The Operation
Once the decision has been taken to perform a total hip replacement, it is not just a matter of turning up on the day and allowing everything to happen. What occurs preoperatively, and immediately postoperatively, is as important as the operation itself.
Preoperative Assessment
Many surgeons run preoperative assessment clinics to assist in assessing the condition of the patient as a whole. There may also be an associated anaesthetic assessment clinic where more severe non-surgical problems are considered. The kinds of checks included in a preoperative assessment vary, but some of the commonest are as follows:
- Haemoglobin level (blood count)
- Blood cross-matching
- Electrocardiogram (ECG/EKG)
- Urea and electrolyte estimation
- Urine testing
- XRays (chest and hip)
Thought should also be given preoperatively about what is going to happen post-operatively. What facilities does the patient have at home? Will family and friends rally round in support or is it necessary to book a convalescent home? What kitchen and bathroom aids exist at home, if any? Is there a steep, winding staircase leading to the bedroom, implying that the patient's bed should be brought downstairs for a few weeks once they have returned home? There are many questions to be asked before hip replacement surgery. Don't wait until you arrive in hospital to ask them!
Admission to hospital is normally either the day before surgery, or even on the day of the operation itself. The attraction of coming in on the day of surgery is that it allows a patient to remain in the familiar surroundings of their home environment right up to the last minute.
The Operation
In most modern operating theatres, anaesthetics are administered in an anaesthetic room immediately adjacent to the operating theatre. Assuming that a general anaesthetic has been chosen (hip replacements can also be performed under local anaesthesia), the process of putting a patient to sleep is called induction. For this, only a small needle need be used. Once the patient is safely asleep, the anaesthetist will then be able to pass a breathing tube (endotracheal tube) to control breathing throughout the operation.
Once asleep, the patient is wheeled by trolley into the operating theatre, lifted onto the operating table, and positioned accordingly. In this practice the patient is positioned on their side, but in some practices the patient may be supine throughout the operation. The surgical team then scrubs up, dons their gowns and surgery commences. Before any surgical instrument is used, however, it is essential that the patient's skin is cleaned. A special solution is used to kill all skin bacteria. However clean we think we are, it is a sad fact that the normal human skin surface is crawling with the little beasts. It is vital they are killed before surgery begins, otherwise there is an increased risk of the hip replacement becoming infected. This process is called skin preparation and is followed by the application of surgical drapes. Once they are in position the operation proper begins.
Many people are involved with a hip replacement. As well as the surgeon performing the operation, there may also be a surgical assistant standing opposite him. Occasionally there can be two assistants, and sometimes three! The assistants' job is to help with tasks such as patient positioning, tissue retraction, blood vessel coagulation, stitch cutting, and the like. A theatre sister hands the instruments to the surgeons - a good sister will not even need to be asked what instrument is required next. She (or he) will be so experienced that the operation will be second nature. Helping the theatre sister is a circulating nurse (sometimes called a runner) and helping the anaesthetist will be an operating department assistant (ODA). Added to these individuals will be recovery nurses, instrument cleaners, auxiliaries, and administrators. At the last count a primary hip replacement required fourteen separate individuals within the theatre complex alone, few of whom the patient ever sees, or is aware of.
A typical operating time would be approximately 90 minutes from first incision to final skin closure (skin-to-skin time in the trade). However, due to anaesthetic and recovery, the time away from the ward may be much greater (as much as 3 hours, or more). For relatives waiting for news this can be a worry, so be prepared for a long absence of your loved one before information is available. It does not mean anything is going terribly wrong! Full operative details will not be given here, though can be found in the book mentioned on the Introduction page.
After The Operation
Once the final skin stitch, or staple, is inserted, the patient is transferred from the operating table to bed. It is usual at this stage for the leg to be held in some form of immobilising device. The simplest and most widely used of these in an abduction pillow. This is a triangular pillow that is placed between the patient's legs to hold them apart. This abducted position is the most stable position a hip can adopt.
Mobilisation normally begins on the first or second postoperative day. Surgical drains are generally removed after twenty-four hours, though in some cases may remain in place until forty-eight hours. Blood tests may be undertaken at 48 hours and prophylactic treatment may also be given to reduce the chances of thrombosis forming in the calf veins. This can take the form of stockings, anticoagulants, or even simple aspirin. There are many different ways of tackling the thrombosis issue. Antibiotics may also be given, though are normally provided in a few high intravenous doses to cover the period immediately surrounding surgery.
By the seventh postoperative day the patient is normally ready for discharge, though may occasionally stay in hospital for as long as ten days. In some countries the total length of stay can be as little as three to four days. Hospitalisation time has dramatically reduced in recent years.