By John Irving, M.D.
Dr. Irving currently uses a direct anterior (or frontal) approach for most total hip replacements. He has been using this approach or a variation of it since 1995, starting with cemented hip stems. The anterior approach uses a 3 -5 inch incision near the groin, almost in the seam or pleat line of slacks. This way to do a total hip has been said to be the least invasive way to do the operation. Both parts of the hip replacement, the stem and the cup, can be precisely placed through this one incision. Most of the time no muscle is cut or released during the operation which minimizes post-operative discomfort while allowing a very fast return to normal lifestyle, work and recreational activities. Pain is low level after this hip replacement with patients requiring minimal narcotic use for 2-3 weeks afterward. The risk of the hip coming out of joint or dislocating in the early post-operative period is certainly reduced with this approach. When used with contemporary uncemented hip stems, patients can be up walking the same day as surgery. While some younger healthier patients can go home the day after surgery, the usual hospital stay is 2 days. Patients, who for safety and social reasons, elect to go a rehab center will stay in the hospital 3 days.
Patients initially use a walker or crutches. They are instructed on the use of a cane while hospitalized to be safe, comfortable and confident getting in and out of bed, on and off a toilet and up and down stairs. Because the femoral stem of implant is uncemented, and because a patient has just had major hip surgery, the leg must be protected for a short period of time. Dr. Irving asks patients to use the walker or crutches for a week post-operatively then progress to a cane. Patients usually can wean themselves off of the cane by 3 to 4 weeks after the operation. Still, some discomfort can persist as the healing process matures. Golf and other recreational activities can be attempted after 4 weeks.
Dr. Irving pioneered a 2-incision total hip approach which was used extensively between 2000 and 2008. He lectured on, demonstrated and taught this surgery to hundreds of surgeons from around the world. This operation incorporated a small portion of the anterior approach to place the socket and a small part of the standard posterior approach to place the hip stem. The introduction into the US of newer more compact uncemented hip stems allowed the hip replacement to be done again via one anterior incision. But, this is an operation Dr. Irving still uses for certain complex hip cases, especially revisions.
Less than 10% of patients undergoing a hip replacement need a blood transfusion, or have any kind of blood clot and the infection rate is well below 1%.
Total hip replacement is one of the best orthopedic reconstructive operations done today. Patients can return to most activities and live a normal life. The direct anterior approach is one option to help with an accelerated recovery.
By Shannan Hardy MSN, APRN
You have had your surgery, you have undergone rehabilitation and you’re back on your feet. When and how will your life begin to resemble your pre-surgical life? You will soon be able to begin to resume many activities that were too painful before surgery. Recovery from total hip replacements and total knee replacements is different in several ways. Hip replacement patients recover more quickly than knee patients. This includes the length and type of rehabilitation, how quickly you will return to your desired level of functioning and the activities that are in the realm of possibility for you in the years after your replacement.
The first few weeks or months can be frustrating and uncomfortable, with the reality of just having had surgery. This is especially true if you have preconceived notions of how fast you should be independent that might not be true. Continue to follow the directions of your surgeon and your therapists. This stage is time limited and the more effort you put into your immediate recovery, the more you will get out of it. If a single joint is replaced you probably will be done with a walker, crutches or cane by a month give or take after your surgery.
During the first year, you should steadily regain strength and flexibility in your total joint. If you adhere to your exercise program and stay active, your artificial hip or knee will show steady and ongoing improvement. Just as every person is different, every recovery is different. Don’t compare yourself to your spouse, your friend or a co-worker that had a similar surgery. It’s important to have realistic expectations about your new total joint. You shouldn’t expect your total joint to function exactly the same as it did earlier in life, before you had arthritis. They are good joints, not normal joints. For example, knees may not bend as much as original knees and it may not be as comfortable to kneel. Hips may not be quite as flexible as they once were or be able to withstand extremes of rotation.
Some experts say that high impact activities such as running, jogging, court sports, and contact sports should be avoided. Most surgeons say that what a patient can do after surgery is directly related to their level of functioning prior to surgery, their exercise or sports history and how vigorously the patients participate in rehabilitation. Realistic activities following total knee replacement include unlimited walking and gym exercising, swimming, golf, hiking, biking, ballroom dancing, and other low-impact sports. However patients who work hard with physical therapy, especially on muscle strengthening and mobility, can ski, skate, play hockey, do extreme yoga and play doubles and even singles tennis!
The goal of a total joint replacement is to relieve pain and increase mobility thereby improving safety, lifestyle and independence. Successful patients are compliant, have a strong desire to continue to lead an active life and will make short term sacrifices for long term gain. Please remember, it takes at least a year for your body to completely heal and rehabilitate from a total joint! Occasional discomfort, clicks, pops, stiffness and swelling can continue for a time after surgery. You will have more good days than bad days, as time goes on. If you have questions regarding your joint replacement or are thinking about having a joint replacement but are concerned about activity afterwards, please don’t hesitate to ask your surgeon or the staff.
Q: How long do I have to wait to drive?
A: If your left hip or knee was replaced and you have an automatic transmission, you may be able to begin driving in 1-2 weeks or so, provided you are no longer taking narcotic pain medication. If your right hip or knee was replaced, avoid driving for at least 3 weeks. Remember that your reflexes may not be as sharp as before your surgery.
Q: When can I have sex after total joint surgery?
A: Sexual activity can be safely resumed approximately 2 - 4 weeks after surgery. Some caution and creativity is recommended.
Q How soon can I fly after surgery?
A: As soon as you are comfortable with sitting down, you can fly. Usually, 1 -2 weeks is the depending on your mobility. You will be on a blood thinner for 3 weeks after surgery. During flying or driving on long trips, exercise your calf muscles and ankles frequently. Also, get out of the seat and walk the aisle of the airplane, and stop to walk around your car every hour to avoid the possibility of blood clots. Take the blood-thinners prescribed after surgery to reduce the risk of blood clots and wear your white anti-embolism stockings. If you can take aspirin, consider taking 325mg daily if traveling long distances by car or airline for the first 3 months after your total joint.
By Christopher B. Lynch, M.D.
Although surgery itself can be a significant source of stress for patients about to undergo a joint replacement, many patients seem to have more apprehension about the anesthesia than any other aspect of the procedure. The fear of going to “sleep”, trusting they will ultimately “wake up” and not having control of the situation during the procedure weighs heavy on some patients.
Most patients still believe, however, that anesthesia for routine total joint replacement involves general anesthesia. This is a method of anesthesia, still utilized in many other surgeries, that involves receiving one or more of several potent sedatives, a complete body paralytic (paralyzes the entire body including the diaphragm which allows you to breathe on your own) and placement of an endotracheal tube through your mouth and throat into your lungs so a machine can breathe for you during the procedure. Fortunately for the majority of routine joint replacement surgeries, general anesthesia is no longer required, nor is it recommended.
One of the greatest advances in joint replacement surgery in the last few decades has been the utilization of regional anesthesia rather than general anesthesia. Regional anesthesia involves the isolated “numbing” of specific nerves and nerve distributions that receive pain sensations from the lower extremities (legs), allowing the surgery to be performed without “going to sleep”. No intubation is required.
For hip replacements my standard anesthesia protocol includes a small amount of pre-operative “relaxation” on the way to the operating room and a spinal performed by our team of anesthesiologists once in the operating room. A spinal is a single injection of a local anesthetic into the spine that very quickly and completely numbs, and temporarily paralyzes, the lower extremities from the waist down. This block typically wears off after about 3hrs or so. This allows me time to prepare and position you for the procedure, perform the surgery and get you to the post-op care area pain- free. Motor and sensory function to your legs will return while in the post-anesthesia care unit, and when it does, we move you up to the floor to start you walking with all your weight on your new hip.
For partial and total knee replacements, in addition to the protocol mentioned above, patients also receive an injection into the upper thigh called an adductor canal block that additionally “numbs” only the sensory (not motor) pain fibers of the thigh and knee. A fishing wire- thin catheter is also placed at the same time into this adductor canal by the block team. This is currently done in the pre-operative holding area prior to heading into the operating room. Placement of the catheter allows for 24-48hrs of continuous dosing of pain controlling anesthetic to the knee and tissues surrounding the knee. During the procedure two additional long acting local anesthetics are injected into the areas around the bone, tissues and skin as an additional way for me to help control the early post-operative pain. Like the anesthesia utilized in the hip, the spinal wears off after 3hrs or so, and at that point we begin to get you mobile on the orthopaedic floor.
Although, there are still situations in which general anesthesia is recommended or required in joint replacement surgery, such as an extended lumbar spine fusion where there is no access to the nerves in the spine, this use of regional anesthetic has all but made the use of general anesthesia obsolete in joint replacement surgery. Patients are given the option of receiving sedation during the case and literally taking a nap or, if they wish, being completely awake and aware of everything that’s taking place in the operating room. Currently most patients are choosing the “nap”.
Theoretic benefits of the regional blocks also include less post-operative nausea and grogginess, decreased blood loss, decreased risks of blood clots, decreased use of narcotics in the early post-op period and quicker recovery due to decreased pain. It is my opinion that the best thing to happen to joint replacement surgery in the last 2 decades has less to do with custom implants or instruments, navigation or surgical technique, but more to do with these continued advances in peri-operative anesthesia and immediate post-operative pain management.