Wrightington -Total Hip Replacement Programme

Blood Clots

• Deep vein thrombosis (DVT) (blood clot in the leg)
• Pulmonary embolism (PE) (blood clot in the lung)

Blood clots can occur after any operation but are more likely to occur following lower limb orthopaedic operations. When these clots occur, a blockage can develop in the veins of the leg causing swelling, pain, and warmth. Swelling in the leg after surgery is very common and can take time to resolve. If there is any doubt, you should seek the advice of your doctor.

A blood clot in the lungs is termed a pulmonary embolus (PE). In rare circumstances (1 in 1000), this can cause death. Symptoms of a PE include shortness of breath, sharp chest pain and blood coughed up in your phlegm.

Preventative Measures

• We now get patients moving as soon as possible following hip replacement surgery, usually on the same day. This has the advantage of increasing blood flow to the leg and maintaining the circulation.
• Your individual consultant will instruct you regarding the use of elasticated stockings whilst an inpatient
• We assess all patients’ individual risk of blood clots, as recommended by the National Institute of Health and Care Excellence (NICE). Following risk assessment, most patients are advised to take blood thinning agents. You will be advised by your doctor or nurse on how to take this medication and for how long; it may be an oral or injectable medication.

Joint Infection

You will be screened for bacteria and methicillin resistant staphylococcus aureus (MRSA) before you come in for your operation to reduce the risk of infections. It is very important that there are no cuts, grazes or wounds on your legs when you come for surgery. It may be worthwhile considering avoiding activities such as gardening for a few weeks prior to your surgery.

We will also encourage you to lose weight, as being overweight significantly increases the chances of infection following surgery. We also encourage smoking cessation, as there is evidence that smoking increases your chances of infection, with the wounds taking longer to heal.

During the operation, you will be given intravenous (IV) antibiotics. Your surgery will take place in an advanced air-flow operating theatre, which helps reduce the bacterial levels.

Deep infection in an artificial joint is a very serious complication. It occurs in about 1% of patients. More commonly, patients can develop an infection on the skin surface, and occasionally, this can progress deeper. We take any infection seriously. If you have had a wound problem, you should always let us know immediately via the Orthopaedic Practitioner helpline using the number from the list at the back of this booklet. If necessary, we will inform your surgeon and arrange for you to be reviewed.

Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust (WWL) currently takes part in Surgical Site Infection Surveillance. This is a structured process developed by Public Health England to monitor post-operative wound infections, with particular attention given to orthopaedics and joint replacements. As a Trust, we monitor all hip and knee surgical procedures, both first time and repeat procedures, for a full 12 month period following the date of operation. As an important part of your plan of care, we need to monitor the progress of your wound. At day 14 after the operation, your wound should be healed. If you have sutures or clips, these will be removed by the Community Nursing Team or the General Practitioner (GP) Practice Nurse.

In the unlikely event that you develop a surgical site infection, your GP or nurse may be already treating the infection, but we would still like to be informed. 

If a deep infection is not treated within the first few weeks, then repeat surgery may be needed. Early treatment can help reduce this risk.

Dislocation of the Joint

Occasionally, following hip replacement, the ball can dislocate from the socket. This can occur in up to 5% of patients. Normally, the hip is relocated with a short anaesthetic.

Occasionally, patients need to have further operations to make the hip more stable.

Joint Loosening

Total hip replacements have a limited lifespan. They are mechanical devices which will eventually wear out. The younger and more active you are, the more likely you are to need a repeat operation in the future. Your surgeon will discuss these risks with you.

Around 90% of hip replacements do not cause problems at 25 years following surgery.

Unequal Leg Length

It is not uncommon after hip replacement to have a difference in your leg length of a few millimetres. In most cases, it is less than 1cm and therefore not noticeable but occasionally, your leg will feel slightly longer or shorter. This can be treated with a “raise” either in or on the heel of your shoe.

Fracture

There are occasions when a bone may break during this procedure. The risk is very low; most fractures are very minor and require no specific treatment. If treatment is necessary, fractures can be treated with plates or wires during your hip replacement surgery.

Everyone gets a routine X-ray check after the operation. In rare circumstances, a return to theatre may be necessary to fix the fracture.

Nerve Injury

There are several nerves located around the hip, and these can be damaged during total hip replacement surgery. These nerves both supply skin sensation and power the muscles in the leg. Normally, the nerves recover themselves over a period of weeks or months. Occasionally, the problems can be permanent and may lead to pain, weakness, and loss of sensation.

Information Resource

The National Joint Registry (NJR) for England, Wales and Northern Ireland collects information on joint replacement surgery. The Registry helps to monitor the performance of implants and the effectiveness of different types of surgery, improving clinical standards and benefiting patients, clinicians, and the orthopaedic industry. Please see their website for further information www.njrcentre.org.uk

Outpatient Clinic

When you attend the outpatients clinic, your name will be added to the waiting list for your procedure. Your consultant will work closely with the Admissions Team and Preoperative Assessment Team to agree a suitable date for your surgery. Once this date has been agreed, you will be notified in writing. You will be encouraged to reduce weight if necessary and stop smoking. These two measures have been proven to lower complications following surgery. If there is availability and you have time, your surgeon will send you for preoperative assessment on the same day as your outpatient clinic appointment. If you have complex medical problems, you may be required to see the Anaesthetist prior to surgery.

Bone Donation

When you attend outpatients and are listed for surgery, donated bone may be requested for use in your surgery. Your Consultant / surgeon will talk to you in more detail if they require donated bone for your surgery.

You may also be asked about bone donation (leaflets available), as we have a Live Bone Donation Programme; to be part of this, you will need to complete a Medical History Questionnaire and sign a consent form.

Preoperative Assessment

It is essential that you attend this appointment.

During this visit, you will undergo assessment to ensure you are fit for surgery. You will undergo simple checks on your heart and lungs and have blood tests taken. Skin swabs will be taken to test for MRSA. You may require an X-ray and will be asked questions about your medical history. It is important that you bring any relevant documentation and list of medications to this visit. If you are on blood thinning tablets e.g. aspirin, warfarin, clopidogrel or dipyridamole, please inform the nursing staff, as you may have to stop these before surgery. This would only be under the direction of a doctor.

If you have a long-term illness of the heart or lungs, or a metabolic condition (e.g. diabetes, thyroid), an Anaesthetist will examine you to ensure you are fit for surgery. It may be necessary for you to be seen by a specialist if you have a more serious health problem. If you are not considered fit for surgery, the operation will be cancelled. You will receive an outpatient appointment with your consultant, who will discuss alternative treatment options.

Please tell the doctor or preoperative assessment nurse if you are already taking the above medications for other reasons, or if you are taking another medication called pregabalin.

Therapy Preoperative Education

It is important that you attend a therapy preoperative education assessment if you are invited. If you have specific concerns around equipment or managing after your operation, please call us. Therapy preoperative education assessments are either a group session or telephone consultation when invited. You will be provided information on:

• how to prepare for having your hip replaced
• what to expect during your hospital stay
• how to carry out daily living tasks immediately after your hip replacement and
• what to do once you are at home

A member of the therapy team will also be available to assess social circumstances, discuss your home environment and any areas of need in daily living tasks. This way we can pre-empt any problems, to enable your discharge from hospital to run smoothly.

It is important to practice the exercises shown to you at the education class. This will strengthen your muscles and aid recovery.

How long will I be in Hospital?

You will only be discharged home when you are medically stable and can manage safely. There is a range of discharge dates; most patients will be discharged on the day of their operation (day 0), with most people going home the following day.

Admission

The day you are admitted will be the day you undergo surgery. Please follow the fasting guidelines, which you will have received from the preoperative assessment clinic or in the letter you receive from our admissions department.

Reminder: Please ensure you have a bath or shower before you arrive at the hospital. We need you to be as clean as possible to reduce the risk of infection.

It is also important that you do not apply creams or make up after your bath or shower. If you shave your legs, please do not shave for at least three weeks prior to the operation. Shaving is known to increase infection rates in joint replacement, unless conducted immediately before the operation. It is not known whether hair removal creams increase infection risk, so these are best avoided.

You will normally be admitted on the morning of your surgery to Ward D or to the Orthopaedic Admissions Unit (OAU) at Wrightington Hospital. Following your operation, you will be transferred to one of the orthopaedic wards.

Please do not bring too many possessions into hospital with you, as storage space is limited. Bring well-fitting comfortable flat shoes and slippers to walk in. There may be some swelling in your foot after your surgery, therefore consider this when selecting suitable footwear; shoes without backs are not recommended. If your hip replacement is undertaken in the morning, we would anticipate that you would be up and walking and dressed in normal clothes the same day.

On admission, the final checks prior to surgery will be undertaken. If your temperature is low, you may be warmed using blankets, as this has been shown to minimise the risk of infection. Occasionally, delays in theatre or unexpected changes to the operating list may mean you have to wait longer than anticipated. If this happens, you may be offered a drink after discussion with your anaesthetic team. You may wish to bring reading material with you.

Recovery

From the operating theatre, you will be transferred into the recovery ward. The staff here will:

• Check your general condition
• Take your observations: pulse, blood pressure and oxygen levels
• Check your wound dressing
• Monitor your spinal anaesthetic
• Assess your pain control

Your surgeon may request an X-ray of your new hip.

After a short time, you will return to your ward. The ward staff will continue to monitor you and make sure you are comfortable.

Pain Relief

You will have regular pain relief prescribed. If you feel your pain relief is inadequate at any time, then you must let the ward nurses know. We also have a dedicated team of pain nurse specialists who may come to see you after your operation.

Exercises

It is essential that you commence the following exercises as soon as you can after your operation, and whenever you are resting, so as to help prevent blood clots.

Ankle Exercises

These should be done every hour for approximately 5 minutes or longer if possible. This helps maintain the circulation in your calf muscles. If you experience any pain or tenderness in the calf, please contact the nursing staff immediately. You may not initially be able to do the exercises until the spinal anaesthetic has worn off. This is normal and the movement will return in time.

Deep Breathing Exercises

This helps to keep your chest as clear as possible. Take 3 or 4 deep breaths. Try to breathe as deeply as possible, and after the last breath, try to “huff” out the air. This may stimulate a cough. Some people may experience a productive cough after anaesthetic.

Movement Restrictions

You can move in any way you find comfortable after your operation; however, do not force movement if painful, and avoid taking your hip into extreme positions for the first 6-12 weeks. For example, we would advise that you exercise care and caution when taking your hip into a deep bend. We advise you not to cross your legs until the 6-week mark.

In some circumstances, you may be asked by your surgeon to limit some movement, due to individual factors relating to your surgery. This does not mean that anything has gone wrong; it may be your surgeon’s preference if he feels the new joint needs extra protection over the first few weeks. This will be clearly explained to you.

Mobility

As a rule, you will be allowed to walk either the same day or the day after your operation. Do not worry if this is not the case for you. You will be told as soon as possible when you will be able to get up.

You will be instructed on the use of crutches / walking aid, and the correct way to walk. Once assessed by the Therapy Team, you may walk with another member of staff. The aim is to help you regain independence with the crutches / walking aid as quickly as possible.

However, it is important to understand that everyone is different, and that the appropriate amount of help will be given to you according to your needs.

Day of Surgery (Day 0) – on the Ward

You may be encouraged to get up for a few hours after your return to the ward. This will initially be with the help of the Therapy Team and nursing staff, who will show you how to walk.

The walking sequence should be:

• Move your walking aid
• Step forwards with your operated leg
• Step forwards with your un-operated leg

You will then be encouraged to sit in a chair and wear day clothing. You will also be encouraged to return to normal functioning, including completing your exercises independently throughout the day.

Post-operative Day 1

You will be encouraged to be as independent as possible.

You will usually get dressed into your normal clothes. Please bring easy-fitting clothes and well-fitting slippers when you are admitted.

You will attend to your own personal hygiene and continue with regular moving and leg exercises.

You may take routine pain relief and your usual medication.

You will be visited on the ward by the Therapy Team, including weekends.

They will complete assessments to ensure you are independent with daily living tasks, such as getting in/out of bed, getting dressed, sitting/standing safely from your chair, and using the toilet with or without equipment

You will continue to practice walking with crutches / walking aid until independent

You will practice stair climbing if necessary

You will go for a check X-ray if this has not been done already

Remember: It is important you also exercise independently.

Discharge Criteria

However long your hospital stay, you will need to meet several goals before you are discharged home:

Aquacel wound dressing must be intact; this should remain on until Day 14 after surgery. You may shower with this dressing in place

Walking independently with crutches / walking aid

Getting in / out of bed and on / off the chair / toilet by yourself

Being able to get up / downstairs if required at home

Having an X-ray of your new joint

Having all the equipment / help necessary at home

You will be contacted by telephone at around Day 3 following your discharge from hospital by the Therapy team to check your progress

Getting In and Out of a Car

• Ask your driver to push the seat all the way back and recline it slightly
• If needed, use a small cushion to make the seat level
• Put a plastic bag on the seat, as this can help you slide and turn into position
• Back up to the car until you feel it against the back of your legs
• Carefully lower yourself onto the seat, keeping your operated leg straight out in front of you as you sit down
• Slide across the seat towards the handbrake, to give you sufficient room to get your legs into the car
• Turn towards the dashboard, reclining backwards as you lift your operated leg into the car
• To get out of the car, reverse this procedure

Follow-up

Although you have been discharged from hospital having made satisfactory progress following your operation, we are still here to support your recovery should you need us.

If you have any concerns regarding your recovery, or if you think you may be developing a problem, please contact the helpline. It is particularly important that you contact us if you are concerned about your wound.

Monday to Friday: 8am until 4pm

Orthopaedic Practitioner team: 01257 256372

Therapy Helpline number: 01257 488282 (answerphone)

Out of these hours, please contact the ward where you had your operation

Orthopaedic Admissions Unit (OAU): 01257 256219

Ward D:....................................................................................... 01257 256269

Ward A:....................................................................................... 01257 256276

Ward B:....................................................................................... 01257 256277

John Charnley Unit..................................................…………….01257 256265 / 256267

Reminder: please seek advice if you notice any excessive bleeding, or any difficulty with breathing. If you become urgently unwell, please call 999.

You will also have a clinic appointment approximately 6-8 weeks after your surgery. You will often be seen by the Orthopaedic Practitioner at this point. This is to ensure you are progressing well and to answer any questions you may have. If for any reason you do not receive an appointment through the post, or if you have a problem with your Outpatient appointment, please contact us on the telephone numbers above.  

You will not routinely have a physiotherapy follow-up appointment unless your surgeon feels that you require some specific therapy. It is important to continue your exercises at home.

Once at Home

Please remember you have undergone major surgery, and your recovery can take up to 12 months. It is important that you follow these guidelines when you return home:

• Continue to take painkillers as prescribed
• Use both crutches when moving. The length of time these are needed may vary and could be up to 12 weeks. Your healthcare practitioner or surgeon will inform you of how long to remain on both crutches. When it is time to gradually wean yourself off your aids, do so as your leg becomes stronger, and your confidence increases. If you are using two crutches / sticks and you wish to try with one, always use it on the opposite side to your operated leg
• Gradually try to increase your walking distance. Walk frequently throughout the day