Total Hip Replacement-Anterior approach
Hip replacement surgery, regardless of the approach, involves placing a new ‘cup’ into the hip’s existing arthritic socket and replacing the hip’s ‘ball’ with a new prosthetic one that sits inside the bone.
When the surgeon does this by approaching the hip through the front of the joint, it’s called the direct anterior approach (DAA). The total recovery takes at least 12 months, but we will have you walking on the day it’s performed. Most patients can walk without sticks by 4-6 weeks.
The hip joint is composed of the ball (femoral head) and socket (acetabulum). These are both covered in joint cartilage which cushions joint and helps glide and move freely. Hip osteoarthritis means that this cartilage has worn away, leaving bone rubbing on bone. This can cause significant pain and stiffness which limits daily activity.
When the surgeon does this by approaching the hip through the front of the joint, it’s called the direct anterior approach (DAA). The total recovery takes at least 12 months, but we will have you walking on the day it’s performed. Most patients can walk without sticks by 4-6 weeks.
It’s important to discuss your thoughts with the surgeon to weigh up the pros and cons.
The approach used is based on many factors including age, bone strength, bony anatomy, and muscle mass.
It has been well publicised that anterior hip replacement surgery can lead to quicker recovery, but this is not in all patients. The risk of some complications that can seriously slow recovery time are higher in the anterior approach.
A Total hip replacement surgery is rarely an urgent surgery and results are generally better with proper preparation.
It is vital that you work with your Physiotherapist and/or Exercise Physiologist to maximise your range of motion and hip strength PRIOR to surgery to be prepared for the rehab and recovery. Our MTP Health Hip Program is designed specifically for this.
It is important to consider the rehabilitation and recovery time from the surgery and what effect the timing of surgery will have on:
- Family events and holidays
- Work trips or busy periods
At MTP Health, we take your preparation for surgery very seriously. It is our policy to prepare you over a minimum period of 4-6 weeks in order to ensure that you get the best outcome through being psychologically prepared, physically strong and medically safe enough to undergo this procedure.
These tests will include -
- Planning imaging including a CT scan and functional x-rays
- Routine blood tests
- Swabs for MRSA
If there are any specific concerns or medical issues, we will ensure that they are optimised prior to the surgery and to do this we will also organise for you to be seen by:
- A Cardiologist to ensure there are no issues with your heart during the anaesthetic
- Any other of your treating physicians e.g.: for your diabetes or lung conditions
Finally and importantly, we will help you to get strong:
- Our team of Physiotherapists and Exercise Physiologists will assess your level of function
- You will be given a personally designed program in the lead up to your operation to make sure you are ready to start recovering as soon as you wake up from the anaesthetic
Please see the “Preparing for surgery” for more detail.
We need to know about all your medications but especially those for diabetes, blood pressure or blood thinning as we may need you to stop some or all of them up to 1 week before surgery. It is highly recommended that if you are a smoker, that you refrain from smoking for as long as possible prior to surgery to ensure the best outcomes.
You must ensure that your hip area remains free from scratches in the weeks before surgeries - NO LAST MINUTE GARDENING. If this occurs, please tell us as it increases your infection risk and your surgery may need to be delayed. This can happen in the anaesthetic bay if we don;t know about it beforehand. If not sure, send us a picture.
The hospital will contact you in the week of surgery and they will confirm with you on the day before your surgery, the time you need to arrive and when you need to start fasting.
For our patients, if you are on a morning list you need to stop all food from midnight and stop clear fluids from 0530or 2 hours before the planned start of the list, whichever comes first.
For afternoon lists that time is 11am.
Acceptable clear fluids include water, ‘see through’ apple juice with no bits or ‘see through’ energy drink such as gatorade. It does not include milk or cloudy juice with bits.
You will arrive at the hospital between 1 and 2 hours before your surgery. You will have your hip area prepared by a nurse who will shave the skin and paint on a coloured antiseptic solution. You will then meet one of our anaesthetic team.
They will make sure you are comfortable and safe during the procedure.
Before your anaesthetic, your surgeon will see you and ask you “Which JOINT and What SIDE?” This is critical as they will then check this matches your consent form and draw an arrow on the hip that you specify and point to. This is the most effective way of stopping ‘Wrong Side surgery.”
At the start of the procedure you are transferred from your nice warm bed to lie on your back on a hard and cold operating table - apologies in advance. The most common anaesthetic for a joint replacement surgery is a spinal block with a light general anaesthetic. This means you will be asleep. A urinary catheter is placed before the operation but this will be removed in recovery in most cases. The Surgical team then performs the “Time-out” procedure to Double check that your name band, imaging and the arrow drawn on your hip all match with your signed consent form.
The surgery is performed through a cut approximately 15cm long on the front of the hip joint, overlying your outer, upper thigh, immediately below the crease where your lower belly meets your thigh.
Hip replacement surgery, regardless of the approach involves placing a new ‘cup’ into the existing arthritic socket of the hip joint and replacing the ‘ball’ of the hip joint with a new prosthetic one that sits inside the bone.
At the end of the procedure the incisions are injected with local anaesthetic, sutured with dissolvable sutures and then glued to provide a strong waterproof closure.
The surgery takes between 90 minutes to 2 hours on average with additional time before for anaesthetics and after for recovery. For the waiting relatives or partners, it is usually between 3-5 hours from leaving the admissions area to getting back to the ward.
After the operation, you wake up in the recovery room, where you are monitored for approximately 1 hour. During this time, your surgeon will call your relative. It is important that they realise that this may be more than 4 hours from the time you were ‘taken into the operating theatres’ due to waiting and preparation times.
Once stable, you can be transferred to the ward to begin your post-surgical recovery. The hip replacement that has been placed is strong enough for you to walk on it straight away with all your weight and the team will have you walking within 4 hours of waking up. If you are light headed or nauseated, they will help you to stand and march on the spot.
WALKING - The hip replacement that has been placed is strong enough for you to walk on it straight away with all your weight and the team will have you walking within 4 hours of waking up. If you are light headed or nauseated, they will help you to stand and march on the spot. You are encouraged to bend it as much as you can tolerate.
DRESSINGS - You will have a waterproof dressing that you should leave on until you have your wound check at 10-14 days. It is common for a small amount of ooze to dry into the dressings over the first 24-48 hours..
You can shower with this dressing but avoid soaking in the bath, a pool or the ocean. If it comes loose or gets soaked, please replace it. We do not allow hydrotherapy within the first 3 weeks of joint replacement surgery until the wound is healed and watertight.
GAME READY - If you have been supplied with a Game Ready machine, we advise that you use it on program 2 or 3 and for up to 2 hours at a time. You can use it as often as you like in a day as long as you manage to complete your rehabilitation exercises. If your pain and swelling are well controlled then you don’t need to use it. When supplied by Jointworks you have the Game Ready for 2 weeks. At the end of this time it will be picked up by a courier unless you want to continue to rent it yourself.
LENGTH OF STAY - We call the day after surgery ‘Day 1 post surgery.’ Your aim on this first day is to pass all your discharge tests from the hospital physiotherapists and plan for going home. We will organise an x-ray of the hip if not done in recovery and a blood test to check for blood loss and kidney function. It is safe for some to go home on the same day of surgery but more usually, patients stay overnight and possibly a second night.
SURGEON FOLLOW UP
Your first post-operative visit will be with your surgeon at 2 weeks. This appointment is critical for checking your wound healing and to assess your new hip as well as to answer any questions you may have.
Further follow up with your surgeon with x-rays at some visits to check the prosthesis -
- 6 weeks after surgery + XR
- 12 weeks after surgery
- 6 months after surgery
- 1 year after surgery and annually ongoing + XR
Your recovery starts the minute you are awake from the anaesthetic.
You start with the simple exercises including ‘Pumping’ your calf muscles to encourage blood movement through the legs and contracting your thigh muscles to squash the back of your knee into the bed.
The Physiotherapist will assist you in getting out of bed and sitting out in a chair. A walking aide such as a tall walking frame is used to help you balance initially and this is progressed quickly to a smaller frame and then crutches, as shown in the MTP Surgical Journey Workbook.
Your job is to get the Physiotherapists to sign you off as ‘READY FOR DISCHARGE HOME’ on DAY 1 which needs you to be safe on crutches and able to climb stairs.
Your main focus in the first 2 weeks following the operation is to take the painkillers you need to be able to do your exercises that will help you strengthen up your leg muscles again.
Most patients do not need inpatient rehabilitation services but they are very useful for those that live alone or have many stairs to get into their house. We have many options for helping you to successfully rehabilitate at home and we will go through all these in your preparation sessions.
Two weeks following the operation, we will examine your surgical wound and ensure that it is healing well. The dressings can then be removed, and you will be able to shower without covering the wound. The sutures are dissolvable and will not need to be removed.
Six weeks from the operation, we will ask you to get an x-ray where we can check that the prosthesis is still secure and functioning well.
Return to work and sport depends on your line of work, recovery speed and reliance on transport.
Returning to work
Office jobs can be restarted as soon as you are comfortable and no longer taking strong painkillers. Although sitting for long periods may be uncomfortable, there are no restrictions on doing so. It takes longer to return to more physically demanding jobs for healing and safety reasons. Activities such as climbing ladders and carrying heavy loads are to be avoided for 12 weeks.
Returning to sport
Return to sport is a gradual process that is guided by your pain levels and recovery progress with physiotherapy. It also depends on the activity you wish to return to. Swimming, for example, can be restarted when the surgical wound has healed and you are comfortable (usually after 3 weeks), though it’s best to do this supervised or in water you can stand in initially. Returning to more intensive sports – such as bush walking or golf – is gradual and may take up to 6 weeks. It is not recommended that you run on any hip replacement unless previously discussed with your surgeon.
Returning to driving
It is recommended that you do not recommence driving until you can safely perform an “emergency stop” and are no longer taking strong painkillers. On average, this is at least 4 weeks from a left hip replacement 6 weeks from a right hip replacement. Please check with your surgeon and your car insurance company.
Hip replacement is a safe procedure when well planned but there are always some general risks with joint surgery.
The surgical complications include the general risks of:
- Blood clots (DVT/PE) in the veins
- Infection
- Injury to blood vessels
- Injury to nerves - sciatic or femoral nerves
- Sciatic nerve damage can cause ‘foot drop’ and numbness.
- Femoral nerve damage can cause weakness of thigh muscles and numbness
- Damage to the bone including fractures
Specific surgical complications relating to hip replacement include:
- Leg length discrepancy - the operated leg can be made longer or shorter during the operation. This is generally less than 5-10mm and this is well tolerated by most and may need just a small insole to manage. In some cases the difference can be up to 25mm.
- Dislocation - this describes the ball of the hip coming out of the socket. This usually requires a trip to hospital to have it put back under sedation.
Specific to the Anterior approach to the hip:
- The most common risk is bruising or stretching of a nerve that supplies the sensation in the outer part of your upper thigh. This damage can result in numbness over that area of skin. It usually gets better over time, but in some cases it remains permanently numb. It does not cause any muscle weakness
- The femoral nerve can be damaged by retractors more commonly in this approach and this can lead to weakness in the quadriceps muscle - straightening the knee. The risk of this is less than 1in 100.
Other uncommon complications include anaesthetic risks of allergic reaction to medications, heart damage, lung damage, stroke and death.