Patient Information Sheet

Revision Hip Replacement


Revision total hip replacement - Before your operation

Between being seen by your Consultant and the time of your operation, there are several things you should do to prepare yourself.

To reduce the risk of an infection occurring around your new hip, it is important that any possible sources of infection elsewhere are eradicated prior to your hip operation. Common areas of concern are the teeth or gums, skin infections, bladder infections, leg ulcers, in-growing toenails and athlete’s foot. Any source of infection, however seemingly minor, must be dealt with prior to surgery. If you are concerned, please see your dentist for a check up or see your GP for advice.

Plan how you will cope at home. Most people go home on the third day after their operation. You will normally need a walking aid for the first weeks and you are discouraged from driving during this time. If you normally live alone, it is usually best to arrange for a friend or relative to come and stay for a short while, or for you to stay with them, whilst you recover. Please make these plans in advance of your hospital treatment.

Probiotic yogurt-like products such as Yakult or Actimel are dietary supplements that may help suppress antibiotic changes to the gut flora that can occur whilst you are in hospital. They may also be beneficial in minimising constipation that can occur after surgery and in preventing the possibility of hospital acquired infections. We suggest you buy one of these products from your supermarket and start drinking a tube a day starting a week before surgery and continue until at least a week after surgery.

Pre-operative Assessment Appointment.

A week or two before your operation you will be invited to attend the hospital for a pre-operative assessment.  Staff will go over the details of your general health and medications with you. Some drugs should be stopped in advance of your operation. These include clopidogrel (plavix) (at least 2 weeks) the contraceptive pill (preferably 6 weeks), aspirin (1-2 weeks) and warfarin (usually 5 days, but varies – please discuss with staff in the clinic). HRT is not normally a problem and can be continued. You will have a number of blood tests and x rays and a heart trace (ECG). An MRSA screen will be carried out. You will also see a physiotherapist and often an occupational therapist. They will explain how you will mobilise after the operation, organise any adaptations that may be needed in your home and discuss your discharge plans with you.

Admission to hospital.

Normally admission takes place on the day of surgery. You should not eat for 6 hours but may drink clear fluids up to 4 hours before your scheduled admission.

A nurse will go through your personal details and plan your individual nursing care with you.

Your Consultant will see you again in your room. Please feel free to ask any further questions you have, or raise any concerns, at this time. The Consultant will mark the correct hip with an indelible pen, and ask you to sign the Consent for Surgery.

The anaesthetist will see you and perform a further final check of your heart, lungs and general health. He/she will also review any medication you are taking, and the need for any pre-medication. He/she will discuss with you the type of anaesthetic planned. This usually involves a spinal or epidural anaesthetic to numb the legs and hip area, combined with a light general anaesthetic.

A physiotherapist will instruct you in the appropriate exercises, including breathing exercises to lower the risk of chest complications and leg exercises to improve circulation and maintain muscle tone. Crutches will be supplied to you and you will be shown how to use them.

Post-operative procedure

There have recently been huge advances in the immediate post-operative management of patients. With the advent of less invasive hip surgery, patients are mobilised much more quickly, thereby reducing the risk of post-operative blood clots and the risk of acquiring a hospital-related infection. Your speed of recovery will depend a little on what was carried out at your revision operation and your surgeon will discuss with you the details of what can be expected afterwards. Most patients should able to go home by the 3rd or 4th post-operative day. If you live alone every effort should be made to arrange for a relative or friend to come and stay at home for a few days.

Day 0
Immediately after the operation you will be taken to the recovery room. The most straightforward revision hip replacements are mobilised on the day of surgery after you are transferred back to the ward. This usually involves just standing out of bed with crutches or a frame with assistance but might involve taking a few paces. On the night of surgery regular checking of pulse and blood pressure is necessary so it is difficult to get a good night’s sleep. Pain relief can be administered in a variety of ways and the anaesthetist will have discussed this with you. Standard practice is to have given a spinal anaesthetic to which diamorphine is added. This method usually gives extremely good pain relief for at least the first 24 hours post surgery. Oral painkillers will usually also be given.

Day 1
Today walking with aids is encouraged under supervision and sitting out for a short period of time is allowed. If walking to the bathroom is achieved, the urinary catheter (if inserted) can be removed. The blood level (haemoglobin) is checked and, if satisfactory, then the drip is removed from the arm. Occasionally a blood transfusion is required.

Day 2
More walking is encouraged with frequent walks up and down the ward. You will be advised how much weight you should take through the operated leg. Stair climbing is commenced in patients progressing on schedule. The wound is checked.

Day 3
Walking distance is increased and stair-climbing practice continues. If performed satisfactorily, and if able to dress and undress alone, then you are ready for discharge!

At home.
Continue to use your walking aids as instructed by the physiotherapist until your 1st out-patient review at 6 to 8 weeks post-surgery. Gradually increase your walking distance as time passes.

Post-operative complications and precautions taken to avoid them

As with any form of surgery there is the potential for complications to occur. However, total hip replacement is not a high-risk procedure and hip surgery is one of the most successful procedures available. The vast majority of patients are delighted with the improvement in the quality of life a new hip provides. None of the complications listed below is common and all precautions are taken to avoid any of them occurring. The risks are slightly higher for a revision procedure than for a primary (first time) operation.

Thromboses & Emboli (blood clots):
To help prevent blood clots forming in the legs calf or foot pumps are applied and early mobilisation (exercises & walking) is encouraged. In most cases the blood is thinned by a subcutaneous injection whilst you are in hospital and then aspirin is given by mouth to reduce the risk of thrombosis. People at high risk of developing a clot will be treated with Warfarin.

Thrombosis in the lower calf veins is not considered to be a major medical problem. Thromboses that occur further up the leg can be dangerous and lead to pulmonary emboli (clot in the lungs). Pulmonary emboli can sometimes be fatal and if a proximal thrombosis is diagnosed you will have your blood thinned with anticoagulants. Do seek prompt medical advice if you experience acute chest pain or start coughing blood up in the early weeks after surgery.

Superficial Infection:
You will not be discharged unless the appearance of the wound is satisfactory. Please inform the Surgeon if you have any problems with healing of the wound in the weeks following your discharge from the hospital.

Deep Infection:
A deep infection of the joint is rare (<0,5% in primary operations, a little higher for revision procedures) but most often starts when bacteria gain access to the tissues at the time of surgery. Great lengths are taken in theatre to reduce the risks of this happening. Operations are carried out in ultra-clean air and you will be given prophylactic antibiotics at the time of surgery. Occlusive clothing is worn by the surgical team. Despite all the precautions taken infections can still occur. Washing the joint out and an extended course of antibiotics may sometimes cure an early infection. However, depending on the type of infection and the microbe involved it is sometimes necessary to remove the new hip and then to attempt to replace another one at further operation after a period of intensive treatment with antibiotics.

An infection can occur at any stage in the life of a hip. The reason for this is that any infection in the body can circulate in the blood & settle on the surface of the implant. Once there it forms its own environment, or “bio-film”, & can thrive. Unfortunately, antibiotics cannot penetrate this film, although they may keep the symptoms under control. Usually the only way to eliminate later deep infections of this type is to remove the artificial implant as described above.

Leg length: It is rarely possible to make the operated leg shorter & sometimes it is necessary to lengthen the leg in order to tighten any slack tissues & improve stability of the prosthetic hip joint. The Surgeons aim for equal length & in the vast majority of cases it is possible to achieve this. A noticeable leg length difference may, however, be inevitable. Small differences may not cause any problems but if the difference is significant it can be corrected by using a shoe insert or heal-raise on the opposite side.

Nerve Damage: Very occasionally one of the nerves that go past the hip can be damaged during the operation. This can cause a foot-drop or paralysis of other muscle groups in the leg. Although the nerve often recovers over a period of months the paralysis can persist.

Swelling of the leg: Some degree of post-operative swelling of the leg is to be expected, as it is a normal response to the operation. Patients are encouraged to continue leg exercises & to lie flat once or twice a day so that their feet are not dependent for long periods. Walking is also helpful but standing unnecessarily should be avoided. If the swelling is accompanied by tenderness in the calf or groin, a temperature or respiratory symptoms, you should ask a doctor to examine you.

Dislocation: Dislocation of the ball from the socket of an artificial joint can occur. The joint is especially vulnerable in the first 8 weeks whilst the soft tissues are healing. Avoidance of the most common potential position of dislocation is useful: Do not bring the knee of your operated leg and the opposite shoulder towards each other.

If the joint does dislocate it needs to be reduced in the Accident & Emergency Department. A hip brace is usually prescribed for 6 weeks to allow the soft tissues to heal again. There is an increased chance, once a dislocation has occurred, of it happening again. Rarely further surgery may be required if the joint recurrently dislocates.

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 occasionally leads to long-term stiffness of the joint.

Urinary problems: Depending on the type of anaesthetic used it may be necessary to introduce a catheter into the bladder. This is occasionally required in the post-operative period for other reasons. In men, especially if there were previous symptoms of an enlarged prostate, the advice of a Urologist my prove necessary.

Medical problems: Complications of myocardial infarction, stroke, chest infection etc. 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 for any particular patient.

Aching in the joint, stiffness, limp etc
The operation of hip replacement requires a degree of soft tissue dissection and there are a group of patients who limp post-operatively. This is less common if a posterior approach to the hip has been used compared with some other types of approach. A very small proportion of patients, for whatever reason, remain less then 100% satisfied with their new hip joint.

Long-term survival of the Exeter Hip: For a straightforward procedure you have over 90% chance of still having the same hip in place & functioning well at 15 years after the operation. This is based on 30 years of experience with the Exeter Hip. If the revision procedure is complex the risk of further surgery if somewhat higher and depends on the details of the reconstruction.

Do not be daunted by the information above which we are required to share with you. The majority of patients who have a simple hip replacement forget, after a while, that they have had surgery at all and lead a fully active, normal life. If you have had multiple previous operations on your hip the final result will depend on what has gone on before. Your surgeon will explain to you what you can expect.