Hip Replacement Consent
Total Hip Replacement
The hip joint is a ‘ball and socket joint’, and is a very important joint as it allows a great deal of movement but is also weight-bearing. As a result of this, it is often prone to ‘wearing away’. This is a simplified reason as to why arthritis occurs. Arthritis can be a very painful disorder, causing you to slow down walking or even stop you from sleeping.
During a total hip replacement, the severely damaged hip bone is replaced with an artificial ball (mounted on a metal stem) and socket that does the function of the natural joint.
The aim of the surgery is to reduce the pain in your hip joint, allow you to move more easily, and improve your quality of life.
If however you decide not to have surgery, there are alternative ways to reduce the pain, which you may have already tried. These include:
- Weight-loss
- Stopping strenuous exercises or work
- Physiotherapy and gentle exercises
- Medicines, such as anti-inflammatory drugs (e.g. ibuprofen, steriods)
- Using a stick or a crutch
What happens during the surgery?
During the surgery you will be asleep (with a general anaesthetic) or remain awake but be completely numb from the hips down (spinal anaesthetic). If you have an spinal anaesthetic, you will not be able to see the surgery, but may be able to hear what is going on.
Before the surgery begins your skin will be cleaned with antiseptic fluid, and clean towels (drapes) will be wrapped around the hip.
In order to remove the arthritic bone, we make a cut in the skin, fat and muscles which lie in the way of the hip bones. The thigh bone (femur) and socket (acetabulum) are cut away, and the new replacement stem, socket and ball are secured in their place.
When the Surgeon is satisfied with the position, the wound is closed with stitches under the skin, and metal clips on top. Dressings are then applied.
Are there any risks or possible complications of the surgery?
As with all procedures, there are some risks and complications that may result following the surgery, some are more common than others. Here we discuss these individually.
COMMON (2-5%)
Blood clots
A DVT (deep vein thrombosis) is a blood clot in a vein. These may present as red, painful and swollen legs. The risks of a DVT are greater after any surgery (and especially bone surgery). A DVT can pass in the blood stream and be deposited in the lungs (causing a pulmonary embolism – see below). This is a very serious condition, which affects your breathing. To limit the risk we give you medications (tablets or as an injection) to thin the blood, and ask you to wear stockings on your legs to keep blood circulating around the leg. Starting to walk and getting moving is one of the best ways to reduce the risks of blood clots from forming.
Bleeding
This is usually small and can be stopped in the surgery. However, large amounts of bleeding may need a blood transfusion or iron tablets. Rarely, the bleeding may form a blood collection or large bruise within the wound which may become painful and require surgery to remove it.
Pain
The hip will be sore after the surgery. If you are in pain, it is important to tell staff so that pain medicines can be given. Pain will improve with time. Rarely, pain will be a long-term problem.
Prosthesis wear
The mean lifespan of a Total Hip Replacement is over 15 years. However some implants last significantly less. The loosening reason is often unknown. If it is due to an infection, this may require implant removal and revision surgery
Altered leg length
The operated leg may appear shorter or longer than the other. This rarely requires surgery to correct the difference, or may require shoe implants.
Joint dislocation
The new hip is less stable than your original hip. If the hip does dislocate, the joint may be put back into place without the need for surgery. If not, surgery is required and a hip brace is worn. Rarely if the hip keeps dislocating, a revision surgery may be necessary.
LESS COMMON (1-2%)
Infection
You will be given antibiotics just before and after the surgery and procedure will be performed in sterile conditions with sterile equipment. This is usually treated with antibiotics, but surgery to wash the joint may be necessary. In rare cases, the implants may be removed and replaced at a later date. The infection can sometimes lead to sepsis (blood infection) and stronger antibiotics are required.
RARE (<1%)
Keloid
The wound may become red, painful and thickened scar especially in Afro-Caribbean people. Massaging the scar with cream when it has healed may help.
Nerve injury
Nerves around the hip are at risk. This may cause temporary or permanent altered sensation or weakness along the leg.
Bone injury
The thigh bone may be broken when the implant (metal replacement) is put in. This may require fixing at the time or at a later surgery.
Vessel damage
The blood vessels around the hip may rarely be damaged. This may require further surgery by the vascular surgeons.
Pulmonary embolism
This is a consequence of a DVT. It is a blood clot that spreads to the lungs and can make breathing very difficult, and may be fatal.
Death
This can occur from any of the above complications.
If you believe you have any of the above complications when you are home, contact your GP or go to your local Emergency Department.
Anaesthesia for Hip Replacement
Two types of Anaesthetic techniques are commonly used.
- Spinal Anaesthesia (Or Epidural Anaesthesia OR Combined Spinal & Epidural Anaesthesia) with OR without Sedation
OR
- General Anaesthesia (GA)
Spinal Anaesthesia (OR Epidural OR Combined Spinal & Epidural Anaesthesia) with or without Sedation
A Hip Replacement can be done under Spinal Anaesthetic, where an injection is placed in your back, which makes you numb waist downwards. It is currently the preferred choice for a Hip Replacement, as immediate recovery is considered better compared to General Anaesthesia.
Spinal Anaesthesia
Advantages of Spinal Anaesthesia:
- Least effect on Lungs and breathing
- Excellent pain relief during and for few hours after the operation
- Less need for stronger painkillers like Morphine
- Less sickness (nausea & vomiting) compared to General Anaesthetic
- Ability to eat and drink soon after the operation
- Spinal Anaesthetic might decrease the chances of developing blood clots (deep vein thrombosis)
Technique:
You will then be transferred into the operating theatre where you will be securely positioned on your side. You will be re-connected to monitor and oxygen mask. At this point your Anaesthetist will administer sedative drug to keep you calm and comfortable throughout the operation.
Sedation:
Sedation is routinely offered to all patients who have Spinal/ Epidural anaesthesia. Sedative drugs are given through intravenous cannula, which makes you calm, comfortable and (may be) slightly sleepy. Sedatives will NOT result in complete sleep. You will be able to hear the noises arising from the operating theatre including the conversations. You can also talk to your Anaesthetist or Surgeon during the procedure (and vice versa).
Complications of Spinal/Epidural Anaesthesia
- Nerve damage:
There is 1 in 12,000 chance of temporary nerve damage in the spine that can cause numbness or weakness in your legs, which can last from 6 weeks to 6 months. Permanent nerve damage is very rare
- Drop in Blood Pressure
(BP) can make you feel ‘dizzy’. Your Anaesthetist will monitor it continuously and manage any drop in BP
- Shivering
occasional, quite often not related to body temperature
- Itching
uncommon and can be treated
- Headache
up to 1 in 300 due to spinal fluid leak. You should report to Anaesthetist if headache is persistent or worsening.
- Backache for a few days
You may not notice backache, as you will be taking painkillers. Spinal Anaesthetic is not known to cause long-term backache.
- Urinary retention
can happen in up to 10 percent of patients and may require urinary catheterisation.
- Infection of spine causing meningitis
extremely rare
- Bleeding into spine causing spinal haematoma
extremely rare
- Complete paralysis (Paraplegia) or death
extremely rare (1:50,000- 1:140,000).
- Failure of the Spinal Anaesthetic
If the spinal anaesthetic doesn’t work, you will be offered general anaesthetic
General Anaesthesia (GA)
General Anaesthesia (or simply called GA) involves administration of anaesthetic drugs through intravenous cannula (IV cannula or drip). Your Anaesthetist will insert an IV cannula first. You will be connected to routine monitors (ECG, Blood Pressure (BP) and Pulse Oximetry). The Anaesthetist will then inject the anaesthetic drugs directly into your vein through the IV cannula. As soon as the drugs are injected, you will fall asleep. After that you will NOT know, see, hear or feel any sensation until the procedure is over. The Anaesthetist will also insert an airway device into your throat (Laryngeal Mask) or into your windpipe (Tracheal tube) when you are asleep. At the end of the operation, the Anaesthetist will switch off/reverse the anaesthetic drugs and you will begin to wake up. You may still feel sleepy as you recover in the Recovery Room.
A recovery nurse will monitor you until you are completely awake, comfortable and fit to go back to the Ward. Your Anaesthetist will also prescribe combination of painkillers, anti-emetics, laxative and IV fluids. You will be able to eat and drink as soon as possible provided your recovery is straightforward. Modern anaesthetic drugs are much safer, short acting and have fewer side effects. However, you can still have complications from general anaesthetic.
Complications/side effects of General Anaesthesia (GA)
- Pain
on injection of anaesthetic drugs into your vein- common
- Nausea and Vomiting–
common but manageable with routine anti-emetics
- Damage to teeth/crowns/caps/dentures/lips/tongue–
uncommon, but can happen when the airway device is inserted or removed.
- Fluctuations in Blood Pressure (BP) and Heart Rate (HR)
Your Anaesthetist will monitor you continuously and manage any fluctuations in BP or HR.
- Drowsiness
is common until anaesthetic drugs wear off completely. Painkillers like Morphine can also make you drowsy and tired.
- Shivering
occasional, either due to exposure to cold in operation theatre or sometime not related to your body temperature.
- Itching
is a common side effect of analgesics like Morphine. It can also be caused by an allergy to anything you have been in contact with, including drugs, sterilising fluids, stitch material, latex and dressings. It can be treated with drugs
- Breathing difficulties
some people wake up after GA with slow or slightly difficult breathing. If this happens to you, you will be cared for in the Recovery Room until your breathing is better.
- Sore throat
can happen due to airway intervention. It can last a few days and usually responds to simple pain killers
- Damage to Eyes
It is possible that surgical drapes or other equipment can rub the cornea (clear surface of the eye) and cause a graze. Anaesthetists take care to prevent this. Serious and permanent loss of vision can happen, but it is very rare.
- Nerve damage (paralysis or numbness)
has a number of causes during local, regional or GA. Temporary nerve damage can happen due to pressure points, but full recovery often follows. Permanent nerve damage is uncommon
- Bladder Problems
Difficulty passing urine, or leaking urine, can happen after most kinds of moderate or major surgery. If this happens, the team looking after you will consider whether you need a urinary catheter
- Confusion or Memory Loss
This is common among older people who have had a GA. It may also be due to an illness developing such as chest or urine infection. There are other causes, which the team looking after you will take care of. It usually recovers but this can take some days, weeks or months.
- Postoperative Delirium
can happen especially in elderly patient population
- Postoperative Cognitive Dysfunction
has been reported after GA. However, it generally affects elderly patients
- Serious allergy to drugs
difficult to predict
- Equipment failure
difficult to predict
- Chest infection
is more likely to happen after major surgery on the chest or abdomen, after emergency surgery and after surgery in people who smoke. Occasionally severe chest infections develop which may need treatment in the intensive-care unit. These infections can be life threatening.
- Awareness under General Anaesthesia (GA)
Extremely rare, about 1 in 20,000 Anaesthetics.
- Death due to General Anaesthesia
is extremely rare in healthy patients undergoing non-emergency surgery (about 1 in 100,000 general anaesthetics)
If you are having any complications of General Anaesthesia, please report it to your ward Doctor who will contact Anaesthetic Team if necessary.
Death due to General Anaesthesia is extremely rare in healthy patients undergoing non-emergency surgery (about 1 in 100,000 general anaesthetics)
If you are having any complications of General Anaesthesia, please report it to your ward Doctor who will contact Anaesthetic Team if necessary.
General Information
- Your Anaesthetist (Consultant or a junior Doctor) will see you on the day of the operation. This is your opportunity to discuss any issues related to your Anaesthesia & ask any questions you may have regarding your anaesthetic.
- Irrespective of the anaesthesia technique, the Surgeon will generally inject local anaesthetic drug around your joint and wound at the end of the operation. This will help you with pain relief.
- You may need more blood tests, X-rays or scans whilst in the hospital if necessary
For more information about your anaesthetic please go to https://www.rcoa.ac.uk/patientinfo/anaesthesia-information-leaflets
FAQ
What happens before my surgery date?
Once listed for surgery, you will be given a date to attend the pre-operative assessment clinic. The pre-operative assessment clinic gives the team an opportunity to make sure you are fit enough for the anaesthetic and the surgery.
They will want to review your medications so please bring these with you. If you are taking any blood thinning medications (such as aspirin, clopidogrel, or warfarin), these will need to be stopped a few days before your surgery, and you will be given special instructions regarding these.
In the clinic your blood pressure will be checked, you will have blood tests, have swabs to look for MRSA, and we may need to listen to your chest and do a tracing of your heart (ECG).
Once cleared by pre-operative assessment, the admissions coordinator will contact you and give you the date of your admission to hospital (usually the day of the surgery, or in special circumstances the day before).
What should I bring into Hospital ?
Please bring with you:
- All tablets, medicines or inhalers that you have been prescribed (including those stopped prior to surgery) with the exception of Temazepam and Pethidine. Please ensure that all medication is in the original packaging, labelled with your name. Please do not mix tablets or bring them in your own tablet dispenser tray or dosette box from your local pharmacy
- Personal items – including night clothes, dressing gown and slippers, bedjacket or shawl.
- Comfortable day clothes
- Your spectacles (labelled with your name)
- Denture pot (as you will be asked to remove any false teeth)
- Toiletry items (toothbrush, toothpaste, flannel, soap, shampoo, shaving equipment, comb or hairbrush etc).
- Mobile phone – please use with consideration for other patients and keep on silent.
You might also want to bring:
- Tissues and baby wipes
- Proof of entitlement to free travel costs if appropriate
- Items of religious importance to you
- Your hearing aid
- Sanitary products such as tampons
- Mobility aids such as a walking stick or frame
- Some money to purchase newspapers or to use the telephone
- Books, magazines, knitting
- Writing paper and pen
- Non perishable snacks, squash
Please do not bring:
- Large amounts of money or credit cards
- Large bags or suitcases, as bed space is limited
- Food that needs reheating (we cannot reheat food for infection control reasons)
What do I do on the day of my surgery?
All patients need to fast for 6 hours (for solid food) before any anaesthesia or sedation is administered. You may drink clear liquids like Water, Black Coffee or Black Tea up to two hours before the operation. Please do not chew gum or eat sweets. Milk, fizzy drinks (including Red Bull and Lucozade), fruit juice or milky tea/coffee are not allowed.
Please follow the advice of the Hospital Pharmacist (or Anaesthetist or Pre-op Assessment nurse) regarding taking or stopping your routine medication before the operation. Please bring all your medicines with you to the hospital
If you are using any devices (eg. CPAP machine), please bring it with you. You may need it whilst in the hospital
If you are having spinal anaesthetic, we may allow you to listen to your own music. You may wish to bring your own iPod (or similar device) and ear piece You will be expected to attend the ward shown on your letter at the specific time indicated.
Prior to surgery a nurse will take you to your bed where health checks and a nursing assessment will be completed. You will be given a gown, underwear and stockings to change into, however you will remain in your own clothes until the theatre team are ready to start your operation. This may be some hours after your arrival.
You will meet the Orthopaedic team undertaking the surgery. They will ask several questions about the symptoms and examine your knee, and then draw an arrow on the side of the surgery (using a thick black marker). They will then consent you for the surgery, and answer any questions that you may have. The team may also ask you to partake in research that may be running alongside the surgery (they will give you further information about their research separately). Once all the checks have been done, and it is your turn for surgery, you will be escorted to the operating theatre.
What happens immediately after the surgery?
The surgery can take between one to two hours. Immediately after the surgery you will rest in the recovery unit until you are more awake, before being taken to the inpatient ward.
It is normal to be sore around the knee, and the team will ensure you have enough pain medications available. This may involve tablets, injections given by the nursing team, or injections that you control (PCA). A PCA will give you a small volume of pain medications after you have pressed a button – keeping you in control.
You will have a white waterproof dressing on the wound and a bulky dressing around the knee, which will stay in place until the next day before the team looks at the wound on the ward. When the bulky dressing is removed, you will be given a stocking to wear on the operated leg. You may also have a ‘drip’ attached to your hand (or arm), which is giving you fluids to help hydration.
It is not unusual to have some difficulty to pass urine on the night of surgery so occasionally we may need to insert a tube into your bladder (catheter) to empty your bladder or monitor your urine. Once the team is satisfied with your urine production, the catheter will be removed.
What do I do when I am on the ward?
You will normally stay on the same ward for the duration of your stay.
During this time, you will be seen daily by the ward doctor or member of the Orthopaedic team to make sure you are recovering well, and blood tests and X-rays will be undertaken. They may examine your leg and review the wound to ensure there are no complications.
Medication that you were previously on will be restarted, and you will be given an injection or pill to reduce the risk of blood clots from forming in your leg or lungs (see risks above).
Part of the recovery from the surgery is regaining your mobility, and the Physiotherapists will see you regularly on the ward. They will encourage you to sit out of bed on the first day after your surgery (if the pain is well under control, and there are no complications).
Over the next few days they will aim to progress your mobility, as they help you mobilise with a frame or crutches, and give you an exercise program (further information regarding individual exercises is available from the Physiotherapy team).
When will I leave hospital?
The expected length of stay for a total hip replacement surgery is 2 – 3 days. When the doctors, physiotherapists, occupational therapists, and the nurses are happy with your progress you will be able to go home.
When you are discharged from hospital a pack will be made with all your medications. This will include the new painkillers and medication to thin your blood. The medication to thin your blood should be continued for 28 days from your surgery, and your stockings must also be worn for this amount of time.
What should I expect when I am home?
When you are discharged from hospital a follow-up appointment will be made for you with the Orthopaedic team at 6 to 8 weeks. This will be sent to you in the post.
Your wound generally, will be closed with dissolvable stitches but you will be required to visit the nurse at your GP practice to check the wound and change the dressing if required (the nursing staff on the ward will give specific instructions before you leave hospital).
Not all hip replacement patients require physiotherapy after discharge but if you do, you will be informed by the physiotherapist on the ward. A referral will therefore be sent off on your behalf and you should expect to be contacted within 2 – 4 weeks.
It can take between 3 to 6 months to recover from the surgery. The pain associated with your old hip may be gone, but it takes a while for your muscles to heal, and for your body to adjust to your new hip. It is therefore important that you give yourself time to recover, and avoid pushing yourself too soon after the surgery.
What else should I know?
Hip movements
There is a risk of dislocating your hip in the first few weeks after surgery until your tissues have healed. This takes approximately 3 months. After this time you can increase the range of motion and position of your hip with caution.
In the meantime, avoid twisting your knee inwards when your knee is bent at right angle, and do not bend over your operated hip with your knees together (especially when sitting down or getting on and off your chair)
Sleeping
We suggest not sleeping on the operated side until the wound has healed, which may take 6 weeks. If you cross your legs when sleeping, keep a pillow between your knees and take care when turning in bed.
Bathing
It is best to shower or sponge bath until your wound has healed, and avoid getting in and out of the bath for 3 months to reduce risk of dislocating
Driving
Your insurance company should be informed about your operation. Some companies will not insure drivers for a number of weeks after hip surgery, so it’s important to check your policy.
Before driving, you need to be fully recovered from your surgical procedure, free from the distracting effect of pain or of any pain relief medication, and be able to safely control your car, and perform an emergency stop.
Work
Time off from work depends on the physical demands expected of you, especially if it involves heavy lifting, standing for long periods of time, or lots of walking. Everyone recovers differently but in most cases if you have a light job or are office-based you may return quite early. If your job involves heavy duties, you may need to be off work for several weeks with a phased return.
