomiting in the last 48 hours, they should stay away from the hospital to prevent the spread of infection
• Visitors should avoid sitting on the bed. Please use the chairs provided

Anaesthesia

Preparing yourself for anaesthetic

• It is difficult to separate the risks of anaesthesia from the risks of the operation and your general health. The risks to you depend on whether you have any other illnesses or other factors, such as smoking and weight
• If you smoke, giving up for several weeks before the operation reduces the risk of breathing problems and improves healing of the tissues. If you cannot stop, cutting down will help
• If you are very overweight, reducing your weight will reduce many of the risks of having an operation and anaesthetic

What will happen before my surgery?

You will meet your anaesthetist before your operation. They will ask you questions about your health, previous anaesthetics and usual medicines and will need to check your answers to other questions. They may need to examine your chest with a stethoscope and examine your neck and mouth. Please ask questions and tell them of any worries you may have.

You will receive clear instructions when to stop eating and drinking before your operation. It is very important to follow these, or your operation may be delayed or cancelled. 

Types of anaesthesia during surgery

There are two main types of anaesthesia, general anaesthesia and local anaesthesia. They are often combined.

General anaesthesia

A general anaesthetic is a combination of drugs which are given to make you completely unconscious. During a general anaesthetic you do not feel anything and will not be aware of what is going on around you. It is uncommon for general anaesthesia alone to be used for hip surgery. It is usually combined with a local anaesthetic (spinal anaesthetic or epidural). A sedation technique may be used instead of a general anaesthetic. This makes you relaxed and sleepy during the operation, but you are not unconscious.

Modern general anaesthetic is very safe. There are some common side effects and some less common side effects:

Common side effects or complications:

• Sore throat
• Feeling sick
• Shivering
• Headache

Less common side effects or complications:

• Chest infection
• Muscle pain
• Damage to the teeth, lips or eyes
• Excessive drowsiness

Serious complications related to general anaesthesia are rare but include life threatening allergy to drugs and breathing difficulties and cardiac issues such as heart attack and stroke.

Regional anaesthesia

Regional anaesthesia uses local anaesthetics which are drugs that have a numbing effect. They stop you feeling pain and other sensations in part of your body but on their own do not cause any loss of consciousness.

Types include the following:

1. Spinal anaesthetic

• Local anaesthetic is injected near to the nerves in your back
• You go numb from the waist downwards
• You feel no pain but you remain conscious
• If you prefer, you can also have drugs that make you feel sleepy and relaxed (sedation). You are likely to have little memory of the time during which you have been given sedation

2. Epidural

• This is similar to a spinal anaesthetic. It involves inserting a very fine plastic tube, through which the local anaesthetic is given. It can be used to continue pain relief for several days after your surgery

Pain control after surgery

Pain following your hip operation is inevitable. We aim for your pain to be at an acceptable level to allow you to move around after your surgery and recover.

Pain control is an essential part of your care

The nurses and acute pain team are able to give you advice and support. Pain relief is available in different forms and strengths. If you need support, please ask a member of our team for help.

Oral medication

When you are able to drink and eat then you may take your painkillers by mouth. Most patients will need to take painkilling medication regularly after surgery to keep their discomfort to a minimum.

Local anaesthetic

Most patients will receive a spinal anaesthetic and will have long-acting pain killers added to this injection. This can provide very effective pain relief for up to 24 hours after the operation.

Injecting local anaesthetic drugs close to the nerves going to the hip, the spinal region or the operation site blocks painful messages from being sent to the brain. The Anaesthetist will discuss this with you in further detail.

Pharmacy

What is the role of the pharmacist?

The pharmacist visits all the in-patients and checks their drug charts for legibility, safety, drug interactions and effectiveness of each drug prescribed by the doctor. The pharmacist will also check for any drug allergies as well as dispense any newly prescribed items.

Before you come into hospital

You will be seen by a practitioner in the Pre-Operative Assessment Clinic (POAC), who will check what medication you are prescribed and tell you if and when you need to discontinue any of your drugs before surgery. In most cases you will continue on all the drugs usually prescribed by your GP. You should bring all your usual medication into hospital with you, which will be locked away in a medicine locker beside your bed. It is better to store and bring them in their original containers rather than to decant them or bring in single strips. This is so that we can check your dosage instructions and positively identify them as belonging to you.

If your medication runs out, a further supply will be dispensed from our pharmacy department. If the dosage of any medication has changed then the pharmacy team will supply a new pack or re-label your own pack with new instructions on how to take or use your medication. If any medication has been stopped, then these will be removed and destroyed by pharmacy, where consent has been given. These should not be used during your stay as any deviation from what is prescribed by the hospital doctors can be potentially harmful to your health.

Whilst you are in hospital

Your drugs will be checked, counted and recorded by the nurse on admission. The doctor will prescribe on your drug chart your usual medication and any further drugs that you might need whilst in hospital. These usually consist of anti-sickness medication, antibiotics and analgesia (painkillers) as well as blood thinning injections or tablets. The pharmacist 
also checks your drug chart and dispenses any regular new treatments prescribed.

Discharge from hospital

Before discharge, the pharmacist will dispense any medications prescribed by the doctor. You may be transferred to the discharge lounge while you wait for your tablets to take home (TTOs).

Blood transfusion

Why might you need a blood transfusion?

Blood contains many different cells. The red cells are essential for carrying oxygen around the body. A lack of these red blood cells is called anaemia.

Most people cope well with losing a moderate amount of blood (e.g. two to three pints from a total of around eight to ten pints). This lost fluid can be replaced with a salt solution. Over the next few weeks your body will make new red blood cells to replace those lost. Medicines such as iron can also help compensate for blood loss. However, if larger amounts are lost, a blood transfusion is the best way of replacing the blood rapidly.

What might I do to reduce my need for blood before an operation?

• Eat a well-balanced diet in the weeks before your operation
• Boost your iron levels - ask your GP or Consultant for advice, especially if you know that you have suffered from low iron levels in the past
• If you are on blood thinning medication such as Warfarin or Aspirin, stopping these drugs may reduce the amount of bleeding. You will be advised if you need to stop these before your operation

Are transfusions safe?

Almost always, yes. The main risk from a transfusion is being given blood of the wrong blood group. A smaller risk is catching an infection. To ensure you receive the right blood, the clinical staff make careful identification checks before any transfusion. They will ask you to state your full name and date of birth. They will then check the details on your wristband to ensure that you receive the right blood. They will regularly monitor you during your transfusion and ask how you feel.

Donated blood will be specially selected to match your own blood for the most important blood groups. But, because your red blood cells carry over 100 different blood groups, an exact match is not possible. About one in every 15-20 patients develops an antibody to the donated blood and will need to have specially matched blood. If you have a card saying that you need to have special blood, please show it to your nurse and ask them to tell the hospital blood bank.

Fortunately, severe reactions to blood transfusions are extremely rare. But when they do occur, staff are trained to recognise and deal with them. Please inform us if your religious or spiritual belief prevents you from accepting a blood transfusion.

How will I feel during my blood transfusion?

Most people feel no difference at all during their transfusion. However, some people develop a slight fever, chills or a rash. These are usually due to a mild immune reaction or allergy and are easily treated with Paracetamol, or by giving the blood more slowly.

Other information

If you are interested in finding out more about blood transfusions and have access to the internet, you might find the following website useful: National Blood Services - www.blood.co.uk

Preparing for your surgery

Fitness and diet

Do as much moderate exercise as your pain will allow, but in particular make sure that you do pre-surgery exercises you have been given.

Ensuring that you eat healthily in the days/weeks before your operation should help you to recover more quickly.

Stop smoking (including e-cigarettes) – your chest needs to be clear for your anaesthetic.

Drink alcohol only in moderation.

Healthy eating

If you are overweight and your consultant has recommended that you lose weight before your operation it is best to eat a varied healthy diet. This will help maintain your vitamin, mineral and protein levels which is ideal for an operation. 

If you want more detailed information, please see the NHS Choices website or ask your GP to refer you to a community dietician.

General healthy eating advice

Eat more fruit, vegetables and cereals. Fruit, vegetables and cereals are all rich in vitamins and fibre (roughage). All fruits, vegetables and salads are beneficial and you should try and have 5 portions a day. Wholemeal/ wholegrain foods like wholemeal bread/pasta/rice, porridge, Weetabix and other high fibre cereals, beans, lentils and oats are also good for you 
to try and keep healthy.

Cut down on sugar

Sugar contains no useful nutrients apart from energy and we can get all the energy we need from other foods. Reduce your intake of sweets and limit adding sugar to foods and drinks. Reduce sugar containing drinks.

Getting ready to return home

It is very important that your home situation is suitable for you to return to following your surgery, especially if you live alone. Here are some things you should do: 

• Clean and do the laundry and put it away
• Put clean sheets on the bed
• Prepare meals and freeze them in single serving containers
• Pick up loose rugs and mats
• Ensure everyday items are in reach
• Make sure there is room to walk from room to room without obstacles getting in your way (remember you may be using walking aids)
• You will only be in hospital for a short time. Please avoid having any maintenance work done to your property

Our Occupational Therapists aim to assess all patients to enable timely ordering of equipment required to help you maintain your independence.

Pre-operative process

This will provide you with the opportunity to discuss the medical, nursing and therapy requirements needed to help you plan for your admission to hospital and discharge following surgery. At the POAC your medical fitness for an anaesthetic will be assessed and any tests required organised.

All patients are screened for MRSA during their Pre-Assessment Clinic appointment. If you are found to be a carrier of MRSA you will be given treatment prior to your operation.

Please inform the nurse if you have been diagnosed in the past with MRSA, C-Diff, VRE, CPE or CJD. Or if you have received treatment in a hospital in this country or abroad, within the last 12 months.

During your appointment you may have some or all of the following:

• Height, weight, blood pressure, urine test
• A detailed nursing assessment
• An examination of your general health
• An ECG (tracing your heart)
• Blood tests
• MRSA screening
• Spirometry (breath tests)

Occasionally other tests are required depending on your state of health.

What to bring

• Reading glasses
• All your regular medications

You will be given advice about taking medicines on the day of your operation and will inform you of any that may need to be omitted for a period of time before your surgery. Please avoid using skin cream or moisturiser before your appointment as it can interfere with our medical equipment.

When you have finished all your assessments, please do not leave the clinic area without speaking to a nurse, so we can confirm that everything required has been completed. You will be given a bottle of antimicrobial body wash to be used before your surgery.

If for any reason you cannot attend this appointment it is important to call the clinic on 0121 685 4362 as soon as possible. This assessment helps us to ensure that you are fit enough to have the operation and it cannot go ahead without it.

You will be given a green medication bag to put all your medication in. On admission, please bring in all the medication that you take, including tablets, liquids, capsules, creams, eye drops, inhalers, patches, sprays, injections, and any other medication you may have bought from a chemist, supermarket or health food store. If you have any tablet organiser boxes 
(dosette), please also bring these in.

Your health after your pre-operative assessment

If you become seriously unwell immediately prior to your operation date and are therefore not fit to have your surgery, it is vital that you ring and inform us on 0121 685 4362. You will then be sent a new date for your operation. It is also important that you contact us on this number if your medication changes prior to your admission.

Cough, cold, sore throat

If you develop cold symptoms, please contact the nurse in the Pre-Operative Assessment clinic for advice on 0121 685 4362.

Skin

For certain types of surgery, it is important that your skin is not broken or damaged in any way, e.g. leg ulcers, rashes, inflamed cuts, as these may be a source of infection. If you develop skin symptoms, please contact the nurse in the pre-assessment clinic for advice on 0121 685 4362.

Teeth and gums

If you develop any problems with your teeth or gums prior to the operation, please see your dentist and inform the nurse in the pre-assessment clinic on 0121 685 4362.

Urine and digestive system

If your urine becomes unusually smelly or cloudy or you experience pain or burning when passing urine, or if you develop a stomach upset or diarrhoea prior to coming into hospital, you must inform the nurse in the Pre-Operative Assessment clinic on 0121 685 4362.

It is also vital that you inform us if you have been a patient in another hospital while you are waiting for your operation.

On the morning of your admission

On the morning of your operation, have a bath, shower or full wash and wash and dry your hair. Do not apply deodorants, creams, products or make-up as you will be asked to remove it. Do not shave your operation site.

Please bring in your green medication bag containing all your medications. If you have a repeat prescription request slip normally attached to the green NHS prescription from your GP, please also bring this with you.

You will receive instructions on fasting and drinking prior to your admission.

What to expect when you arrive

• The anaesthetist and a member of the surgical team will visit you before surgery. The anaesthetist will explain the anaesthetic and methods of pain control. You will have the opportunity to ask any further questions. They will also discuss your consent again prior to surgery
• A member of the surgical team will draw an arrow on your leg to ensure the correct side is operated on. Do not wash off this arrow!
• You may be given pre-operative pain relief. This will help ensure that they are in your bloodstream before surgery
• You will be given an indication of the time you will be going to theatre. Theatres run all day so your surgery could be in the afternoon
• Before you go to theatre, you will be given a theatre gown to wear
• When it is time for your operation, one of our team will take you to the changing room. They will then go through a series of safety checks and then one of our theatre team will take over your care
• There will be a final series of checks before you are connected to monitoring equipment
• You will then be given an anaesthetic

The operation

When you have been anaesthetised, you will be taken to the operating theatre. While you are asleep the anaesthetist will remain with you at all times, monitoring to ensure you are safe. If you are awake or under light sedation, you will be aware at times of some noises and vibrations. The anaesthetist will be there at all times to reassure you. You may wish to 
bring an iPod or tablet to either listen to music or watch a movie.

What to expect - immediately after surgery

The operation to replace your hip takes approximately one hour. 

At the end of the surgery, the anaesthetist will wake you up and take you to the recovery area. You may find several items in place to help your recovery. An oxygen mask over your mouth and nose helps your breathing. The drip in your arm should be removed once you are tolerating food and drinks. Your pain control will be established and your vital signs 
monitored. Once you are fully awake you will then return to the ward.

Once back on the ward you will be given regular pain relief by the nursing staff in the form of an injection or tablet as required.

Observations including blood pressure, pulse, respiration rate, oxygen levels and temperature will be recorded. Your skin will be checked and our team will encourage you to change your position regularly to prevent pressure sores.

Pain management

You may experience some significant discomfort following surgery. You will be given regular painkillers, so you are able to do exercises and move your new hip. You should take the pain medication you have been prescribed whether you are in immediate pain or not.

Painkillers include paracetamol, ibuprofen-type drugs (non-steroidal anti-inflammatory drugs) and morphine-like drugs (opioids). Initially, you will need strong painkillers to help you to move. We will give you strong painkillers for one or two days after your surgery.

Please remember to let the doctors and nurses know if your pain is not controlled or above or if the pain stops you doing your exercises. We may need to alter or increase your painkillers.

Please don’t be afraid to ask if you need support managing your pain. We’re here to help you.

Some patients experience side effects. These can include:

• Drowsiness (feeling sleepy)
• Nausea or sickness
• Indigestion (heartburn)
• Constipation

If you have any concerns about your pain or the painkillers that you are given, you may discuss this with your nurse or doctor.

Back on the ward

• The consultant who operated on you will visit you to review your progress
• You will be encouraged to wash and dress
• The physiotherapist will see you and start your exercise regime
• You will be assessed and may be helped out of the bed to sit in a chair
• You will be encouraged to eat and drink
• The dressing on your wound will be checked
• Your pain levels will be assessed and pain relief will be given as appropriate
• It is possible the pain medication will make you constipated and so we will give you laxatives to help prevent this
• Throughout your stay, please let the nurses know if you have not had your bowels open so they can address the problem

Steps towards discharge

• You will be encouraged to sit in your chair for meals and encouraged to dress in loose fitting, comfortable clothing during the day
• The physiotherapist will continue with your exercises and progress your mobility with a walking frame or sticks/elbow crutches
• You will be encouraged to walk to the bathroom for your wash
• Blood tests will be taken
• You will have an x-ray of your new joint
• If you have them, your drain and catheter will be removed
• Please confirm your transport home with your family/friend

Preparing for home

• You will be taught how to go up and down stairs
• You will be encouraged to walk with sticks or elbow crutches independently
• You will be shown how to use your dressing aids and to get on and off the bed
• You will be shown how to give the blood thinner injection
• Your wound will be checked
• When you have achieved all of your discharge goals you will move to the discharge lounge to enable our discharge nurses to explain all of your medication, your discharge paperwork and wait for your family/friend to pick you up

Physiotherapy

After your operation you will be encouraged to be as independent as possible. This is achieved by starting your rehabilitation within a few hours of your operation. The Physiotherapy and Occupational Therapy staff will support you in performing the following exercises and activities.

Hip precautions

After a hip replacement there are certain movements of the hip that you may be asked to avoid for six weeks. We call these ‘precautions’ and they aim to prevent your new hip from dislocating whilst the muscles around it heal.

The three main precautions are: 
1. Do not bend the hip more than 90 degrees (a right angle). For example:

• Do not sit on low chairs, beds or toilets. When sitting your knee should always be lower than your hip
• Do not bend down too low to kitchen cupboards or shelves 

2. Do not cross your operated leg across the middle of your body. For example:

• Do not cross your legs when getting in and out of bed
• Put a pillow between your legs when resting or sleeping

3. Do not twist your operated leg. For example:

• When turning take small steps instead of turning your body
• Do not reach for items behind you, e.g. have toilet roll next to you instead of on the back of your toilet

Discharge home from the ward

You may go to the discharge lounge to enable a safe and coordinated discharge. This will allow you time to ask any questions.

We will discuss wound care with you and advise you about when you should make an appointment with your GP Practice Nurse to have your clips or stitches removed. This is 
usually two weeks after surgery.

You will be given painkillers and will be shown how to use your injection at home (if prescribed). You will be given your regular medications to take home as well as a copy of your discharge letter. An outpatient appointment will be arranged before your discharge, or by letter shortly after discharge. This will be four to six weeks following your surgery.

Hospital transport is not routinely available and there are strict eligibility criteria for using it. We therefore request that you organise your own transport wherever possible. If you have any concerns, please speak to your nurse.

Studies have shown that you will recuperate more quickly when you eat and sleep to your normal pattern. This also lowers the risk of post operative complications and hospital acquired infections. Therefore, anything that can be done to minimise this risk through careful planning is worth the time and effort.

Back at home

You will be assessed prior to discharge to see if you require support from our community service – the ‘ROCS’ team. The team can visit you at home to offer further medical and physical support to aid your recovery. It is very important that you have organised the necessary support for when you return home. After major surgery you may feel that it is a good idea to ask friends or family members to stay with you or to help with simple chores. They will also be on hand to give you moral support.

General wellbeing

• It is not unusual to feel tired and your sleep patterns may take a while to return to normal. Remember to have your rest on the bed every afternoon for at least an hour to reduce swelling in your legs and feet
• Your appetite as well as your bowel habits may take a while to recover. Make sure you drink plenty of fluids and try to eat a healthy balanced diet
• Try not to feel frustrated at not being able to do all the things you want straight away. Increase your activity levels gradually. Start with short distances around the house and garden in the first 2 weeks then increase as you feel able
• Avoid tight clothing including belts and tight underwear. Loose garments are generally more comfortable and are a lot easier to put on 

Eating

• Due to your reduced activity, you may lose your appetite or suffer from indigestion. Small meals taken regularly can help. If you have lost your appetite, then milky drinks provide a source of energy and goodness

Medication

• It is important that you continue to take all your medication as instructed
• You will have been given a supply of painkillers to take home. Continue to take these as directed until you no longer feel that you need them. Remember your pain should be controlled enough to allow you to move about comfortably and to be able to practice the exercises to strengthen your hip
• You may have been given tablets or injections to administer to thin your blood. It is important that you continue with these as directed

Compression Stockings

• If you have been told to wear your ‘Anti-Embolic’ stockings at home, apart from 30 minutes each day, these must be worn day and night for six weeks following your operation. The stockings should be hand-washed and dried away from direct heat to preserve their beneficial effect

Going to the toilet

• For the first two weeks after surgery it is very common for bowel movements to become irregular. This can be due to the effect of analgesia combined with inactivity and a change of routine. This will resolve itself as you get back into your usual routine at home
• However you can help yourself by eating high fibre foods such as fruit, vegetables and wholemeal bread. If necessary, try taking a mild laxative for a few days until you return to your normal routine. If you need any further advice regarding your diet please do not hesitate to ask

Washing 

• You should follow the special advice given by the Occupational Therapy staff, which may include the use of special equipment, that will assist you to maintain your independence 
• You may use a walk-in shower when you feel ready, but please do not have a bath for six weeks

Dressing

• When dressing, sit on the side of the bed or in a suitable chair. This will help your balance
• Collect all the clothes you intend to wear and put them on the bed next to you before you start. Avoid twisting and overstraining to reach them
• Always dress your operated leg first and undress it last
• Do not cross your legs when dressing e.g. putting socks on

Driving

Most patients are instructed not to drive for six weeks after their surgery, but your consultant will advise you on this.

For comfort, slide the seat back on its runners, recline the seat slightly to give yourself maximum legroom. It will be easier if the car is parked away from the kerb, so that you get into it on the level. 

Make sure you can reach and use the pedals without discomfort. Have a trial run without the engine on. Try out all controls and go through the emergency stop procedure. Start with short journeys and when you do a long trip stop regularly to get out and stand up and stretch. Please be aware that if you drive soon after your surgery and have an accident, insurers may consider you liable for damage.

Sleeping

• You should try to sleep on your back for six weeks following surgery
• Changes in routine and restricted movement can cause difficulty in sleeping. Some people are awakened by the discomfort caused by sudden movement. If this happens, you may wish to take a painkiller to help you sleep

Continuing your activities at home

If you need to bend down to the oven, fridge, or low cupboard, you will find it easier on your new hip to take that leg behind you while bending the un-operated leg.

Safety and avoiding falls - all areas

• Pick up loose rugs, and tack down loose carpeting. Cover slippery surfaces with carpets that are firmly anchored to the floor or that have non-skid backs
• Be aware of all floor hazards such as pets, small objects or uneven surfaces
• Provide good lighting throughout
• Keep extension cords and telephone cords out of pathways. DO NOT run wires under rugs, this is a fire hazard
• DO NOT wear open-toe slippers or shoes without backs. They do not provide adequate support and can lead to slips and falls
• Sit in chairs with arms. It makes it easier to get up
• Rise slowly from either a sitting or lying position in order not to get light-headed
• DO NOT lift heavy objects for the first three months
• Stop and think. Use good judgement

Walking at home

If you are allowed to take full weight on your operated leg, you should use two sticks initially. When walking inside you may feel that you are able to use only one stick. You may do this when you feel safe and able to walk without a limp.

When walking with one stick remember to hold your stick in the opposite hand to the side of your operation. If you are not allowed to take all your weight on your operated leg, you will have been provided with appropriate walking aids by the physiotherapist and advised how to progress.

Sitting

Choose a chair that is comfortable for you but avoid low seats for the first six to eight weeks after surgery. Chair arms will help you get up and down safely in the first few weeks after surgery. To sit down and stand up safely, walk to your chair, slowly step back until you feel the back of your legs touching the seat. If you are using crutches, take your arms out of them and hold the handles in one hand.

Place your operated leg in front of you and place both hands onto the chair arms. Take your weight through your arms and un-operated leg, then ease yourself down onto the chair.

Once you are sitting, you can bend the knee of your operated leg, so your foot rests on the floor. Sit with your heels together, knees apart and toes turned out and don’t cross your legs.

To get up from the chair - reverse the process.

Stairs

Always use a handrail if there is one.

Going up - lead up with the unoperated leg, followed by the operated leg and the stick/crutch. 

Going down - lead down with the stick/crutch and the operated leg, followed by the unoperated leg.

A lot of people use this to remember – “Up with the good, down with the bad”.

Keep this method up until you feel strong enough to walk upstairs normally. Many patients can manage this between weeks four and six (a few stairs at a time).

Household jobs

You should avoid all strenuous and taxing jobs immediately after surgery. Only when you feel up to it, should you attempt small chores and even then, ideally you should have somebody helping you.

• Do not get down on your knees to scrub floors. Use a mop and long handled brushes
• Plan ahead! Gather all your cooking supplies at one time. Then, sit to prepare your meal
• Place frequently used cooking supplies and utensils where they can be reached without too much bending or stretching
• To provide a better working height, use a high stool, or put cushions on your chair when preparing meals
• If you need to bend down to the oven, fridge, or low cupboard, you will find it easier on your new hip to take that leg behind you while bending the un-operated leg

Gardening

Avoid strenuous activity such as digging, pushing a wheelbarrow or mowing the lawn immediately after surgery. You may work at a bench in a greenhouse sitting on a high stool. Avoid reaching across your body for things. Avoid the temptation to do too much when you start gardening. Build up your strength, starting with lighter tasks and then progress as 
your stamina increases.

Kneeling

Kneel onto operated leg first. Get up on un-operated leg first (let the un-operated leg take the strain).

Return to sport, leisure and work

• Low impact sports such as golf, bowls, cycling, swimming and walking may normally be resumed after three months. Check with your consultant at your follow up appointment
• High impact sports, i.e. jogging, singles tennis, squash, jumping activities, football are not recommended therefore are participated in at your own risk
• Return to work usually takes place between six and 12 weeks post-operatively
• Heavy manual work may require longer. Your consultant will guide you on this

Your physiotherapist can advise you about exercises and choice of sport.

Sexual activity

You are advised to refrain from sexual intercourse for six weeks after your operation and then resume with care mainly to prevent dislocation, muscle strain or injury around the hip. Choose positions that avoid twisting and excessively bending your hip. Our clinical staff are comfortable to give you advice. Please ask. 

Equipment loan and return

Any equipment that is recommended as a result of the therapy assessment process is provided on a short-term loan. It is your responsibility to return or arrange the return of any loaned equipment at the expiry of the agreed loan. More information is available from your Occupational Therapist.

Consultant follow-up

Your consultant or a member of the clinical team will review your progress at your follow-up appointment approximately four to six weeks after your operation. You will either be given the appointment before you leave the ward or you will be sent a letter informing you of this in the post. We advise that you write down a list of questions prior to this appointment and take them along, as you may not see your consultant again. 

Please remember that this booklet is a general guide only and your treatment may vary from this.

Wound care

You may find that the area around your wound feels numb, tingly, itchy or slightly hard. This is normal and should disappear over the next few months. During this time you should protect it from sunlight as it will burn easily.

Avoid the temptation to scratch the area until it is fully healed. You may wash around your wound with soap and water unless otherwise advised. If you have stitches or clips in your wound you will be asked to arrange an appointment with the practice nurse at your GP surgery to remove them. We will give you a letter and some clip removers (if required) to 
give to the nurse.

If you develop any new redness around the wound or if the wound leaks after leaving hospital, it is important that you telephone the Wound Care Helpline on 0121 685 4308 8am - 4pm, Monday - Friday. 

If you have any symptoms that you are concerned about and you require urgent, non-emergency advice contact 111. For all other Medical Emergencies please call 999.

Wound dressing

You will have an aquacel dressing over your wound which should stay in place for up to 14 days. You will be provided with a dressing to take home should you need a dressing change.

Recognising & preventing potential complications

1. Infection

Signs

• Increased swelling and/or redness at wound site
• Change in colour, amount, odour of drainage
• Increase in pain in hip
• Fever greater than 38°C

Prevention

• Take proper care of your wound as explained
• If visiting the dentist, advise the practice that you have undergone joint replacement surgery

2. Blood clots

Surgery may cause the blood to slow and pool in the veins in your legs which could cause a clot. If a clot occurs despite preventative measures, you may need hospital treatment to thin the blood further. Prompt treatment usually prevents the more serious complication of pulmonary embolus.

Signs

• Swelling in thigh, calf or ankle that does not go down with elevation of the leg
• Pain, tenderness and heat in the calf muscle of either leg

Prevention

• Foot or calf pumps
• Early mobilisation / walking
• Compression stockings
• Blood thinners may be prescribed by your doctor
• Maintain good fluid intake

3. Pulmonary Embolus

An unrecognised clot could break away from the vein and travel to the lungs. This is an emergency and you should call 999 if this is suspected.

Signs

• Sudden chest pain
• Difficult or rapid breathing
• Sweating
• Confusion

Prevention

• Prevent blood clot in legs (as above) 
• Recognise a blood clot in the leg and contact your GP promptly

4. Dislocation

Signs

• Severe pain
• Rotation/shortening of leg
• Unable to walk/move leg

Prevention

Follow the hip precautions stated and advised by your therapists.

In the event of non-emergency please contact the ward you were discharged from.

More information

Why have I still got swelling?

Healing tissues are more swollen than normal tissue. This swelling may last for several months. Ankle swelling is due to the fact that each time we take a step the calf muscles contract and help pump blood back to the heart. If you are not putting full weight on the leg, the pump is 
not as effective and fluid builds up around the ankle. By the end of the day lots of people complain their ankle is more swollen.

What can I do about it?

When sitting the ankle pump exercises work the calf muscles and help pump the fluid away. Try to put equal weight through each leg and 
“push off” from your toes on each step. Have a rest on the bed after lunch for one hour. You can put one or two pillows lengthways under 
your leg whilst resting but do not use them at night.

Why is my scar warm?

Even when the scar has healed there is still healing going on deep inside. This healing process creates heat, which can be felt on the surface. This may continue for up to six months. This is a different warmth to that of an infection.

Should you develop any problems or concerns about your wound, please contact the ward you were discharged from for advice rather than contacting your GP.

Signs of infection

• Increased swelling, redness at incision site.
• Change in colour, amount, odour of drainage.
• Increased pain in hip.
• Fever greater than 38°C.

If you have any concerns regarding your wound please call our Wound Infection Helpline on 0121 685 4308.

Why do I get pain lower down my leg?

The tissues take time to settle and referred pain into the shin or behind the knee is quite common.

Why do I stiffen up?

Most people notice that whilst they are moving around they feel quite mobile. After sitting down the hip feels stiff when they stand and they need to take three to four steps before it loosens up. This is because those healing tissues are still swollen and are slower to respond than normal tissue.

Is it normal to have disturbed nights?

Yes, very few people are sleeping through the night at six weeks after the operation. As with sitting you stiffen up and the discomfort then wakes you up. Also many people are still sleeping on their backs, which is not their normal sleeping position so sleep patterns are disturbed.

You may sleep on your side when you feel comfortable. Most people find it helpful to have a pillow between their legs.

I have a numb patch - is this okay?

Numbness around the incision is due to small superficial nerves being disrupted during surgery. The patch usually gets smaller but there may be a permanent small area of numbness.

My new hip clicks occasionally – is this normal?

This can be normal and it is usually a sign that those swollen tissues are moving over each other differently than before. You should not let this worry you, as again this should improve as healing continues. If you have any concerns please speak to your surgeon.

When should I stop using a stick?

Stop using the stick when you can walk as well without it as with it. It is better to use a stick if you still have a limp so that you do not get into bad habits that are hard to lose. Limping puts extra strain on your other joints especially your back and other leg. Use the stick in the opposite hand to your operated hip.

Many people take a stick out with them for three to four months after the operation as they find they limp more when they get tired.

Will I have any extra physiotherapy as an outpatient?

You will be referred to outpatient physiotherapy on discharge from the hospital. It is very important that you continue with the exercises you have been taught.

How far should I walk?

This varies on your fitness and what your home situation is. You should feel tired not exhausted when you get home, so gradually build up distance, remembering you have to get back.

When can I resume driving?

Always be guided by your consultant. Make sure you can reach and use the pedals without discomfort. Have a trial run without the engine on. Try out all controls and go through the emergency stop procedure. Start with short journeys and when you do a long trip stop regularly to get out and stand up and stretch. You may like to check and confirm your insurance cover.

When can I have sex?

You are advised to refrain from sexual intercourse for six weeks after your operation and then resume with care mainly to prevent dislocation, muscle strain or injury around the hip. Choose positions that avoid twisting and excessively bending your hip. Our clinical staff are comfortable to give you advice. Please ask.

Will I set off the security scanner alarm at the airport?

Most joints are made of stainless steel and these may set off the alarm. If this happens have a word with security staff and explain the situation.

Will it get better?

Yes, do not despair! Do remember that most people who have hip replacement surgery have had hips that have bothered them for a long 
time. Therefore it will take time to recover from surgery and your body to get used to your new hip.

When can I fly?

You can complete a short haul flight after six weeks. It is recommended that you do not fly long haul for three months.

Physiotherapy