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Welcome to First Choice Physical Therapy’s patient resource about Artificial Joint Replacement of the Shoulder.

Shoulder joint replacement surgery (also called shoulder arthroplasty) is not as common as replacement surgeries for the knee or hip joints. Still, when necessary, this operation can effectively ease pain from shoulder arthritis. Most people experience improved shoulder function after this surgery.

This article will help you understand:

• how the shoulder works
• what parts of the shoulder are replaced in surgery
• what to expect after shoulder replacement surgery

What parts make up the shoulder?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

Shoulder Bones

The rotator cuff connects the humerus to the scapula. The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Rotator Cuff

Tendons attach muscles to bones. Muscles move bones by pulling on the tendons. The rotator cuff helps raise and rotate the arm. As the arm is raised, the rotator cuff also keeps the humerus tightly in the socket. A part of the scapula, called the glenoid, makes up the socket of the shoulder. The glenoid is very shallow and flat.

Glenoid

The part of the scapula that connects to the shoulder is called the acromion.

  A bursa is located between the acromion and the rotator cuff tendons. A bursa is a lubricated sac of tissue that cuts down on the friction between two moving parts. Bursae are located all over the body where tissues must rub against each other. In this case, the bursa protects the acromion and the rotator cuff from grinding against each other.

The humeral head of the shoulder is the ball portion of the joint. The humeral head has several blood vessels, which enter at the base of the articular cartilage. Articular cartilage is the smooth, white material that covers the ends of bones in most joints. Articular cartilage provides a slick, rubbery surface that allows the bones to glide over each other as they move. Cartilage also functions as sort of a shock absorber.

The shoulder joint is surrounded by a watertight sac called the joint capsule. The joint capsule holds fluids that lubricate the joint. The walls of the joint capsule are made up of ligaments. Ligaments are connective tissues that attach bones to bones. The joint capsule has a considerable amount of slack, loose tissue, so that the shoulder is unrestricted as it moves through its large range of motion.

What conditions lead to shoulder joint replacement?

The most common reason for undergoing shoulder replacement surgery is osteoarthritis. Osteoarthritis is caused by the degeneration of the joint over time, through wear and tear. Osteoarthritis can occur without any injury to the shoulder, but that is uncommon. Because the shoulder is not a weight-bearing joint, it does not suffer as much wear and tear as other joints. Osteoarthritis is more common in the hip and knee.

Most of the time osteoarthritis occurs many years after an injury to the shoulder. For example, a shoulder dislocation can result in an unstable shoulder. The extra movement or repeated dislocation of the unstable joint causes damage to the articular cartilage and other joint tissues. Over time, this damage leads to osteoarthritis.

Osteoarthritis is not the only type of arthritis that affects the shoulder joint. Systemic diseases, such as rheumatoid arthritis, may affect any joint in the body.

Whatever the type or cause of the arthritis, the shoulder may become painful and difficult to use.

If you and your doctor can’t find ways to control your pain, or if it becomes impossible to use your shoulder for daily tasks, your doctor may recommend shoulder replacement surgery.

Certain types of shoulder fractures can injure the blood vessels of the humeral head.

The fracture may heal, but the blood vessels don’t.

When the blood vessels are damaged, the humeral head no longer has any blood supply.

This condition leads to a condition called:

Aseptic Necrosis

In necrosis, parts of the joint surface actually die. Over time, necrosis of the shoulder joint can lead to arthritis.

When fractures affect the humeral head, doctors may recommend a shoulder joint replacement.

In some cases, the risk of developing necrosis is so high that it makes sense to replace the humeral head immediately.

In most cases, doctors see shoulder replacement surgery as the last option. Sometimes there is a benefit to delaying shoulder replacement surgery as long as possible.

Your doctor will probably want you to try nonsurgical measures to control your pain and improve your shoulder movement, including medications and physical or occupational therapy.

Like any arthritic condition, osteoarthritis of the shoulder may respond to anti-inflammatory medications such as aspirin or ibuprofen. Acetaminophen (Tylenol) may also be prescribed to ease the pain. Ensure that you consult with your doctor or pharmacist regarding the use of pain relief or anti-inflammatory medication. Some of the newer medications such as glucosamine and chondroitin sulfate are more commonly prescribed today. They seem to be effective in helping reduce the pain of osteoarthritis in all joints. There are also new injectable medications that lubricate the arthritic joint. These medications have been studied mainly in the knee. It is unclear if they will help the arthritic shoulder.

Physical or occupational therapy may be suggested to help you regain as much of the motion and strength in your shoulder as possible before you undergo surgery.

An injection of cortisone into the shoulder joint may give temporary relief. Cortisone is a powerful anti-inflammatory medication that can ease inflammation and reduce pain, possibly for several months. Most surgeons only allow two or three cortisone shots into any joint. If the shots don’t provide you with lasting relief, your doctor may suggest surgery.

What do I need to do to get ready for surgery?

Some severe degenerative problems of the shoulder may require replacement of the painful shoulder with an artificial shoulder joint. You and your surgeon should make the decision to proceed with surgery together. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

You may also need to spend time with the physical or occupational therapist who will be managing your rehabilitation after surgery. This allows you to get a head start on your recovery. One purpose of this pre-operative visit is to record a baseline of information. Your therapist will check your current pain levels, ability to do your activities, and the movement and strength of each shoulder.

A second purpose of the pre-operative visit is to prepare you for surgery. You’ll begin learning some of the exercises you’ll use during your recovery. And your therapist can help you anticipate any special needs or problems you might have at home, once you’re released from the hospital.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. Come prepared to stay in the hospital for several nights. The length of time you will spend in the hospital depends a lot on you.

The Artificial Shoulder

There are two major types of artificial shoulder replacements — a:

Cemented Prosthesis

and an:

Uncemented Prosthesis

A cemented prosthesis is held in place by a type of epoxy cement that attaches the metal to the bone. An uncemented prosthesis has a fine mesh of holes on the surface. Bone grows into the mesh. Over time, this anchors the prosthesis to the bone.

Both types of artificial joints are widely used. Your surgeon may also use a combination of the two types. The surgeon determines the type of replacement joint based on your age, your lifestyle, and the surgeon’s experience.

Each prosthesis (artificial joint) is made up of two parts. The humeral component replaces the humeral head, or the ball of the joint. The glenoid component replaces the socket of the shoulder, which is actually part of the scapula.

The humeral component is made of metal. The glenoid component is usually made of two parts. A metal tray attaches directly to the bone, and a plastic cup forms the socket.

The plastic is very tough and very slick, much like the articular cartilage it is replacing. In fact, you can ice skate on a sheet of this plastic without causing it much damage.

The Operation

Shoulder replacement surgery can be done in one of two ways.

When the cartilage of both the humeral head (the ball) and the glenoid (the socket) is worn away, both parts of the joint must be replaced. This surgery is called arthroplasty, which is the term used for joint reconstruction.

If the glenoid still has some articular cartilage, your surgeon may replace only the humeral head. This procedure is known as a hemiarthroplasty. (Hemi means half.) The hemi-arthroplasty is most commonly used after a fracture of the shoulder where the blood supply to the ball portion (the humeral head) of the humerus is damaged. Research has shown that when the shoulder is being replaced for arthritis, the complete shoulder arthroplasty performs better. Patients have less pain immediately after surgery and in the long run have a better functioning shoulder with less complications and are less likely to need a second operation.

You will most likely need general anesthesia for shoulder replacement surgery. General anesthesia puts you to sleep. It is difficult to numb only the shoulder and arm in a way that makes such a major surgery possible.

Shoulder replacement surgery is done through an incision on the front of your shoulder. This is called an anterior approach. The surgeon cuts through the skin and then isolates the nerves and blood vessels and moves them to the side. The muscles are also moved to the side.

The surgeon enters the shoulder joint itself by cutting into the joint capsule. This allows the surgeon to see the joint.

At this point, the surgeon can prepare the bone for attaching the replacement parts. The ball portion of the humeral head is:

Removed

with a bone saw. The hollow inside of the upper humerus is prepared using a:

Rasp

This lets your surgeon mold the space to anchor the metal stem of the humeral component inside the bone.

If the glenoid will be replaced, it is prepared by grinding away any:

Remaining Cartilage

on the surface. This is done with an instrument called a burr. The surgeon usually uses the burr to:

Drill Holes

into the bone of the scapula. This is where the stem of the glenoid component is anchored.

Humeral Component

Glenoid Component

Humeral Ball is attached.

Once the joint is anchored, the surgeon tests for proper fit. When the surgeon is satisfied with the fit, the joint capsule is stitched together. The muscles are then returned to their correct positions, and the skin is also stitched up.

Your incision will be covered with a bandage, and your arm will be placed in a sling. You will then be woken up and taken to the recovery room.

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following artificial shoulder replacement are

• anesthesia
• infection
• loosening
• dislocation
• nerve or blood vessel injury

Anesthesia

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Infection following joint replacement surgery can be very serious. The chances of developing an infection following artificial joint replacement, however, are low (about one percent). Sometimes infections show up very early, before you leave the hospital. Other times infections may not show up for months, or even years, after the operation.

Infection can also spread into the artificial joint from other infected areas. Once an infection lodges in your joint, it is almost impossible for your immune system to clear it. You may need to take antibiotics when you have dental work or surgical procedures on your bladder and colon. The antibiotics reduce the risk of spreading germs to the artificial joint.

Loosening

The major reason that artificial joints eventually fail is that they loosen where the metal or cement meets the bone. A loose joint prosthesis causes pain. Once the pain becomes unbearable, another operation will probably be needed to fix the artificial joint.

There have been great advances in extending the life of artificial joints. However, most will eventually loosen and require another surgery. In the case of artificial knees, you can expect about 12 to 15 years, but artificial shoulder joints tend to loosen sooner.

Dislocation

Just like your real shoulder, an artificial shoulder can dislocate. A shoulder dislocation occurs when the ball comes out of the socket. There is a greater risk of dislocation right after surgery, before the tissues have healed around the new joint. But there is always a slightly increased risk of dislocation with an artificial joint. Your therapist will teach you how to avoid activities and positions that tend to cause shoulder dislocation. A shoulder that dislocates more than once may need another operation to make it more stable.

Nerve or Blood Vessel Injury

All of the large nerves and blood vessels to the arm and hand travel through the armpit. (This area is called the axilla.) Because shoulder replacement surgery takes place so close to the axilla, it is possible that the nerves or blood vessels may be injured during surgery. The resulting problems may be temporary if the injury was caused by stretching to hold the nerves out of the way. The nerves and blood vessels rarely suffer any kind of permanent injury after shoulder replacement surgery, but this type of injury can happen.

What happens after surgery?

After surgery, you’ll be transported to the recovery room. You will have a dressing wrapped over your shoulder that will need to be changed frequently over the next few days. Your surgeon may have inserted a small drainage tube into the shoulder joint to help keep extra blood and fluid from building up inside the joint. An intravenous line (IV) will be placed in your arm to give you needed antibiotics and medication.

Your shoulder may be placed in a continuous passive motion (CPM) machine immediately after surgery. CPM helps the shoulder begin moving and alleviates joint stiffness. The machine straps to the shoulder and continuously bends and straightens the joint. This motion is thought to reduce stiffness, ease pain, and keep extra scar tissue from forming inside the joint. You’ll use a shoulder sling to support your arm when you’re not using the CPM machine.

What will my recovery be like?

Your Physical Therapist at First Choice Physical Therapy will start working with you soon after surgery to begin your rehabilitation program. The Physical Therapy treatments will gradually improve the movement in your shoulder. If you are using CPM, our Physical Therapist will check the alignment and settings. We will go over your exercises and make sure you are safe getting in and out of bed and moving about in your room.

Our first few Physical Therapy treatments will focus on controlling pain and swelling. Ice and electrical stimulation treatments may help. Our Physical Therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain. Continue to use your shoulder sling as prescribed.

As your rehabilitation program evolves, our Physical Therapist will choose more challenging exercises to safely advance the shoulder’s strength and function.

Finally, a select group of exercises can be used to simulate day-to-day activities, like grooming your hair or getting dressed. We will also choose specific exercises to simulate work or hobby demands.

When your shoulder range of motion and strength have improved enough, you’ll be able to gradually get back to normal activities. Ideally, you’ll be able to do almost everything you did before. However, you may need to avoid heavy or repeated shoulder actions.

Although the time required for recovery varies, you may be involved in our progressive rehabilitation program for two to four months after surgery to ensure the best results from your artificial joint. In the first six weeks after surgery, you should expect to see your Physical Therapist two to three times a week. At that time, if everything is still going as planned, you may be able to advance to a home program.

At First Choice Physical Therapy, our goal is to help speed your recovery so that you can more quickly return to your everyday activities. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Shoulder joint replacement surgery (also called shoulder arthroplasty) can effectively ease pain from shoulder arthritis. Most people experience improved shoulder function after this surgery. Unfortunately certain patients are not candidates for a traditional joint replacement of the shoulder because they lack the muscle function necessary to stabilize the joint. A different type of shoulder replacement, called a reverse shoulder replacement, may be available for many of these patients and provide pain relief as well as a stable functioning shoulder that is adequate for their daily needs.

This guide will help you understand:

• how the shoulder joint works
• what parts of the shoulder are replaced in a reverse shoulder replacement
• how reverse shoulder replacement differs from a regular shoulder replacement
• what to expect after reverse shoulder replacement surgery
• what First Choice Physical Therapy’s approach to rehabilitation is

What parts of the shoulder are involved?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

The rotator cuff connects the humerus to the scapula.

Four muscles and their associated tendons form the rotator cuff: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Tendons attach muscles to bones. Muscles move the bones by pulling on the tendon that they attach to. The rotator cuff muscles help raise and rotate the arm. As the arm is raised, the rotator cuff also keeps the humerus tightly in the socket. The socket of the shoulder is part of the scapula bone and is called the glenoid fossa. The glenoid fossa is very shallow and flat so without the rotator cuff muscles the top part of the humerus (the head) would slide out of the centre of the fossa.

The part of the scapula that connects to the lateral shoulder is called the acromion. A bursa is located between the acromion and the rotator cuff tendons. A bursa is a lubricated sac of tissue that cuts down on the friction between two moving parts. Bursae are located all over the body where tissues must rub against each other. In this case, the bursa protects the acromion and the rotator cuff from grinding directly against each other.

The humeral head of the shoulder is the ball portion of the shoulder joint. The humeral head has several blood vessels, which enter at the base of the articular cartilage. Articular cartilage is the smooth, white material that covers the ends of bones in most joints. Articular cartilage provides a slick, rubbery surface that allows the bones to glide over each other as they move. Cartilage also functions as a shock absorber in the joint.

A watertight sac called the joint capsule surrounds the shoulder joint. The joint capsule holds fluids that lubricate the joint. The walls of the joint capsule are made up of ligaments. Ligaments are connective tissues that attach bones to bones. The joint capsule has a considerable amount of slack (loose tissue), so that the shoulder is unrestricted as it moves through its large range of motion.

What conditions lead to reverse shoulder joint replacement?

The most common reason for undergoing shoulder replacement surgery is osteoarthritis. Osteoarthritis is caused by the degeneration of the joint over time, through wear and tear. Being that the shoulder is not a weight-bearing joint, it does not suffer as much wear and tear as other joints such as the weight-bearing hip and knee joints. Although osteoarthritis in the shoulder can occur without any causative injury to the shoulder, this is uncommon; usually it is a subsequent result of another injury or disease in the shoulder joint.

Rotator cuff problems are common conditions in the shoulder, especially as we grow older. Degeneration or wear and tear of the rotator cuff tendons occurs as we age. Over time this can lead to weakening of the tendons and may result in a rotator cuff tear.

Surgery to repair a rotator cuff tear is fairly common in people who are middle aged or older. Small, medium and many large tears can be repaired either through arthroscopic or open surgical procedures. Most rotator cuff repairs are successful but in a portion of patients the torn tendon has become so degenerated that the tendon cannot be repaired. Unfortunately, many large tears that are untreated for a long time may retract which renders them unfixable.

A shoulder joint without an intact rotator cuff may still function relatively well. Some patients will have some weakness, pain and may not be able to completely raise the arm, however, they get by without full function of their rotator cuff fairly well. There are many people who choose not to have surgery to repair a rotator cuff tear and will simply live with the limitations. Patients with massive rotator cuff tears, however, may not be able to lift the arm without significant pain and weakness, which severely limits them on a daily basis. When the arm cannot be lifted, this is called a pseudoparalytic shoulder.

A normal functioning rotator cuff helps to keep the shoulder stable so that it can move well, and also helps to create part of the joint capsule, which holds the joint fluid that lubricates the joint.  Over time, a shoulder without an intact rotator cuff becomes arthritic; the shoulder joint wears out due to the abnormal motion in the joint, the instability, and the decreased joint fluid lubrication. This type of wear and tear arthritis in the shoulder is called (rotator) cuff tear arthropathy.

Cuff tear arthropathy is difficult to treat. The shoulder is weak and painful. Patients may not be able to raise the arm above shoulder level. Patients with this type of arthritis would seem to be good candidates for a shoulder replacement, but replacing the shoulder in the traditional fashion has not been successful.

The answer to this dilemma was to rethink the mechanics of the shoulder joint and to design an artificial shoulder that worked differently than the real shoulder joint. The solution was to reverse the socket and the ball, placing the ball portion of the shoulder where the socket use to be and the socket where the ball or humeral head use to be.

This new design led to a much more stable shoulder joint that could function without a rotator cuff. The artificial joint itself provided more stability by creating a deeper socket that prevented the ball from sliding up and down as the shoulder was raised. The large deltoid muscle that covers the shoulder could be used to more effectively lift the arm, providing better function of the shoulder. The final result is a shoulder that functions better, is less painful and can last for years without loosening.

Other reasons to consider a reverse shoulder replacement include failed rotator cuff surgery leading to a pseudoparalytic shoulder even without arthritis. As mentioned previously a pseudoparalytic shoulder refers to a situation where you cannot raise the arm and shoulder. Pseudo means false and paralysis means that the nerves that control the muscle can no longer do so. A pseudoparalytic shoulder appears paralyzed, but instead of the nerve being damaged causing the paralysis, the reason that you cannot raise the shoulder is because the rotator cuff tendons (attaching to the muscles on the humerus which raise the shoulder) are torn. The power of the muscles cannot be transmitted to the humerus to raise the shoulder.

Older patients with very severe fractures of the head of the humerus are another group of patients that appear to do very well with reverse shoulder replacements as opposed to a standard shoulder replacement. Patients who have had previous shoulder replacements that have failed or become loose will also require a reverse shoulder replacement to fix the loose or painful prosthesis.

In most cases, doctors see any type of shoulder replacement as a last option for a patient. Sometimes there is a benefit to delaying shoulder replacement surgery as long as possible. Your doctor will probably want you to try nonsurgical measures to control your pain and improve your shoulder movement, including medications and Physical Therapy.

Like any arthritic condition, cuff tear arthropathy of the shoulder may respond to anti-inflammatory medications such as aspirin or ibuprofen. Acetaminophen or paracetamol may also be prescribed to ease the pain. Some of the newer medications such as glucosamine and chondroitin sulfate are more commonly prescribed today as they seem to be effective in helping to reduce the pain of arthritis in all joints. There are also new injectable medications that lubricate the arthritic joint. These medications have been studied mainly in the knee but are presently being studied also for the shoulder.

An injection of cortisone into the shoulder joint may give temporary relief to your shoulder. Cortisone is a powerful anti-inflammatory medication that can ease inflammation and reduce pain, possibly for several months. Most surgeons only allow two or three cortisone shots into any joint. If the shots don’t provide you with lasting relief, your doctor may suggest surgery.

Physical Therapy can be very useful and can assist you if you decide not to undergo surgery and live with the problem in your shoulder.  If you plan to undergo a shoulder replacement, Physical Therapy prior to the surgery will be encouraged to help you gain as much of the motion and strength in your shoulder as possible prior to the surgery.  Regular Physical Therapy treatment at First Choice Physical Therapy will also be required post-surgically.

What do I need to do to get ready for surgery?

When cuff tear arthropathy of the shoulder requires replacement of the painful shoulder with an artificial shoulder joint, a reverse shoulder replacement may be recommended. You and your surgeon should make the decision to proceed with surgery together. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

Plain x-rays of the shoulder will allow your surgeon to evaluate the severity of arthritis and give an indication regarding the status of the rotator cuff. A CT scan or MRI is often required before any kind of shoulder replacement to determine the degree of damage to the bones (glenoid and humeral head) for surgical planning.

As mentioned above, you will need to spend time with a Physical Therapist at First Choice Physical Therapy who will be managing your rehabilitation after surgery. This pre-operative visit will allow your therapist to record a baseline of information. Your therapist will check and record your current pain levels, your ability to do your activities, and will measure the movement and strength of each shoulder.

A second purpose of the pre-operative visit with your Physical Therapist is to prepare you for your post-surgical rehabilitation. You’ll begin learning some of the exercises you will use during your recovery. In addition, your therapist can help you anticipate any special needs or problems you might have at home, once you’re released from the hospital.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. Come prepared to stay in the hospital for several nights. The length of time you will spend in the hospital depends a lot on how well you are doing with your rehabilitation program post-surgically.

What happens during reverse shoulder replacement surgery?

Before we describe the procedure, let’s look first at the reverse artificial shoulder itself.

The Reverse Artificial Shoulder

The reverse shoulder prosthesis (artificial joint) is made up of two parts. The humeral component replaces the humeral head, or the ball of the joint. The glenoid component replaces the socket of the shoulder, which is actually part of the scapula.

In the traditional artificial shoulder prosthesis, the glenoid prosthesis is a shallow socket made of plastic and the humeral component is a metal stem attached to a metal ball that nearly matches the anatomy of the normal shoulder. In the reverse shoulder replacement, the ball and the socket are reversed such that the ball sticks out of the shoulder itself.

The humeral component is a combination of a metal stem that fits into the marrow cavity of the upper humerus and, on top of the metal stem, a plastic socket. This plastic socket fits onto the humeral component to create a ball and socket type bearing. The glenoid component is usually made of two parts: a metal tray and a metal ball.  The metal tray (base plate) attaches directly to the bone. This base plate is inserted into a small peg hole drilled into the bone and is secured with special screws through the base plate into the bone. Attached to that metal tray, there is a metal ball that will fit into the plastic socket attached to the humeral component. The plastic is very tough and very slick, much like the articular cartilage it is replacing. This plastic is so tough that you could actually ice skate on a sheet of this plastic without causing it much damage.

The reverse shoulder replacement surgery is performed almost identically to the traditional shoulder replacement except that different artificial parts are inserted.

You will most likely need general anesthesia for a reverse shoulder replacement surgery. General anesthesia puts you to sleep. It is difficult to numb only the shoulder and arm in a way that makes such a major surgery possible. While nerve blocks can be helpful with postoperative pain control, they are not usually effective enough to be used as the only anesthetic for this kind of operation.

Shoulder replacement surgery is done through an incision on the front of your shoulder. This is called an anterior (deltopectoral) approach. For reverse shoulder replacements, especially for patients with multiple previous surgeries, a superior approach through the deltoid muscle may be used.  No matter which approach is used, the surgeon cuts through the skin and then isolates the nerves and blood vessels and moves them to the side. The muscles are also moved to the side.  If the deltoid requires cutting, a delay in your rehabilitation will be needed to allow the deltoid muscle to heal before putting stress through it.

The surgeon enters the shoulder joint itself by cutting into the joint capsule. This allows the surgeon to see the joint. In more advanced cases of cuff tear arthropathy, and in patients with previous surgery, there may be no capsule and rotator cuff remaining.

At this point, the surgeon can prepare the bone for attaching the replacement parts. The ball portion of the humeral head is removed with a bone saw. The hollow inside of the upper humerus is prepared using a rasp, which allows your surgeon to mold the space in order to anchor the metal stem of the humeral component inside the bone.

The glenoid will be replaced with a ball of metal. The arthritic glenoid surface is prepared by grinding away any remaining cartilage and flattening the surface. This is done with an instrument called a reamer. The surgeon usually uses the reamer to drill holes into the bone of the scapula and to flatten the deformed glenoid surface so the base plate rests on a smooth, flat surface. This is where the stem of the glenoid component is anchored.

Finally, the humeral component and the glenoid component are inserted.

Once the joint is anchored, the surgeon tests for proper fit. When the surgeon is satisfied with the fit, the joint capsule is stitched together. The muscles are then returned to their correct positions, and the skin is also stitched up.

Your incision will be covered with a bandage, and your arm will be placed in a sling. You will then be woken up and taken to the recovery room.

What happens after surgery?

After surgery, you’ll be transported to the recovery room. You will have a dressing wrapped over your shoulder that will need to be changed frequently over the next few days. Your surgeon may have inserted a small drainage tube into the shoulder joint to help keep extra blood and fluid from building up inside the joint. An intravenous line (IV) will be placed in your arm to give you needed antibiotics and medication.

You arm will be placed in a sling usually with a large pillow that supports your arm in a position away from your body.  Generally the sling will remain on for 3-4 weeks.  In some cases, the use of the sling will be required for up to 6 weeks, particularly if a revision surgery has been completed.

What will my recovery be like?

Generally a Physical Therapist will see you the day after surgery to begin your rehabilitation program while you are in the hospital. Your therapist will make sure you are safe getting in and out of bed and moving about in your room with your sling on.  Next they will prescribe specific range of motion exercises for you that you will begin immediately as long as your surgeon allows it.  Your therapist will teach you how to remove your sling for your exercises and also how to put it back on after you have completed your exercises. The sling should be worn at all times except during showering and while performing rehabilitation exercises.

When the immobilizer is removed following surgery, you will experience some pain when you start to move your shoulder, wrist, elbow and forearm, and this is normal. This pain is from not using the joints very well prior to the surgery and also from the surgical process itself. The pain you feel should only be mild to moderate and any sharp or severe pain should be heeded.  In addition, the muscles in your arm may already appear small and atrophied. Again, this is normal; once your strength beings to return your arm will start to look more normal again.

Simple finger, hand and wrist movements, as well as elbow and neck range of motion exercises will be prescribed to ensure you regain motion in these joints.  For your shoulder, generally pendular exercises are prescribed along with passive range of motion exercises that encourage shoulder elevation (raising in front) as well as gentle external rotation. Pendular exercises assist with pain, help to maintain some shoulder range of motion, and assist in preventing unwanted scar tissue forming in the joint. These exercises are performed by leaning forward or to the side, letting the arm hang clear of the chest, and then initiating movement with your trunk so that the dangling limb passively and gently moves.  This action provides some traction to the glenohumeral joint, which aids in pain relief, and also assists the shoulder into a relatively elevated motion (in relation to the trunk.) It is important that the pendular activity is done as passively as possible without initiating motion from the shoulder muscles.
The exercise should be similar to a weighted pendulum that randomly swings on the end of a piece of string.  Icing your shoulder will be encouraged after your exercises as well as several other times during the day.

In cases where the reverse shoulder arthroplasty has been done as a revision to a traditionally replaced shoulder, or where the surgical approach has included cutting through the deltoid muscle, the initiation of early exercises will need to be delayed to allow a prolonged period of healing before putting the shoulder under any stress. In these cases your surgeon and therapist will direct you in regards to which exercises are initially allowed, and which should be avoided.  In all reverse shoulder replacement cases the specific post-surgical protocol of your surgeon should be strictly adhered to.  Each surgeon has their own protocol based on personal preference and experience, as well as surgical technique.

No matter which post-surgical protocol is followed, protecting the new joint is of particular importance after a reverse shoulder arthroplasty.  Due to the biomechanics of a reverse arthroplasty there is a higher risk of shoulder dislocation following a reverse shoulder arthroplasty versus a traditional shoulder replacement.  Unlike a traditional shoulder replacement, which is more likely to dislocate with the arm in abduction and external rotation, the reverse shoulder replacement is at risk of dislocation during isolated extension as well as the combined movements of extension, internal rotation, and adduction.  Your therapist will review these movement precautions with you and you should refrain from putting your shoulder in any of these positions on their own or in combination for a minimum of 12 weeks post-surgically.  Activities involving these positions, such as tucking in one’s shirt or performing personal hygiene of the back passage, are simple activities but can lead to dislocation so must be strictly avoided.  It can be helpful in respecting these precautions by remembering that you should always be able to see the elbow on your surgical side during all activities with that arm.

Once you are managing your exercises well in the hospital, you are independent in doing most activities to care for yourself, and when your surgeon feels it is appropriate, you will be sent home.  You will need to continue an extensive rehabilitation program once you are discharged from the hospital.  In some cases, a Physical Therapist or occupational therapist may visit your home to check to see that you are safely getting around in your home and managing your everyday tasks with your arm in your sling.  Your therapist may also review and assist you with your exercises at this time. If it is particularly difficult for you to get out of your home to attend Physical Therapy at First Choice Physical Therapy then a Physical Therapist may continue to visit you at your home for several treatments in order to review and advance your exercises. As soon as you are able, however, it is best for you to attend rehabilitation at First Choice Physical Therapy as there are several more modalities as well as exercise equipment that can be used in the clinic versus at home, which can expedite your recovery.

As an initial goal of rehabilitation your Physical Therapist at First Choice Physical Therapy will focus on relieving your pain and decreasing any swelling that may be lingering from the surgery. We may use modalities such as heat, ice, or electrical current to assist with decreasing any pain or swelling you have around the shoulder, anywhere along the arm, or into the hand. Due to some of the muscles of the neck and upper back connecting to the shoulder, you may also have pain in these regions, which we can treat in order to make movement of your entire upper body easier. We may also use massage or mobilizations for the neck, upper back, shoulder, elbow, forearm, or wrist to improve circulation and assist with any pain that may be present.

Due to the ongoing possibility of dislocation with a reverse shoulder arthroplasty, once you have begun therapy at First Choice Physical Therapy your therapist will review the shoulder motion precautions of shoulder extension, internal rotation, and adduction that will strictly need to be avoided for the first 12 weeks post-surgically, or until your surgeon advises you otherwise.

The next part of our treatment will focus on regaining the range of motion, strength, and dexterity in your wrist, hand, elbow, and shoulder. Your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of your home exercise program. These exercises may include the use of rehabilitation equipment such as pulleys and poles for range of motion exercises, and light weights or exercise band for resistance work of your upper limb. The shoulder joint is the upper limb’s link to the rest of the body so it needs to be strong and well controlled for the limb and hand to work well.  Exercises following a reverse shoulder arthroplasty will focus initially on gaining passive then active-assisted range of motion, while initiating some early light strengthening of the deltoid muscle as well as the other muscles around the shoulder blade that support the shoulder girdle.  All exercises should be done with pristine technique as to not compromise the new shoulder joint.  Your shoulder precautions should strictly be abided by and, in addition, once you have more range of movement you should be careful not to support your body weight at all with your surgical limb (ie: pushing off of a chair to get up or pushing a door open) nor lift much more than the weight of a coffee cup until your therapist clears you to do so.

Your Physical Therapist will be crucial in providing feedback during your exercises in order to ensure they are being done properly and safely.  As time and range of motion progress, strengthening will become the major focus and will be advanced so that light weights or elastic bands are used and endurance of the muscles is improved.  Your therapist will monitor your progress and advance your exercises as your shoulder can tolerate them.  Along with more advanced strengthening exercises active range of motion of the shoulder will be encouraged in order to assist with strengthening and control of the entire shoulder girdle.

Proprioception is the ability to know where your body is without looking at it. As a result of any injury or surgery, this ability declines in function. A period of immobility adds to this decline. Although your arm and shoulder girdle are not traditionally thought of as weight-bearing parts of the body, even an activity such as assisting yourself with your arms to get out of a chair or pulling a plate from a cupboard requires weight to be put through your shoulder girdle and for your body to be proprioceptively aware of your limb.

The proprioceptive control of the scapula on the rib cage (scapulothoracic motion) is especially important in being able to use your shoulder girdle and upper limb effectively without causing further injury. For this reason, your Physical Therapist will teach you how to properly control your scapula during your rehabilitation exercises as well as during everyday activities. Your Physical Therapist will also remind you about maintaining good shoulder posture even when sitting or using your upper limb in activities below shoulder height, such as working on the computer. Rounded shoulders in this position crowds the shoulder joint and can lead to shoulder impingement and pain. Regaining proprioception of the shoulder girdle and upper limb can require concentrated work, and most people have not previously needed to focus so intently on such controlled motions of this joint. The concentrated effort of shoulder rehabilitation however, has a substantial reward; good scapulothoracic control is the key to regaining maximum shoulder girdle control and thus improved shoulder functioning while avoiding future shoulder pain.

Proprioceptive exercises might include activities such as rolling a ball on a surface with your hand, holding a weight up while moving your shoulder, or push-ups on an unstable surface. Advanced exercises may include activities such as ball throwing or catching.  As often as possible, exercises will be incorporated that mimic your everyday activities such as grooming yourself and getting dressed, in addition to those activities that simulate your work or hobbies.

As rehabilitation advances most patients with a reverse shoulder replacement will be able to lift their arm with little or no pain. Some patients, however, may take many months to recover to this stage.  It should be noted that with all reverse shoulder arthroplasty surgeries the return of full shoulder elevation or external rotation is not expected.  A goal of approximately 105 degrees elevation should be anticipated. The amount of external rotation following surgery will be dependent on the state of the rotator cuff muscles prior to surgery.  Despite the relative loss of range of motion, for most patients the ability to achieve this range of motion without pain offers a very functional shoulder, particularly in comparison to the shoulder’s pre-surgical status.

Generally rehabilitation at First Choice Physical Therapy after reverse shoulder arthroplasty goes smoothly, however, if during rehabilitation your pain continues longer than it should or therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon or doctor to confirm that the shoulder is tolerating the rehabilitation well and to ensure that there are no hardware issues that may be impeding your recovery.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems.

Some of the most common complications following reverse artificial shoulder replacement are:

• anesthetic problems
• infection
• fracture
• dislocation
• loosening
• nerve or blood vessel injury

Anesthetic Problems

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia itself. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Infection following reverse joint replacement surgery can be very serious. The chances of developing an infection following artificial joint replacement are low (about one percent). Sometimes infections show up very early, before you leave the hospital. Other times infections may not show up for months, or even years, after the operation.

Infection can also spread into the artificial joint from other infected areas. Once an infection lodges in your joint, it is almost impossible for your immune system to clear it.

You may need to take antibiotics when you have dental work or surgical procedures on your bladder and colon. The antibiotics reduce the risk of spreading germs to the artificial joint.

Fracture

During the surgery, the humerus is prepared by cutting off the deformed humeral head and reaming the canal to allow for insertion of the humeral stem. The glenoid is reamed to create a bone tunnel, and flattened to seat the glenoid base plate. In patients with weak bone, fractures can occur during this part of the procedure that may require restricted activity after the surgery while the fracture heals.

Dislocation

Just like your real shoulder, an artificial shoulder can dislocate. A shoulder dislocation occurs when the ball comes out of the socket. There is a greater risk of dislocation right after surgery, before the tissues have healed around the new joint but there is always a slightly increased risk of dislocation with an artificial joint. Your Physical Therapist will teach you how to avoid activities and positions that tend to cause a shoulder dislocation.  As mentioned above under post-surgical rehabilitation, the motions that are prone to a dislocation in a traditional shoulder replacement are different to those that will cause a dislocation in a reverse shoulder replacement therefore consultation with a Physical Therapist should be undertaken to ensure you are aware of the proper precautions. A shoulder that dislocates more than once may need another operation to make it more stable.

Loosening

The major reason that artificial joints eventually fail is that they loosen where the metal or cement meets the bone. A loose joint prosthesis causes pain. Once the pain becomes unbearable, another operation will probably be needed to fix the artificial joint.

There have been great advances in extending the life of artificial joints. However, most will eventually loosen and require another surgery. In the case of artificial knees, you can expect about 12 to 15 years, but artificial shoulder joints tend to loosen sooner.

Nerve or Blood Vessel Injury

All of the large nerves and blood vessels to the arm and hand travel through the armpit (axilla). Being that shoulder replacement surgery takes place so close to the axilla, it is possible that the nerves or blood vessels may be injured during surgery. The resulting problems may only be temporary if the injury was caused by stretching of the nerves to hold them out of the way during the surgery. The nerves and blood vessels rarely suffer any kind of permanent injury after reverse shoulder replacement surgery, but this type of injury can happen.

This article is an introduction to Artificial Hip Dislocation Precautions

Hip surgeries such as total joint replacement and hemiarthroplasty require the surgeon to open the hip joint capsule. This puts the hip at risk of dislocating after surgery. Patients follow special precautions after surgery about which hip positions and movements need to be avoided to keep the hip from dislocating. While you are in the hospital, your health care team will remind you often about the need to follow these hip precautions. Once you get home, you will have to remember to follow these rules until your surgeon approves motion beyond these limits of movement.

This guide will help you understand:

• why hip precautions are needed
• which precautions you should use and when to use them
• ideas you can use at home to protect your hip joint

Which parts of the hip joint are affected by a dislocation?

The hip joint is one of the true ball-and-socket joints of the body.

The hip socket is called the acetabulum and forms a deep cup that surrounds the ball of the upper thighbone, called the femoral head. The ball and socket is surrounded by a soft-tissue enclosure called the joint capsule.

The hip itself is surrounded by the thick muscles of the buttock on the back of the hip and the upper thigh muscles on the front.

Muscles

When the surgeon opens the hip joint capsule on the front edge, the procedure is called an anterior approach. Opening the joint from the back part of the joint is called a posterior approach.

Opening the Hip Joint

Rationale for Hip Precautions

Why are precautions needed to prevent a hip dislocation?

The joint capsule and ligaments keep the ball joint centered in the hip. When these soft tissues are cut during hip surgery, there is a greater risk for the ball to be forced out of the socket and dislocated after surgery while the soft tissues of the hip heal. The hip precautions you’ll learn are used to keep your hip in safe positions. To do this, you need to avoid certain movements and positions. In this way, the ball will be less likely to push against the healing tissues and be forced out of the socket. Most surgeons prefer to have you use these precautions for at least six to twelve weeks after surgery until the healing tissues gain strength.

Dislocation of an artificial hip is uncommon but may occur within the first three months after surgery. The problem usually starts with a popping or slipping sensation. If the ball dislocates, you will be unable to put weight on the affected limb and will most likely experience discomfort in your hip. You should contact your orthopedic surgeon immediately and probably have someone take you to the emergency room. Putting the hip back in the socket will probably require medication given intravenously to relax the hip muscles and allow your surgeon to put the hip back into place.

Most patients will have an opportunity to work with a physical or occupational therapist before having hip joint surgery. However, patients sometimes require emergency surgery, such as after a hip fracture, and are not able to have preoperative therapy instruction.

Your therapist will go over specific precautions with you in the preoperative visit and will drill you often to make sure you practice them at all times for six to 12 weeks after surgery.

Your health care team will remind you often about these precautions. They sometimes place a sign by your hospital bed as a reminder. You’ll continue to review and use these precautions until your surgeon gives the approval for you to stop using them.

Anterior Approach

The main positions and movements to avoid after an anterior approach include bending the hip back, turning your hip and leg out, or spreading your leg outward.

Don’t stretch your hip back. Walk with short steps. Taking a longer step when leading with your nonoperated hip stretches the surgical hip back.

• Don’t kneel only on one knee. Kneeling only on the surgical hip stretches the hip back. Use both knees when you must kneel down.
• Don’t turn your foot out. Place a pillow next to your hip and leg to keep your leg from turning or rolling out while lying on your back in bed.
• Don’t twist your body away from your operated hip. This means don’t stand with your toes pointed out. Keep the toes of your affected leg pointed forward when you stand, sit, or walk. If you turn your body away from your surgical hip without pivoting your foot, your hip will be placed in an unsafe position. Remember to lift and turn your foot as you turn.

What arrangements should I consider in my home to help protect my hip from dislocating?

You may require special equipment at home to keep your hip in safe positions. Following are ideas for different areas of your home.

Bathroom

Several items can be used to increase your safety in the bathroom. For instance, a toilet seat can be elevated with a raised commode seat to keep your hip from bending too far when sitting down. Getting on and off the commode may be easier with the help of handrails or grab bars securely fastened near by. For accessing your bathtub or shower, you may need one or more grab bars. For additional safety and comfort, be sure to obtain an adjustable tub or shower bench. When you first try the bench, be sure your knees are positioned slightly lower than your hips. In this way, you’ll be sure to keep your hip from bending more than ninety degrees while sitting down.

Furniture

To prevent your hip from bending beyond ninety degrees, you may need to elevate your couch, chair, or recliner. A good rule of thumb is to have a seat height that is at least twenty inches above the floor. If you find that your furniture is too low, consider using a platform under your chair or couch to raise it to the desired height. Using four-by-four blocks may be helpful, but be sure that the chair or couch is safe and steady before you sit down.

Shelves and Cupboards

To avoid excessive bending and lifting, arrange your shelves and cupboards with frequently used items at waist to shoulder height. For lighter items on lower shelves, be sure to have your grabber handy to keep from bending over too far at the hip.

If you are able to see your First Choice Physical Therapy physical or Physical Therapist before surgery, you’ll begin going over your hip precautions then. After surgery, our Physical Therapist will begin working with you right away and may see you one to three times each day in the hospital until you are safe to go home.

You are advised to continue using your hip precautions until your surgeon says you may discontinue following them.

Welcome to First Choice Physical Therapy’s resource with respect to recovering from Artificial Joint Replacement of the Hip.

 A hip that is painful as a result of osteoarthritis (OA) can severely affect your ability to lead a full, active life. Over the last 25 years, major advancements in hip replacement have improved the outcome of the surgery greatly. Hip replacement surgery (also called hip arthroplasty) is becoming more and more common as the population of the world begins to age.

This guide will help you understand:

• what your surgeon hopes to achieve
• what happens during the procedure
• what to expect after your operation

How does the hip normally work?

The hip joint

is one of the true ball-and-socket joints of the body. The hip socket is called the acetabulum and forms a deep cup that surrounds the ball of the upper thigh bone, known as the femoral head. The thick muscles of the buttock at the back and the thick muscles of the thigh in the front surround the hip.

The surface of the femoral head and the inside of the acetabulum are covered with articular cartilage. This material is about one-quarter of an inch thick in most large joints. Articular cartilage is a tough, slick material that allows the surfaces to slide against one another without damage.

What does the surgeon hope to achieve?

The main reason for replacing any arthritic joint with an artificial joint is to stop the bones from rubbing against each other. This rubbing causes pain. Replacing the painful and arthritic joint with an artificial joint gives the joint a new surface, which moves smoothly without causing pain. The goal is to help people return to many of their activities with less pain and greater freedom of movement.

How should I prepare for surgery?

The decision to proceed with surgery should be made jointly by you and your surgeon only after you feel that you understand as much about the procedure as possible.

Once the decision to proceed with surgery is made, several things may need to be done. Your orthopedic surgeon may suggest a complete physical examination by your medical or family doctor. This is to ensure that you are in the best possible condition to undergo the operation. You may also need to spend time with the Physical Therapist who will be managing your rehabilitation after the surgery.

One purpose of the preoperative Physical Therapy visit is to record a baseline of information. This includes measurements of your current pain levels, functional abilities, and the movement and strength of each hip.

A second purpose of the preoperative therapy visit is to prepare you for your upcoming surgery. You will begin to practice some of the exercises you will use just after surgery. You will also be trained in the use of either a walker or crutches. Whether the surgeon uses a cemented or noncemented approach may determine how much weight you will be able to apply through your foot while walking.

This procedure requires the surgeon to open up the hip joint during surgery. This puts the hip at some risk for dislocation after surgery. To prevent dislocation, patients follow strict guidelines about which hip positions to avoid (called hip precautions). Your Physical Therapist will review these precautions with you during the preoperative visit and will drill you often to make sure you practice them at all times for at least six weeks. Some surgeons give the OK to discontinue the precautions after six to 12 weeks because they feel the soft tissues have gained enough strength by this time to keep the joint from dislocating.

Finally, the Physical Therapist assesses any needs you will have at home once you’re released from the hospital.

You may be asked to donate some of your own blood before the operation. This blood can be donated three to five weeks before the operation, and your body will make new blood cells to replace the loss. At the time of the operation, if you need to have a blood transfusion you will receive your own blood back from the blood bank.

The Artificial Hip

There are two major types of artificial hip replacements:

• cemented prosthesis
• uncemented prosthesis

A cemented prosthesis is held in place by a type of epoxy cement that attaches the metal to the bone.

An uncemented prosthesis bears a fine mesh of holes on the surface that allows bone to grow into the mesh and attach the prosthesis to the bone.

Both are still widely used. In some cases a combination of the two types is used in which the ball portion of the prosthesis is cemented into place, and the socket not cemented. The decision about whether to use a cemented or uncemented artificial hip is usually made by the surgeon based on your age and lifestyle, and the surgeon’s experience.

Each prosthesis is made of two main parts. The acetabular component (socket) replaces the acetabulum. The acetabular component is made of a metal shell with a plastic inner liner that provides the bearing surface. The plastic used is so tough and slick that you could ice skate on a sheet of it without much damage to the material.

The femoral component (stem and ball) replaces the femoral head. The femoral component is made of metal. Sometimes, the metal stem is attached to a ceramic ball.

The Operation

The surgeon begins by making an incision on the side of the thigh to allow access to the hip joint. Several different approaches can be used to make the incision. The choice is usually based on the surgeon’s training and preferences.

Once the hip joint is entered, the surgeon dislocates the femoral head from the acetabulum. Then the femoral head is removed by cutting through the femoral neck with a power saw.

Attention is then turned toward the socket. The surgeon uses a power drill and a special reamer (a cutting tool used to enlarge or shape a hole) to remove cartilage from inside the acetabulum.

The surgeon shapes the socket into the form of a half-sphere. This is done to make sure the metal shell of the acetabular component will fit perfectly inside. After shaping the acetabulum, the surgeon tests the new component to make sure it fits just right.

In the uncemented variety of artificial hip replacement, the metal shell is held in place by the tightness of the fit or by using screws to hold the shell in place. In the cemented variety, a special epoxy-type cement is used to anchor the acetabular component to the bone.

To begin replacing the femur, special rasps (filing tools) are used to shape the hollow femur to the exact shape of the metal stem of the femoral component.

Once the size and shape are satisfactory, the stem is inserted into the femoral canal.

Again, in the uncemented variety of femoral component the stem is held in place by the tightness of the fit into the bone (similar to the friction that holds a nail driven into a hole that is slightly smaller than the diameter of the nail). In the cemented variety, the femoral canal is enlarged to a size slightly larger than the femoral stem, and the epoxy-type cement is used to bond the metal stem to the bone.

The metal ball that makes up the femoral head is then inserted.

Once the surgeon is satisfied that everything fits properly, the incision is closed with stitches. Several layers of stitches are used under the skin, and either stitches or metal staples are then used to close the skin. A bandage is applied to the incision, and you are returned to the recovery room.

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following hip replacement surgery include:

• anesthesia complications
• thrombophlebitis
• infection
• dislocation
• loosening

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but it is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection can be a very serious complication following artificial joint replacement surgery. The chance of getting an infection following total hip replacement is probably around one percent. Some infections may show up very early, even before you leave the hospital. Others may not become apparent for months, or even years, after the operation. Infection can spread into the artificial joint from other infected areas. Your surgeon may want to make sure that you take antibiotics when you have dental work or surgical procedures on your bladder or colon to reduce the risk of spreading germs to the joint.

Dislocation

Just like your real hip, an artificial hip can dislocate if the ball comes out of the socket. There is a greater risk just after surgery, before the tissues have healed around the new joint, but there is always a risk. The Physical Therapist will instruct you very carefully how to avoid activities and positions which may have a tendency to cause a hip dislocation. A hip that dislocates more than once may have to be revised to make it more stable. This means another operation.

Loosening

The main reason that artificial joints eventually fail continues to be the loosening of the metal or cement from the bone. Great advances have been made in extending how long an artificial joint will last, but most will eventually loosen and require a revision. Hopefully, you can expect 12 to 15 years of service from an artificial hip, but in some cases the hip will loosen earlier than that. A loose hip is a problem because it causes pain. Once the pain becomes unbearable, another operation will probably be required to revise the hip.

After Surgery

What happens after surgery?

After surgery, your hip will be covered with a padded dressing. Special boots or stockings are placed on your feet to help prevent blood clots from forming. A triangle-shaped cushion may be positioned between your legs to keep your legs from crossing or rolling in.

If your surgeon used a general anesthesia, a nurse or respiratory therapist will visit your room to guide you in a series of breathing exercises. You’ll use an incentive spirometer to improve breathing and avoid possible problems with pneumonia.

Physical Therapy treatments are scheduled one to three times each day as long as you are in the hospital. Your first treatment is scheduled soon after you wake up from surgery. Your therapist will begin by helping you move from your hospital bed to a chair. By the second day, you’ll begin walking longer distances using your crutches or walker. Most patients are safe to put comfortable weight down when standing or walking. However, if your surgeon used a noncemented prosthesis, you may be instructed to limit the weight you bear on your foot when you are up and walking.

Your Physical Therapist will review exercises to begin toning and strengthening the thigh and hip muscles. Ankle and knee movements are used to help pump swelling out of the leg and to prevent the formation of blood clots.

Patients are usually able to go home after spending four to seven days in the hospital. You’ll be on your way home when you can demonstrate a safe ability to get in and out of bed, walk up to 75 feet with your crutches or walker, go up and down stairs safely. and consistently remember to use your hip precautions. Patients who still need extra care may be sent to a different hospital unit until they are safe and ready to go home.

Most orthopedic surgeons recommend that you have checkups on a routine basis after your artificial joint replacement. How often you need to be seen varies from every six months to every five years, according to your situation and what your surgeon recommends.

Patients who have an artificial joint will sometimes have episodes of pain, but if you have a period that lasts longer than a couple of weeks you should consult your surgeon. During the examination, the orthopedic surgeon will try to determine why you are feeling pain. X-rays may be taken of your artificial joint to compare with the ones taken earlier to see whether the joint shows any evidence of loosening.

What should I expect during my recovery?

After you are discharged from the hospital, your First Choice Physical Therapy Physical Therapist may see you for in-home treatments. This is to ensure you are safe in and about the home and getting in and out of a car. Our Physical Therapist will review your exercise program, continue working with you on your hip precautions, and make recommendations about your safety.

These safety tips include using raised commode seats and bathtub benches, and raising the surfaces of couches and chairs. This keeps your hip from bending too far when you sit down. Bath benches and handrails can improve safety in the bathroom. Our Physical Therapist may provide other suggestions including the use of strategic lighting and the removal of loose rugs or electrical cords from the floor.

You should use your walker or crutches as instructed by our Physical Therapist. If you had a cemented procedure, you’ll advance the weight you place through your sore leg as much as you feel comfortable. If you had a noncemented procedure, your surgeon may want you to place only the toes of your operated leg down for up to six weeks after surgery. Although recovery time varies, most patients progress to using a cane in three to four weeks once they begin weightbearing on the leg.

Your staples will usually be removed two weeks after surgery. Patients may be able to drive within three weeks and walk without a walking aid by six weeks of weightbearing. Upon the approval of our Physical Therapists, patients are generally able to resume sexual activity by one to two months after surgery.

Home therapy visits end when you are safe to get out of the house, which may take up to three weeks.

Your First Choice Physical Therapy Physical Therapy program usually ends when home care is completed. But a few additional visits in outpatient Physical Therapy may be needed for patients who have problems walking or who need to get back to heavier types of work or activities. During outpatient visits, our Physical Therapist may use heat, ice, or electrical stimulation to reduce any swelling or pain.

First Choice Physical Therapy therapists sometimes treat patients in a pool. Exercising in a swimming pool puts less stress on the hip joint, and the buoyancy lets you move and exercise easier. Once you’ve gotten your pool exercises down and the other parts of our rehab program advance, we may instruct you in an independent program.

When you are safe in putting full weight through the leg, our Physical Therapist will choose several types of balance exercises to further stabilize and control the hip.

Finally, we will use a select group of exercises to simulate day-to-day activities, such as going up and down steps, squatting, and walking on uneven terrain. Our Physical Therapist may then choose specific exercises to simulate work or hobby demands.

Many patients have less pain and better mobility after having hip replacement surgery. Our Physical Therapist will work with you to help keep your new joint healthy for as long as possible. This may require that you adjust your activity choices to keep from putting too much strain on your new hip joint. Heavy sports that require running, jumping, quick stopping and starting, and cutting are discouraged. Patients may need to consider alternate jobs to avoid work activities that require heavy demands of lifting, crawling, and climbing.

At First Choice Physical Therapy, our goal is to help you maximize strength, walk normally, and improve your ability to do your activities. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Welcome to First Choice Physical Therapy’s resource with respect to recovering from Compression Fixation for a Fractured Hip.

A fractured hip can be a life-threatening problem. The hip fracture itself isn’t usually a difficult problem to treat with surgery. But once the fracture occurs, it brings with it all the potential medical complications that can arise when aging adults are confined to bed. The goal of treatment is to get patients moving as quickly as possible after surgery. Fixing the fracture with a compression hip screw and metal plate is fairly simple and usually allows patients to get up and start moving shortly after surgery.

This guide will help you understand:

• what your surgeon hopes to achieve
• what happens during the operation
• what to expect during your recovery

What part of the hip is involved?

The femur is the large bone in the thigh. The ball-shaped femoral head fits into a socket in the pelvis, called the acetabulum. The femoral neck is a thinner part of the femur. It is the short section of bone next to the femoral head that connects the femoral head to the main shaft of the femur.

The intertrochanteric region of the hip is just below the femoral neck. A fracture in this area is called an intertrochanetric hip fracture. This type of fracture is most common when a person falls and fractures the hip. There is usually more than one fracture with more pieces of broken bone to be held together.

Intertrochanetric Hip Fracture

What does the surgeon hope to achieve?

Fixing the hip fracture surgically with a special type of metal plate and screw, called a compression screw, does two things. First, it helps align the bone fragments and hold them in the proper position. Second, the fixation device is strong enough to keep the bones in place as you begin to move about. Before these devices were used, a patient needed to remain in bed usually with traction to hold the bones in alignment. The fixation now holds the bones in place while the bone heals. This allows you to get out of bed sooner because the metal plate and screw are strong enough to hold the bone fragments in place as you move.

The procedure requires only a small incision on the side of the hip, and the plate and screw usually provide a solid connection for the broken bones. Since patients are able to get moving right away after surgery, they are more likely to avoid the serious complications that can arise with being immobilized in bed.

What happens before surgery?

Compression fixation for a fractured hip is usually an emergency surgery, so it is likely you may not have had time to plan and prepare. Ideally a caregiver, such as a family member or friend, will help make arrangements for you while you are in the hospital.

The surgeon and care team will communicate with your caregiver to help with these preparations. Your caregiver will help coordinate your ride home, make sure you have needed supplies, and make follow-up appointments with your surgeon, doctor, and Physical Therapist.

What happens during the operation?

Sometimes, a fractured hip only requires a simple pinning procedure. The procedure for the compression hip screw, however, is more involved. There are usually several fragments of bone that need to be held together. There is also more blood lost during the surgery, which could require that you have a blood transfusion during the operation.

This operation can be done using either a general anesthetic or a spinal block. A general anesthetic puts you completely to sleep. A spinal block puts your body to sleep only from the waist down. The anesthesiologist will also give you medications so that you won’t be aware the operation is being done.

Once you have anesthesia, your surgeon will make sure the skin of your hip is free of infection by cleaning the skin with a germ-killing solution.

With the patient lying flat on a special table, the foot and leg are supported. Tension is applied to get the fractured bones to line up. The surgeon checks the alignment using a fluoroscope, a type of X-ray machine that shows the image on a TV screen.

Next, the surgeon makes an incision over the side of the thigh. A large metal screw is placed through the side of the hip into the femoral head. With the help of the fluoroscope, the surgeon attaches a metal plate to the side of the femur with four to eight small metal screws. The procedure can usually be finished in less than an hour depending on how many fragments of bone are involved in the fracture.

The soft tissues are put back in place, and metal staples or sutures are used to close the incision.

What might go wrong?

Complications after a hip fracture are sometimes the result of being immobilized in bed. These may include pneumonia, bed sores, mental confusion, and blood clots (deep venous thrombosis).

Complications that can result from the compression fixation surgery itself include:

• anesthesia complications
• infection
• thrombophlebitis (DVT)
• nerve or blood vessel injury
• nonunion of the bones

This is not intended to be a complete list of possible complications.

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Any surgery carries the risk of infection. You will probably be given antibiotics before the procedure to reduce the risk. If you get an infection, you will need more antibiotics. If the areas around the metal screws or plate become infected, you may need surgery to drain the infection.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but it is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Nerve or Blood Vessel Injury

Several nerves and blood vessels travel in the area where the surgery is performed. It is possible to injure either the nerves or the blood vessels during surgery, but this is extremely unlikely during this type of procedure. Nerve problems may be temporary if the nerves have been stretched by retractors holding them out of the way. It is rare to have permanent injury to either the nerves or the blood vessels, but it is possible.

Nonunion

Sometimes the bones do not bond together as planned. This is called a nonunion, or pseudarthrosis. This condition requires another operation to add more fixation or to replace the head of the femur, a procedure called hemiarthroplasty.

After Surgery

What happens after the operation?

After surgery, your hip will be covered with a padded dressing. If your surgeon used a general anesthesia, a nurse or respiratory therapist will guide you in a series of breathing exercises. You’ll use an incentive spirometer to improve breathing and avoid possible problems with pneumonia.

A Physical Therapist will direct your recovery after surgery. You’ll be encouraged to move from your hospital bed to a chair several times the first day after surgery. You’ll be encouraged to begin getting up and walking with your crutches or walker, but you may need to keep from placing too much weight on your foot while you stand or walk. You’ll be ready to go home when you can move about safely with your walker or crutches, you are able to do your exercises, and your caregiver has made all the needed preparations for you at home.

You should keep the dressing on your hip until you return to the surgeon. Avoid getting the stitches wet. Your stitches will be removed 10 to 14 days after surgery. Remember to support your outer hip with a pillow when you sit or recline.

What should I expect during my recovery?

Once discharged from the hospital, your First Choice Physical Therapy Physical Therapist may see you for in-home treatments. This is to ensure that you are safe in and about the home and getting in and out of a car. We will make recommendations about your safety, review your exercise program, and continue working with you on walking and strength. In some cases you may require additional visits at home before beginning our outpatient Physical Therapy. Home therapy visits end when you are safe to get out of the house.

Additional outpatient Physical Therapy visits are sometimes needed for patients who are still having problems walking or who need to get back to physically heavy work or activities.

Our Physical Therapist may use hands-on stretches for improving your range of motion. We will add strength exercises to address key muscle groups including the buttock, hip, and thigh. Endurance can be achieved through stationary biking, lap swimming, and using an upper body ergometer (arm cycle).

First Choice Physical Therapy Physical Therapists sometimes treat patients in a pool. Exercising in a swimming pool puts less stress on the hip joint, and the buoyancy lets you move and exercise easier. Once you’ve gotten your pool exercises down, our therapist aill instruct you in an independent program.

When you are safe in putting full weight through the leg, we will choose several types of balance exercises to further stabilize and control the hip. Finally, our Physical Therapist will use a select group of exercises to simulate day-to-day activities, such as going up and down steps, squatting, and walking on uneven terrain. Specific exercises may then be chosen to simulate work or hobby demands.

At First Choice Physical Therapy, our goal is to help you maximize hip range of motion and strength, restore a normal walking pattern, and do your activities without risking further injury. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Welcome to First Choice Physical Therapy’s resource with respect to recovering from Hip Pinning Surgery for a Fractured Hip.

This guide will help you understand:

• what the surgeon hopes to achieve
• what happens during the procedure
• what to expect as you recover

How is the hip designed?

The femur is the large bone of the thigh. The ball-shaped femoral head on the end of the femur fits into a socket in the pelvis called the acetabulum. The femoral neck is a thinner part of the femur. It is the short section of bone that connects the femoral head to the main shaft of the bone. The bump on the outside of the femur just below the femoral neck is called the greater trochanter. This is where the large muscles of the buttock attach to the femur.

Hip fractures in aging adults happen either in the femoral neck or the intertrochanteric area. Fractures occur at about the same frequency for both areas.

What does the surgeon hope to achieve?

Fixing the broken ends of the hip with metal pins or screws is a fairly simple procedure. The procedure requires only a small incision on the side of the hip, and the pins and screws usually provide a solid connection for the broken bones. Patients are able to move right away after surgery, so they are more likely to avoid the serious complications that can arise with being immobilized in bed.

Most hip fractures would actually heal without surgery, but the problem is that the patient would be in bed for eight to 12 weeks. Surgeons have learned over the years that confining an aging adult to bed for this period of time has a far greater risk of creating serious complications than the surgery required to fix a broken hip. The goal of the hip pinning procedure is to set the bones securely in place, allowing the patient to get out of bed as soon as possible.

The hip pinning procedure is used successfully after most fractures within the femoral neck. When the fractured bones have displaced, however, surgeons do not all agree that the hip pinning procedure is the best choice. This is because displaced fractures can damage the blood supply going to the femoral head, leading to avascular necrosis (AVN), a condition that causes the bone of the femoral head to die. With displaced fractures, the risk of developing AVN is so high that some surgeons may suggest not fixing the fracture but instead removing the femoral head and replacing it with an artificial replacement, or prosthesis. This is suggested because pinning the fracture carries a high chance that you will need a second operation several months later if the femoral head dies due to AVN.

How should I prepare for surgery?

The hip pinning procedure is usually an emergency surgery, so it is unlikely that you will have had time to plan and prepare. Ideally a caregiver, such as a family member or friend, will help make arrangements for you while you are in the hospital.

The surgeon and care team will communicate with your caregiver to help with these preparations. Your caregiver will help coordinate your ride home, make sure you have needed supplies, and set up follow-up appointments with your surgeon, doctor, and Physical Therapist.

What happens during the operation?

The operation can be done using either a general anesthetic (one that puts you to sleep) or a spinal block. The spinal block puts your body to sleep from the waist down. With a spinal block, the anesthesiologist will also give you medications so that you won’t be aware the operation is being done.

Once you have anesthesia, your surgeon will make sure the skin of your hip is free of infection by cleaning the skin with a germ-killing solution.

With the patient lying flat on a special table, the foot and leg are supported. Tension is applied to get the fractured bones to line up. The surgeon checks the alignment using a fluoroscope, a type of X-ray machine that shows the image on a TV screen.

A small incision is made on the side of the thigh. The surgeon uses the fluoroscope to guide the metal screws or pins into the correct position to hold the bones together. The fluoroscope allows the surgeon to see the X-ray image of the hip while the screws are placed through the femoral neck.

The soft tissues are put back in place, and metal staples or sutures are used to close the incision.

What might go wrong?

The main complications after a hip fracture sometimes develop as a result of being immobilized in bed. These may include pneumonia, bedsores, and mental confusion.

Complications that can result from the hip pinning surgery itself include:

• anesthesia complications
• thrombophlebitis
• infection
• nerve or blood vessel injury
• avascular necrosis of the femoral head
• nonunion of the bones

This is not intended to be a complete list of possible complications.

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but it is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Any surgery carries the risk of infection. You will probably be given antibiotics before the procedure to reduce the risk. If you get an infection, you will need more antibiotics. If the areas around the metal pins or screws become infected, you may need surgery to drain the infection.

Nerve or Blood Vessel Injury

Several nerves and blood vessels travel in the area where the surgery is performed. It is possible to injure either the nerves or the blood vessels during surgery, but this is extremely unlikely during this type of surgery. Nerve problems may well be temporary if the nerves have been stretched by retractors holding them out of the way. It is rare to have permanent injury to either the nerves or the blood vessels, but it is possible.

Avascular Necrosis (AVN)

As described earlier, all of the blood supply comes into the ball that forms the hip joint through the neck of the femur bone. If this blood supply is damaged, there is no backup. Damage to the blood supply can lead to the bone that makes up the ball portion of the femur actually dying. Once this occurs, the bone is no longer able to maintain itself. When the neck of the femur fractures, the blood supply may be damaged, leading to problems with avascular necrosis. The risk of AVN is much higher when the fracture causes a large displacement in the bones. AVN can show up as late as two years after the surgery.

Nonunion

Sometimes the bones do not bond together as planned. This is called a nonunion, or pseudarthrosis. This condition requires another operation to add more fixation or actually replace the head of the femur, a procedure called hemiarthroplasty.

After Surgery

What happens after surgery?

After surgery, your hip will be covered with a padded dressing. If your surgeon used a general anesthesia, a nurse or respiratory therapist will guide you in a series of breathing exercises. You’ll use an incentive spirometer to improve breathing and avoid possible problems with pneumonia.

A Physical Therapist will direct your recovery after surgery. You’ll be encouraged to move from your hospital bed to a chair several times the first day after surgery. You’ll be encouraged to begin getting up and walking with your crutches or walker but may need to keep from placing too much weight on your foot while you stand or walk. You’ll be safe to go home when you can get up and move about safely with your walker or crutches, you are able to do your exercises, and your caregiver has made all the needed preparations for you to go home.

After surgery, you should keep the dressing on your hip until you return to the surgeon. Avoid getting the stitches wet. Your stitches will be removed 10 to 14 days after surgery. You should support your outer hip with a pillow when you sit or recline.

What should I expect during my recovery?

Once discharged from the hospital, your First Choice Physical Therapy Physical Therapist may see you for in-home treatments. This is to ensure you are safe in and about the home and getting in and out of a car. Our Physical Therapist will make recommendations about your safety, review your exercise program, and continue working with you on walking and strength. In some cases you may require additional visits at home before beginning our outpatient Physical Therapy. Home therapy visits end when you are safe to get out of the house.

Additional outpatient Physical Therapy visits are sometimes needed for patients who still have problems walking or who need to get back to physically heavy work or activities.

Our therapist may use hands-on stretches for improving range of motion. Then we use strength exercises to address key muscle groups including the buttock, hip, and thigh. Endurance can be achieved through stationary biking, lap swimming, and using an upper body ergometer (upper cycle).

First Choice Physical Therapy Physical Therapists sometimes treat patients in a pool. Exercising in a swimming pool puts less stress on the hip joint, and the buoyancy allows you to move and exercise easier. Once you’ve gotten your pool exercises down and the other parts of your rehab program advance, we may instruct you in an independent program.

When you are safe in putting full weight through the leg, our Physical Therapist will choose several types of balance exercises to further stabilize and control the hip.

Finally, we can use a select group of exercises to simulate day-to-day activities, such as going up and down steps, squatting, and walking on uneven terrain. Specific exercises may then be chosen to simulate work or hobby demands.

At First Choice Physical Therapy, our goal is to help you maximize hip range of motion and strength, restore a normal walking pattern, and do your activities without risking further injury to the hip. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Welcome to First Choice Physical Therapy’s resource with respect to Hip Resurfacing Arthroplasty.

A hip that is painful as a result of osteoarthritis (OA) can severely affect your ability to lead a full, active life. Over the last 25 years, major advancements in hip replacement have greatly improved the outcome of the surgery.

Hip resurfacing arthroplasty is a type of hip replacement that replaces the arthritic surface of the joint but removes far less bone than the traditional total hip replacement. Because the hip resurfacing removes less bone, it may be preferable for younger patients that are expected to need a second, or revision, hip replacement surgery as they grow older and wear out the original artificial hip replacement.

This guide will help you understand:

• what your surgeon hopes to achieve
• what happens during the procedure
• what to expect after your operation

What parts of the hip are involved?

The hip joint is one of the true ball-and-socket joints of the body. The hip socket is called the acetabulum and forms a deep cup that surrounds the ball of the upper thighbone, known as the femoral head. Hip resurfacing may only affect the head of the femur or it may involve both the femoral head and the hip socket.

What does the surgeon hope to achieve?

The main reason for replacing any arthritic joint with an artificial implant is to stop the bones from rubbing against each other. This rubbing causes pain. Replacing the painful and arthritic joint with a new surface, allows the joint to move smoothly without pain. The goal is to help people return to many of their activities with less pain and greater freedom of movement.

The most important reason to do a hip resurfacing rather than a traditional artificial hip replacement, is to remove as little bone around the hip as possible. This is especially important when you may need a second, or revision, hip replacement as you grow older.

The most common cause for revision of an artificial hip is loosening of the pieces of the artificial hip joint where it attaches to the bone. The loosening process results in wearing away of the bone around the metal components, or parts of the artificial joint. This is especially true around the stem of the femoral component that fits inside of the femoral shaft in the traditional artificial joint. The femoral component used during hip resurfacing is placed on the outside of the femoral head and the femoral shaft is never disturbed. This means that when a revision is needed, the femoral shaft can be used to hold the femoral component as if there has never been an artificial joint and the bone in this area is virginal.

How should I prepare for surgery?

The decision to proceed with surgery should be made jointly by you and your surgeon only after you feel that you understand as much about the procedure as possible. Many patients wonder when they should consider surgery. Most surgeons agree that surgery is advised when a patient’s pain and discomfort limit daily life and activities.

Once the decision to proceed with surgery is made, several things may need to be done. Your orthopedic surgeon may suggest a complete physical examination by your medical or family doctor. This is to ensure that you are in the best possible condition to undergo the operation. You may also need to spend time with the Physical Therapist who will be managing your rehabilitation after the surgery.

One purpose of the preoperative Physical Therapy visit is to record a baseline of information. This includes measurements of your current pain levels, functional abilities, and the movement and strength of each hip.

A second purpose of the preoperative therapy visit is to prepare you for your upcoming surgery. You will begin to practice some of the exercises you will use just after surgery.

You will also be trained in the use of crutches or a walker. Your Physical Therapist will also assess any needs you will have at home or work once you’re released from the hospital.

You may be asked to donate some of your own blood before the operation. This blood can be donated three to five weeks before the operation, and your body will make new blood cells to replace the loss. At the time of the operation, if you need to have a blood transfusion you will receive your own blood back from the blood bank.

Surgeons perform this operation using several different incisions, or approaches, to the hip joint. The anterior approach from the front of the hip and the posterior approach from the back of the hip. There is no one right approach. Many surgeons prefer the posterior approach because it keeps the joint capsule intact. Keeping the joint capsule intact may reduce the risk of dislocation after the surgery and damage the blood supply less. Either approach is commonly used depending on the training and experience of the surgeon.

The operation begins by making an incision in the side of the thigh. This allows the surgeon to see both the femoral head and the acetabulum (or socket). The femoral head is then dislocated out of the socket. Special powered instruments are used to shape the bone of the femoral head so that the new metal surface will fit snugly on top of the bone.

Shape the Bone

Femoral Head

The cap is placed over the smoothed head like a tooth capped by the dentist. The cap is held in place with a small peg that fits down into the bone.

Small Peg

The patient must have enough healthy bone to support the cap.

The hip socket may remain unchanged but more often it is replaced with a thin metal cup. A special tool called a reamer is used to remove the cartilage from the acetabulum and shape the socket to fit the acetabular component. Once the shape is correct, the acetabular component is pressed into place in the socket. Friction holds the metal liner in place until bone grows into the holes in the surface and attaches the metal to the bone.

Reamer

What could go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following hip resurfacing arthroplasty surgery include:

• anesthesia complications
• thrombophlebitis
• infection
• dislocation
• femoral neck fracture
• leg length inequality
• loosening

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but it is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection can be a very serious complication following artificial joint replacement surgery. The chance of getting an infection following hip joint resurfacing is probably around one percent. Some infections may show up very early, even before you leave the hospital. Others may not become apparent for months, or even years, after the operation. Infection can spread into the artificial joint from other infected areas. Your surgeon may want to make sure that you take antibiotics when you have dental work or surgical procedures on your bladder or colon to reduce the risk of spreading germs to the joint.

Dislocation

Just like your real hip, an artificial hip can dislocate if the ball comes out of the socket. There is a greater risk just after surgery, before the tissues have healed around the new joint, but there is always a risk. The Physical Therapist will instruct you very carefully how to avoid activities and positions that may have a tendency to cause a hip dislocation. A hip that dislocates more than once may have to be revised to make it more stable. This means another operation.

Related Document: First Choice Physical Therapy’s Guide to Artificial Hip Dislocation Precautions

Loosening

The main reason that artificial joints eventually fail continues to be the loosening of the metal or cement from the bone. Great advances have been made in extending how long an artificial joint will last, but most will eventually loosen and require a revision. Hopefully, you can expect 12 to 15 years of service from an artificial hip, but in some cases the hip will loosen earlier than that. A loose hip is a problem because it causes pain. Once the pain becomes unbearable, another operation will probably be required to revise the hip.

Related Document: First Choice Physical Therapy’s Guide to Revision Arthroplasty of the Hip

Fracture of the Femoral Neck

Fracture of the femoral neck is a unique complication of hip resurfacing. The replacement cap fits over the femoral head and ends just about where the femoral neck begins. This meeting point is an area of increased stress risk. Patient obesity, decreased bone mass, and surgical error are common risk factors in femoral neck fracture.

Leg Length Inequality

If there is any bone loss a difference in leg length can occur. When a surgeon does a traditional artificial hip replacement, the leg can be lengthened or shortened to match the other side. Because much less bone is removed during hip joint resurfacing, the surgeon cannot adjust the length of the leg. If you have a leg length difference before the procedure it will remain essentially the same.

After Surgery

What happens after surgery?

After surgery, your hip will be covered with a padded dressing. Special boots or stockings are placed on your feet to help prevent blood clots from forming. A triangle-shaped cushion may be positioned between your legs to keep your legs from crossing or rolling in.

If your surgeon used a general anesthesia, a nurse or respiratory therapist will visit your room to guide you in a series of breathing exercises. You’ll use a breathing device known as an incentive spirometer to improve breathing and avoid possible problems with pneumonia.

Physical Therapy treatments are scheduled one to three times each day as long as you are in the hospital. Your first session is scheduled soon after you wake up from surgery. Your therapist will begin by helping you move from your hospital bed to a chair. By the second day, you’ll begin walking longer distances using your crutches. Most patients are safe to put comfortable weight down when standing or walking. However, if your surgeon used an uncemented prosthesis, you may be instructed to limit the weight you bear on your foot when you are up and walking.

Your therapist will review exercises to begin toning and strengthening the thigh and hip muscles. Ankle and knee movements are used to help pump swelling out of the leg and to prevent the formation of blood clots.

This procedure requires the surgeon to open up the hip joint during surgery. This puts the hip at some risk for dislocation after surgery. To prevent dislocation, patients follow strict guidelines about which hip positions to avoid (called hip precautions). Your therapist will review these precautions with you during the preoperative visit and will drill you often to make sure you practice them at all times for at least six weeks. Some surgeons give the OK to discontinue the precautions after six to 12 weeks because they feel the soft tissues have gained enough strength by this time to keep the joint from dislocating.

Related Document: First Choice Physical Therapy’s Guide to Artificial Hip Dislocation Precautions

Patients are usually able to go home after spending two to four days in the hospital. You’ll be on your way home when you can demonstrate a safe ability to get in and out of bed, walk up to 75 feet with your crutches or walker, go up and down stairs safely, and consistently remember to use your hip precautions. Patients who still need extra care may be sent to a different hospital unit until they are safe and ready to go home.

Your staples will be removed two weeks after surgery.

Most orthopedic surgeons recommend that you have checkups on a routine basis after your joint resurfacing. How often you need to be seen varies from every six months to every five years, according to your situation and what your surgeon recommends.

Patients who have a joint implant will sometimes have episodes of pain, but if you have pain that lasts longer than a couple of weeks, you should consult your surgeon. During the examination, the orthopedic surgeon will try to determine why you are feeling pain. X-rays may be taken of your hip to compare with the ones taken earlier to see if there is any evidence of fracture or loosening.

Portions of this document copyright MMG, LLC.

What should I expect during my recovery?

After you are discharged from the hospital, your Physical Therapist at First Choice Physical Therapy may see you for outpatient visits. This is to ensure you are safe in and about the home and workplace and getting in and out of a car. We will review your exercise program, continue working with you on your hip precautions, and make recommendations about your safety. Our Physical Therapist may use heat, ice, or electrical stimulation to reduce any swelling or pain.

You should use your crutches or cane(s) as instructed. Your surgeon may only want you to place the toes of your operated leg down for up to six weeks after surgery. You’ll advance the weight you place through your sore leg as tolerated.

Although the time required for recovery varies, patients are usually able to drive within three weeks and walk without a walking aid by six weeks. Upon the approval of our Physical Therapist, patients are generally able to resume sexual activity by one to two months after surgery.

Our Physical Therapists sometimes treat our patients in a pool. Exercising in a swimming pool puts less stress on the hip joint, and the buoyancy lets you move and exercise easier. Once you’ve gotten your pool exercises down and the other parts of your rehab program advance, you may be instructed in an independent home program.

When you are safe in putting full weight through the leg, our Physical Therapist can choose several types of balance exercises to further stabilize and control the hip.

Many patients have less pain and better mobility after having hip resurfacing. Our Physical Therapist will work with you to help keep your new joint healthy for as long as possible. This may require that you adjust your activity choices to keep from putting too much strain on your new hip joint.

There is a belief that with hip resurfacing the patient can return to full participation in recreational or professional sports. Long-term results have not been studied to support this idea. Most surgeons agree that joint resurfacing allows patients to be more active than is acceptable for a standard total hip replacement.

Although resurfacing materials are strong, they aren’t immune to wear and tear. Our Physical Therapists usually advise patients to avoid high-impact activities. Heavy sports that require jogging, running, jumping, quick stopping and starting, and cutting are discouraged. Repetitive impact can strain the resurfacing, increasing the risk of loosening.

At First Choice Physical Therapy our goal is to help you maximize strength, weight shift evenly, walk normally, and improve your ability to do your activities. When your recovery is well under way, regular visits to our office will end. Although, we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Welcome to First Choice Physical Therapy’s resource with respect to recovering from Revision Arthroplasty of the Hip.

Over the past 30 years, artificial hip replacements have become increasingly common. Millions of people have gotten a new hip joint. The first time a joint is replaced with an artificial joint, the operation is called a primary joint replacement. As people live longer and more people receive artificial joints, some of those joints begin to wear out and fail. When an artificial hip joint fails, a second operation is required to replace the failing joint. This procedure is called a revision arthroplasty.

This guide will help you understand:

• why revision surgery becomes necessary
• what happens during the operation
• what to expect during your recovery

How is the hip designed?

The hip joint is one of the true ball-and-socket joints of the body. The hip socket is called the acetabulum and forms a deep cup that surrounds the ball of the upper thighbone, or femoral head. Thick muscles of the buttock at the back and the thick muscles of the thigh in the front surround the hip.

The surface of the femoral head and the inside of the acetabulum are covered with articular cartilage. This material is about one-quarter of an inch thick in most large joints. Articular cartilage is a tough, slick material that allows the surfaces to slide against one another without damage.

Why do revisions become necessary?

The most common reasons that a revision needs to be done are:

• mechanical loosening
• infection in the joint
• fracture of the bone around the joint
• instability of the implant
• wear of one or more parts of the implant
• breakage of the implant

Mechanical Loosening

Mechanical loosening means that for some reason (other than infection) the attachment between the artificial joint and the bone has become loose. There are many reasons why this can occur. It may be that, given enough time, all artificial joints will eventually become loose. This is one reason that surgeons like to wait until absolutely necessary to put in an artificial joint. The younger you are when an artificial joint is put in, the more likely it is that the joint will loosen and require a revision. Mechanical loosening can occur in cemented or uncemented artificial joints. (The different types of joints are described later.)

Infection

If an artificial joint becomes infected, it may become stiff and painful. It may also begin to lose its attachment to the bone. An infected artificial joint will probably have to be revised to try to cure the infection. In the hip joint, an infected artificial joint may be able to be exchanged for a new artificial joint at the same operation. You will still need to be placed on antibiotics for several weeks or months after the exchange operation.

Fractures

A fracture may occur near an artificial joint. It is sometimes necessary to use a new artificial joint to fix the fracture. For example, if the femur (thighbone) breaks right below the stem of an artificial hip, it may be easier to replace the femoral part of the artificial joint with a new joint with a longer stem to hold the fracture together while it heals, similar to fixing the fracture with a metal rod.

Instability

Instability means that the joint dislocates (the metal ball slips out of the plastic socket). This is very painful when it happens. If it happens more than once, it’s time to consider revising the artificial hip joint to keep it from coming out of joint.

Wear

As surgeons have become better at understanding how to put in an artificial joint so that it does not loosen as fast, we have begun to see actual wear of the plastic parts of the artificial joints. In some cases, if the wear is discovered in time, the revision may only require changing the plastic part of the artificial joint. If the wear continues until metal is rubbing on metal, the whole joint may need to be replaced.

Breakage

Finally, another type of wear can occur that breaks the metal due to the constant stress that the artificial joint undergoes everyday. In weight-bearing joints such as the hip, this is greatly affected by how much you weigh and how active you are.

What happens before surgery?

Your surgeon will carefully plan the revision operation. Before the operation, many possible options and complications will have to be taken into account. Your surgeon will discuss these with you. Be sure to ask if there are parts of the procedure, your recovery, or the risks associated with a revision joint replacement that you have questions about.

Once the decision to proceed with surgery is made, several things may need to be done. Your orthopedic surgeon may suggest a complete physical examination by your medical or family doctor. This is to ensure that you are in the best possible condition to undergo the operation.

You may be scheduled for a bone scan so the surgeon can check for loosening of the artificial joint. When an artificial joint is loose, the bone around the artificial joint reacts by trying to form new bone, a process called remodeling. The bone scan is done by injecting you with a weak radioactive chemical. Several hours later, a large camera is used to take a picture of the bone around the artificial joint. If the artificial joint is loose and there is remodeling going on, the picture will show a hot spot where the chemical has been added to the newly forming bone. The brighter the hot spot, the more likely that the artificial joint is loose.

If your surgeon suspects that the artificial hip joint is loose, other tests may be necessary to find out why the hip joint is loose. Before any plans are made to revise the artificial joint, most orthopedic surgeons will want to make sure that the hip is not loose due to infection. Your surgeon may order blood tests to look for signs of infection and may suggest placing a needle into the joint and removing fluid to send to the laboratory and check for infection. Replacing any artificial joint that is infected is much more involved than replacing a noninfected, loose artificial joint. In some cases, infection will make a revision impossible.

You may also need to spend time with the Physical Therapist who will manage your rehabilitation after the surgery. The therapist will begin the teaching process before surgery to ensure that you are ready for rehabilitation afterwards. One purpose of the preoperative visit is to record a baseline of information. This includes measurements of your current pain levels, functional abilities, and the movement and strength of each hip.

A second purpose of the preoperative Physical Therapy visit is to prepare you for your upcoming surgery. You will begin to practice some of the exercises you will use just after surgery. You will also be trained in the use of either a walker or crutches.

This surgery requires the surgeon to open up the hip joint to revise the artificial replacement. This puts the hip at some risk for dislocation after surgery. To prevent dislocating their hip, patients follow strict guidelines about which hip positions they are to avoid, called hip precautions. Your Physical Therapist will go over these precautions with you in the preoperative visit and will drill you often to make sure you practice them at all times for six to 12 weeks after surgery.

Finally, the Physical Therapist will assess any needs you may have at home once you’re released from the hospital.

You may be asked to donate some of your own blood before the operation. This blood can be donated three to five weeks earlier. Your body will make new blood cells to replace the loss. If you need to have a blood transfusion during the operation, you will receive your own blood back from the blood bank.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

The Revision Prosthesis

There are two major types of revision implants:

• cemented prosthesis
• uncemented prosthesis

A cemented prosthesis is held in place by a type of epoxy cement that attaches the metal to the bone.

An uncemented prosthesis has a fine mesh of holes on the surface that allows bone to grow into the mesh and attach the prosthesis to the bone.

Both are widely used in revision hip surgery. In some cases, a combination of the two types is used in which the ball portion of the prosthesis is cemented into place, and the socket not cemented. The decision about whether to use a cemented or uncemented prosthesis during the revision surgery is usually made by the surgeon based on your age, your lifestyle, and the surgeon’s experience.

Each prosthesis is made of two main parts. The acetabular component (socket) replaces the acetabulum. The acetabular component is made of a metal shell with a plastic inner liner that provides the bearing surface. The plastic used is very tough and slick, so tough and slick that you could ice skate on a sheet of the plastic without damaging it much.

Acetabular Component

A special type of acetabular component may be used during the revision surgery. This is because the bone of the pelvis may have worn away somewhat since the initial replacement was done. The bone may be weaker, or areas of the bone may be missing. These special components are designed to spread the weight across a wider area on the acetabulum. They attach to the stronger bone outside the area of wear and tear.

The femoral component (stem and ball) replaces the femoral head. The femoral component is made of metal. Sometimes, the metal stem is attached to a ceramic ball.

Femoral Component

There are special types of revision stems as well. This is because the bone of the femur is usually not the same as when the initial replacement was done. The bone may be weaker, or areas of the bone may be missing. A longer stem can reach further down the femoral shaft and distribute your body weight better.

The Operation

Revision joint replacements are much different from primary joint replacements. One reason that revision procedures are not routine is that there is almost always bone loss around the primary prosthesis. The surgeon deals with this problem by placing a bone graft or some other material around the artificial joint to reinforce the bone. This bone graft may come from your own body, such as bone taken from the pelvis during the same operation. This is commonly called an autograft.

Autograft

If the amount of bone needed is too large to take from your body, your surgeon may choose to use bone graft from the bone bank. This type of bone graft has been taken from someone else and placed in the bone bank. This type of transplant is called an allograft.

When the primary artificial joint has been put in using cement, the cement has to be removed from the socket of the hip as well as from the femoral canal (the bone marrow space in the thighbone).

Because the bone is often fragile and the cement is hard, removing the cement sometimes can lead to a fracture of the femur during the operation. This is not unusual, and in most cases the surgeon will simply continue with the operation and fix the fracture as well. In some cases, the femur must be broken open to remove all the cement and the artificial joint. This is one reason that revisions are challenging.

During the operation, samples of bone and marrow tissue are usually removed and sent to a laboratory to see if any infection is present. If the laboratory tests show an infection,
a new artificial hip joint will probably be put in, and you will be placed on antibiotics for several months.

After application of bone and other materials to rebuild the socket and the femur, a new prosthesis is implanted. Because the natural shape can hardly ever be imitated after rebuilding the bone, most of the time a specially designed prosthesis has to be used. All of this is carefully planned by the surgeon before the operation.

A revision joint replacement of the hip is more complex and unpredicatable than a primary joint replacement. Since many factors can influence its longevity, your surgeon will not be able to say exactly how long your revision will last.

In some cases, if an artificial joint fails, it may not be possible to put another artificial joint back in. This can occur if the primary joint has failed because of an infection that cannot be controlled, if the bone has been destroyed so much that it will not support an artificial joint, or if your medical condition will not tolerate a major operation.

Sometimes a choice other than hip revision is best because a big operation might result in a failure, or even death. Removing the prosthesis and not replacing it doesn’t mean the patient can’t walk anymore, but walking will be much more difficult because the leg grows shorter and the power in the leg is reduced.

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following revision arthroplasty of the hip include:

• anesthesia complications
• thrombophlebitis
• infection
• dislocation
• myositis ossificans
• loosening

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but it is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection can be a very serious complication following an artificial joint revision. Some infections may show up very early, even before you leave the hospital. Others may not become apparent for months, or even years, after the operation. Infection can spread into the artificial joint from other infected areas. Your surgeon may want to make sure that you take antibiotics when you have dental work or surgical procedures on your bladder and colon to reduce the risk of spreading germs to the joint.

The risk of infection is higher in revision joint replacement than in primary joint replacement. In a primary hip replacement, the risk of infection is 0.5 to one percent. It goes up to two percent or more in revision cases. These figures are only an estimate and vary between different scientific studies.

Dislocation

Just like your real hip, the revised artificial hip can dislocate if the ball comes out of the socket. There is a greater risk just after surgery, before the tissues have healed around the new joint, but there is always a risk. A Physical Therapist will instruct you very carefully on how to avoid activities and positions that may have a tendency to cause a hip dislocation.

Myositis Ossificans

Myositis ossificans is a curious problem that can affect the hip after both a primary hip replacement and a revision hip replacement. The condition occurs when the soft tissue around the hip joint begins to develop calcium deposits. Myositis means inflammation of muscle and ossificans refers to the formation of bone. This can lead to a situation where bone actually forms completely around the hip joint. This leads to stiffness in the hip resulting in much less motion in the hip joint than normal. It also causes pain.

Myositis ossificans is more common in people who have a long history of osteoarthritis with multiple bones spurs. Something about the genetic makeup in these people makes them more likely to produce bone tissue. Major reconstruction operations such as a hip revision seem to do more damage to the surrounding tissues than primary hip replacements. The operation is simply longer and harder to do. Calcium deposits are also more likely to form.

The treatment of myositis ossificans may actually begin before you get it. In cases where you are at high risk for developing this condition, your surgeon may recommend that you take medications such as indomethacin after surgery. This medication reduces the tendency for bone to form and may protect you from developing myositis ossificans.

A much more effective method that has been used a great deal to prevent the development of myositis ossificans involves radiation treatments immediately after surgery. These are the same type of radiation treatments used to treat cancer. Several short radiation treatments begun the day after surgery and continued for three to five days seem to drastically reduce the risk of developing myositis ossificans.

If myositis ossificans forms despite these precautions, treatment will depend on how much it affects your hip–how much pain it causes and how much it restricts motion. In some severe cases, you may choose to have a second operation to remove the calcified tissue that has formed. This is usually followed by radiation treatments to prevent the calcium deposits from returning.

Loosening

The major reason that artificial joints eventually fail continues to be a process of loosening where the metal or cement meets the bone. A loose revised prosthesis is a problem because it causes pain. Once the pain becomes unbearable, another revision surgery may be needed. The rate of loosening of revision arthroplasties is higher than in primary arthroplasties.

After Surgery

What happens after surgery?

After surgery, your hip is covered with a padded dressing. Special boots or stockings are placed on your feet to help prevent blood clots from forming. A triangle-shaped cushion may be positioned between your legs to keep your legs from crossing or rolling in.

If your surgeon used a general anesthesia, a nurse or respiratory therapist will visit your room to guide you in a series of breathing exercises. You’ll use an incentive spirometer to improve breathing and avoid possible problems with pneumonia.

Physical Therapy treatments are scheduled one to three times each day as long as you remain in the hospital. Your first treatment is scheduled soon after you wake up from surgery. Your therapist will begin by helping you move from your hospital bed to a chair. By the second day, you’ll begin walking longer distances using your crutches or walker.

You may not be allowed to put weight on the affected leg for a period of time. This varies from surgeon to surgeon and is also affected by how well your surgeon thinks the operation went.

Your Physical Therapist will go over exercises to begin toning and strengthening the thigh and hip muscles. Ankle and knee movements are used to help pump swelling out of the leg and to prevent the formation of blood clots.

You will need to follow hip dislocation precautions–just like after your first artificial hip replacement. The risk of dislocation after a revision is higher than after a primary hip replacement.

Patients are usually able to go home after spending four to seven days in the hospital. You’ll be on your way home when you can demonstrate a safe ability to get in and out of bed, walk up to 75 feet with your crutches or walker, go up and down stairs safely, and consistently remember to use your hip precautions. Patients who require extra care may be sent to a different unit until they are safe and ready to go home.

Most of the time your surgeon will see you one or more times during outpatient visits. Depending on what is learned from the examination and X-rays, you may start to put full weight on your leg. Because the operation is more complicated than primary replacement surgery and the period of walking on crutches may take longer, you must realize that it will take at least a year to be able to perform all normal daily activities. In some patients the possibilities are more limited than before. Be aware that a revision hip prosthesis is not as good as a primary prosthesis. There is always a chance that the donor bone will disappear in time because it is dead material and will be reabsorbed by the body. This means that loosening can occur once more. Today no other materials are available that are superior to donor bone.

Most orthopedic surgeons recommend that you have routine checkups after your revision surgery. How often you need to be seen varies from every six months to every five years, according to your situation and what your surgeon recommends. You should always consult your orthopedic surgeon if you begin to have pain in your artificial joint or if you begin to suspect something is not working correctly.

What should I expect during my recovery?

When you begin our First Choice Physical Therapy rehabilitation, our Physical Therapist will design a personalized exercise program, work with you on your hip precautions, and make recommendations about your safety.

These recommendations may include that you use a raised commode seat and bathtub bench, and that you raise the surfaces of couches and chairs in your home. This keeps your hip from bending too far when you sit down. Bath benches and handrails can improve safety in the bathroom. Other suggestions include the use of strategic lighting and the removal of loose rugs or electrical cords from the floor.

You should continue to use your walker or crutches as instructed. If you had a cemented procedure, we’ll advise you to advance the weight you place through your sore leg as much as you feel comfortable. If you had a noncemented procedure, we may want you to place only the toes down for up to six weeks after surgery. Although the time required for recovery varies, most patients progress to using a cane in four to six weeks.

Your staples will probably be removed two weeks after surgery. Patients may able to drive within three weeks and walk without a walking aid by two to three months. Upon the approval of our Physical Therapist, you are generally able to resume sexual activity by one to two months after surgery.

Additional visits to the First Choice Physical Therapy facility may be needed for patients who are still having problems walking or who need to get back to heavier types of work or activities. Our Physical Therapist may use heat, ice, or electrical stimulation if you have swelling or pain.

We sometimes treat patients in a pool. Exercising in a swimming pool puts less stress on the hip joint, and the buoyancy lets you move and exercise easier. Once you’ve gotten your pool exercises down and the other parts of your rehab program advance, we will instruct you in an independent program.

When you are safe in putting full weight through the leg, our Physical Therapist can recommend several types of balance exercises to further stabilize and control the hip.

Finally, a select group of exercises can be used to simulate day-to-day activities, such as going up and down steps, squatting, and walking on uneven terrain. We may then choose specific exercises to simulate work or hobby activities.

Many patients have less pain and better mobility after hip revision surgery. Our Physical Therapist will work with you to help keep your revised joint healthy for as long as possible. This may require that you adjust your activity choices to keep from putting too much strain on your revised hip joint. Heavy sports that require running, jumping, quick stopping and starting, and cutting are discouraged. Patients may need to consider alternate jobs to avoid work activities that require heavy lifting, crawling, and climbing.

Our goal is to help you maximize strength, walk normally, and improve your ability to do your activities. When your recovery is well under way, your regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.