Pathway for total hip replacement and resurfacing hip replacement

This topic provides an overview of the process from the initial appointment to post-operative treatment and what happens after you are discharged from hospital.
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Initial appointment

When we have agreed that you are suitable for a hip replacement, you will be provided with verbal and printed information. Further information can be found on this web site. Orthopaedics WA will consent you for the surgery, and in most instances be able to give you the date of your surgery. Investigations will be arranged as necessary. These will include:
Radiology
Adequate up-to-date X-rays of the hip, which we will use to template for the correct size and type of implant. Occasionally we will require CT scans if the anatomy is more complex. This is commonest in dysplasia of the hip. We will also ask for a chest X-ray, which is required for major surgery by the anaesthetist.
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Blood tests
Routine blood tests include a blood count to exclude anaemia and check for adequate platelets, and electrolytes. Blood will also be taken for determining blood type in case of the need for transfusion. These tests are usually done within a week of the surgery. Further blood test may be requested depending on the presence of other medical problems.
Cardiology
A tracing of the heart is routinely done, again for anaesthetic safety. Further cardiology tests may be required if you have a heart condition.
Bone donation
You may be contacted by Pluslife (Perth Bone and Tissue Bank), who will give you the opportunity to donate your bone so that it can be used to reconstructive surgery on other patients, for conditions such as “redo” hips, tumour surgery and trauma. To find out more about this, follow the link on this page.

Anaesthetic

Professor Yates usually uses Dr Alex Swann as his anaesthetist. Assoc Prof Gareth Prosser usually uses Dr Clinton Paine as his anaesthetist. Mr Gohil usually uses Dr Matt Harper as his anaesthetist.

The anaesthetist will contact you by phone before the surgery, to discuss the anaesthetic. Sometimes they will arrange to see you if there are particular worries. Occasionally, we will arrange for you to see another specialist in order to optimise your medical condition before the surgery.

Read more about Anaesthesia here.

Thrombosis (DVT) and pulmonary embolus (PE)

Thrombosis is an abnormal formation of solid blood constituents within the veins. This can move into the lung where it is called a pulmonary embolus. Minor thrombosis is very common after joint replacement surgery, but only requires treatment in about 1% of people, when it produces excessive pain and swelling of the calf and/or thigh. Pulmonary embolus is rare occurring in less than 1 in 1000 patients after joint replacement. Prevention of these conditions is controversial, and many treatments have been tried. All drug treatments for this have significant potential side effects, and it is the balancing of the risks of developing this problem compared to the benefits of the medications that is difficult to define.

Orthopaedics WA assess all our patients for risk of DVT/PE. our routine regime for prevention after hip or knee replacement is:
  • Spinal/epidural anaesthetic
  • Good hydration
  • Early mobilisation
  • Calf pumps
  • Low molecular weight heparin (LMWH) (hospital policy)
  • Aspirin on discharge for 28 days.

Orthopaedics WA class patients as being very high risk if they have had a previous DVT or PE, are having bilateral surgery, or have a strong family history of DVT/PE. We will usually fully anticoagulate these patients with warfarin for 6 weeks, or may use high dose LMWH.

We believe that this regime reduces the risk of DVT/PE while minimising the risk of complications from other treatments.

Blood Management

'Blood-less' surgery
Our unit at Fremantle is a world leader in peri-operative blood management, with one of the lowest transfusion rates after surgery in the world. We have refined this service further in our private practice. Medications are optimised preoperatively.

Tranexamic acid is routinely used peri-operatively, which halves the blood loss. Spinal anaesthetic, and meticulous control of bleeding during surgery further minimises loss. Transfusion is extremely rare after primary joint replacement surgery (less than 1%).

Furthermore, because transfusion is so rare, it is never necessary for patients to pre-donate blood.

Pre-assessment

Within the week before the surgery, you will be asked to attend a pre-assessment appointment or have a telephone interview. Here, the final details of admission and preparation will be addressed. You will be provided with information about the administration of the admission, and the pre-surgery work up. You will be given a pre-surgery wash. Your urine will be tested for infection, and if this is positive, then further investigations or treatment may be necessary.

You will also be given a foam seat raise and toilet raise which you will use for four weeks.

Orthopaedics WA encourages patients to see the physiotherapists at the pre-assessment appointment. This allows them to better prepare them for surgery by teaching the use of crutches, and manoeuvring in and out of bed before the surgery is performed. This is billed for by the physiotherapists.

Before admission you will need to arrange someone to collect you after your surgery, and to have someone at home with you at least you the first day. If you require special help at home, then this needs to be fully arranged before you come into hospital.

Please ask if you have any questions regarding this.

The day of surgery

Orthopaedics WA admit nearly all their patients on the day of surgery. The nursing staff will prepare you for theatre, and give you a tablet containing tranexamic acid, one hour before surgery. This reduces the amount of bleeding that occurs by about 50%. The anaesthetist will see you on the ward, or in the holding bay in theatre. Pre medications are not prescribed routinely, but you can discuss this with the anaesthetist. I will usually see you in the holding bay, where all the documentation will be double checked, and you operative side will be marked.

You will next be taken through to the operating room, given your anaesthetic. Antibiotics will be given in order to reduce the risk of infection. Routine total hip replacement will take me approximately 40 minutes to perform, and resurfacing about 45–60 minutes. The skin is usually closed with skin clips, with a thick dressing that remains on for up to 72hrs. Orthopaedics WA rarely use drains, but nearly everyone will have a urinary catheter until they are mobile.

Pain management

Orthopaedics WA have a longstanding interest in optimising pain control after surgery. This fits in with the advances in minimally invasive surgery and early mobilisation. We have a rolling program of research and investigation into this subject. The aim is to speed recovery, minimise pain and maximise function.

Pain relief is multimodal and multidisciplinary, involving the patient, the surgeon, the anaesthetist, the nurses, the physiotherapists, and the pain team. All patients are individual, but Orthopaedics WA feel that we have made great advances in this area over the last six years.

Read more about Pain Management here.

Post op

After the surgery is finished, you will be taken through to the recovery room, where you will be monitored until it is safe to return you to the ward. Calf pumps will be placed on your legs, to minimise the risk of thrombosis, and a pain control regime will be in place. Anti sickness medication will be available if required.

Most of our hip replacement patients will be independently mobile with crutches and able to return home by the second postoperative day. Occasionally, patients need a little more help with their rehabilitation and medical problems, and Orthopaedics WA will ask one of the physicians to be involved with your care. They may move you to a rehabilitation facility if needed.
Physiotherapy
Our physiotherapist will review on the day of surgery and, if you have recovered from the anaesthetic and the power has returned to your leg, they will get you to stand.

The physiotherapists will see you twice a day, and teach you your exercises, how to move safely and to help you rehabilitate. They may arrange outpatient physiotherapy, depending on your needs and circumstances.

Discharge

When you are ready for discharge, you will be given medications to take home, including pain relief, anti inflammatory tablets, and aspirin (if possible) (see Pain Management After Discharge).
 

Advice following hip replacement surgery

The dressings must be left untouched until the community nurses come to remove the clips. Sometimes you may get a discharge of blood stained serous fluid from the wound and if the dressing comes off due to oozing, replace it with a clean dressing provided. Please wash your hands before touching the dressing and after.

Your dressings are waterproof so it is safe to shower without covering them.

If you have clips or sutures that need removing, the ward will arrange for a nurse from Health Choices to visit you at home, 10–14 days post-op, to remove them. If this cannot be done you will be advised to make arrangements with your GP.

Swelling is common but will resolve, if there is increasing swelling or calf pain please see your doctor or present to an emergency department.

Bruising is common after hip surgery but this will resolve over the next few weeks. Occasionally a haematoma can form under the wound, like a soft or hard ball, this will resolve. However, call the office if you are worried.

If there is redness or discharge from the wound please see your GP or call the office for instructions. Attend an emergency department if you cannot get to a GP or contact the office.

You may get some pain as you increase your mobility please use the pain killers given to you from the hospital, and you may need to get a further prescription from your GP or if you need us to arrange this please allow up to 4 days.

Occasionally deep sutures, often dark in colour, can work their way to the surface, these simply need to be cut back by your practice nurse.

Sick note – if a sick certificate is needed please contact the office.

Follow-up

Orthopaedics WA rooms will contact you regarding your follow up appointment, which will be between 2–4 weeks. You will usually be able to drive after we have seen you.

What you can do to optimise yourself

We will assess if any changes need to be made to your medications before admission. If you are on a single anticoagulant such as aspirin, for a medical condition, then we will usually continue with this. If you are on two anticoagulants, or warfarin, then they need to be stopped five days before surgery. Sometimes an alternative medication will need to be used in this period.

Stopping smoking will greatly reduce your risks of chest complications, infection, and poor wound healing, as well as benefit your long-term health.

Exercise, weight loss and healthy eating will all improve your outcome.

Problems with your skin, teeth and nails need to be brought to our attention, as they can be a serious infection risk.

What to bring

Toiletries, all X-rays and other investigations, daytime clothes, non-slip flat shoes, all medications.
See the frequently asked questions about hips. Also see the Related links on this page.