A detailed report for Dr. Kozinn’s Anterior Total Hip Replacement Recovery patients in Scottsdale.
Ok- so now you know you will need a hip replacement for that bone-on-bone grinding and pain in your hip. The good news is you are likely a good candidate for the “new” direct anterior approach , which in my hands has been an amazing advance in technology and fast recovery from hip replacement surgery. Only a few surgeons in Arizona are skilled in this technique, and most orthopedists are still offering the “older” posterior approach which cuts through many posterior muscles to get to the hip joint.
Anterior Hip replacement Recovery is such an important topic. ( You may be asking yourself, “If the anterior approach is so much better, Why isn’t every orthopedic surgeon doing it? – ) The simple answer is it is a much harder procedure to learn and do well. Many surgeons do not want to take the time to learn this new technique, since their posterior hip patients seem to do ‘well enough”. The posterior hip patients do have a slower recovery, and time off from work is increased. The posterior total hip patients also have many more restrictions to avoid hip dislocation. I embraced this new procedure as an option for my hip replacement patients with initial skepticism, and then applied it gradually. I travelled to Los Angeles to learn it directly from the “inventor” of the technique, Dr. Joel Matta ( www.hipandpelvis.com ). I then studied the technique intensely by operating on cadavers before doing it on live humans. In the cadavers, I purposely made errors to see what other anatomical structures might be at risk. I learned a tremendous amount from those studies, and my complication rate is now much lower than for the posterior hips. After almost 1000 anterior total hips, my deep infection rate is .1 percent. My dislocation rate is .5%, which is significantly less than the usual 2-3 percent seen after posterior total hips. There has been no femoral or acetabular loosenings requiring revision surgery. There has been a few “anterior soft tissue pains” ( psoas tendonitis – but most have resolved with time). I have seen only 1 proximal DVT in these cases -this is amazing, and is a testament to the early mobilization and minimal tissue disruption during surgery. We use aspirin in the majority of cases to prevent clots in the legs. I have seen only one pulmonary embolism in my group of anterior hip cases cases, and this occurred 3 weeks after surgery, and the patient did very well.
My first “real live patient” Anterior hip was done in “an easier” patient – typically tall, thin people. Thinner patients are easier because no muscle is cut, therefore we retract the muscles temporarily out of the way. Women tend to be easier because they have smaller, and more slender muscles in the thigh. ( BTW: I have now done an male ex-power lifter with huge muscular thighs, as well as some ex pro and college footballers - so there has been significant expansion of the procedure in my hands to “harder” cases. There are still some patients that are so large, that the difficulty sways me to recommend the old posterior approach as a safer option, even though it does cut much more muscle and has a slower recovery. The remaining reason to do a posterior hip, is unusual pathology, such as congenital deformities and post-traumatic deformities. If there is a significant acetabular defect, and bone grafting will be needed, that is another reason NOT to use the anterior approach, which yields a smaller view of the operative field.
The special anterior hip table, called the HANA table, facilitates the procedure by applying traction, and creating temporary “space” to remove the diseased femoral head, and place the metal implants without cutting any muscle. the muscles will stretch under traction, but they “snap back” into position when we remove the traction.
An X-ray machine is brought into the room, so that we can see “inside” the body while we are working through a small opening. The Xray makes the procedure even MORE accurate, as we can directly visualize leg length and implant position. Changes can be made during “trial reductions” of different sized implants.
This paper will focus on the “nuts and bolts” of the recovery process, and not the procedure itself. I have posted videos of the actual procedure on my website video page, and you may (or may not) want to see them. Many patients want to know “when” they will be able to do certain things, and “when” they can safely go back to work. Scottsdale Healthcare did an interview of my patient Mario Gomez, which you may want to listen too. He was walking without support in a few days and back riding his horses a month after anterior hip surgery. View Mario’s video here: Scottsdale Joint Center Videos
After we confirm your operative date during your office visit, Gerry (my surgery scheduler pictured below!) will instruct you about “things to do” before surgery. You must get a “medical clearance” from your family doctor or internist. We can supply an internist who will provide this service and see you in the hospital if you prefer. Medical clearance tests generally include a chest xray and an EKG done within two years. Also, laboratory studies such as : CBC- complete blood count, BMP- basic metabolic panel, bleeding studies PT/PTT, and urinalysis are ordered. If you are elderly, or have a cardiac history, a cardiologist may do a separate cardiac clearance evaluation. we can also help set up that appointment for you.
We send you to a free class in the hospital to learn more about the hospital experience. We give you a book to read to prepare, and we direct you to our website to read about the procedure. The more you know, the better you do! Recovery from the anterior hip procedure is SO FAST, that it is important to be familiar with your surroundings before we do the procedure. Some patients will be so comfortable with all of this, that they may choose to go home the same day as the procedure!
On the morning of surgery, do not eat breakfast, and do not drink fluids. This is because rarely, it is possible for food and water in your stomach to be regurgitated into your lungs during general anesthesia. ( This is called aspiration pneumonia, and with modern anesthesia techniques thankfully a VERY rare occurrence!). Some patients will choose a spinal anesthetic, because they WANT to be more alert during the procedure. We can do the anterior hip with either type of anesthesia, as they both provide muscle relaxation to the hip area muscles. You will be “checked in” about two hours before your scheduled case start time. There is a lot of paper work to do. Nurses will ask you many times about which hip we are doing, and what allergies you may have. I will MARK the hip with a purple marker before we go back into the room. You will be able to ask me once again any questions you like BEFORE we do the surgery. (No you cannot keep the hip bone we remove!).
Once we are back in the OR, you will be placed on the special HANA table. Once on the table, most patients choose to “snooze” through the actual case. Most do not remember anything about the actual operation time, as the anesthetic agents tend to wipe out the short term memory period involved. In the recovery room, you will be made comfortable. Most patients remarkably have little or NO pain! (Some people do, and I can’t figure out why!).
If you had a general anesthetic, you literally could start walking right out of the recovery room, full weight bearing. We do however, wait an hour to get you up to 6 West, the Total Joint Floor at Osborn. I (Dr. Kozinn) am the Medical Director of the floor, and our nurses are specially trained to take care of you! All of the rooms on 6 West are private VIP rooms with free wireless internet access and TV.
If your case is done on a Tuesday, you may be part of our “Grand Rounds” done on Wednesday morning. Education for all care-givers includes focusing on YOU, the patient- in what I call the “patient-centered” approach to hospital recovery. If you had a spinal anesthesia, then we have to wait for it to wear off before you get up! This sometimes takes a bit longer before you are strong enough to fully weight bear. Spinal anesthesia patients will also have a foley catheter, as sometimes the spinal block makes it difficult to urinate for a few hours. We take the foley catheter out as soon as possible. I am told that the pain is minimal and very manageable with oral pain pills.
The physical therapist will help get you up an hour or two after you are back on the floor. You will be walking “all over the place” very quickly. This also helps to prevent clots in your veins ( knock on wood – so far we have a zero percent venous thrombosis rate with the anterior hips, and I am convinced it is because the procedure does not traumatize the femoral veins, and the patients are up walking so quickly, which helps keep the blood moving in the veins. Yet ANOTHER advantage to this procedure over the posterior approach! We do give you a blood thinner for two weeks to take at home to further prevent clots. usually with this procedure two aspirin pills a day is all that is required for blood thinner.
We have had a number of “macho” patients who have requested to go home the same day of the surgery. I am OK with that if you are. Most often the family is “too nervous” to take the patient home, so most patients spend one night in the hospital. I have had a few patients tell me they “drove themselves home” from the hospital – PLEASE DONT DO THAT!
Most patients go home the next morning after a second round of physical therapy. the IV is removed. patients are amazed to hear that they DO NOT have any real hip dislocation precautions to follow. (It is possible to pop your hip out – but it is extremely rare because of the way the intact muscles “snap back” and hold the hip in. The muscles act like rubber bands that keep the hip stable.) That means you can go back to work and activities as soon as you feel comfortable doing them! Many patients are back in the office part-time the same week as surgery. Some are playing golf in two weeks.
We send you home so quickly from the hospital, that we keep the original OR dressing on the hip until the day after you get home. Kelly, my PA -Physician’s assistant- will be happy to see you in the office the first week to help you do the first dressing change if you prefer to do it that way.
We like this as a way to check on your progress, as things move along quite quickly!.
The sutures or staples we put in are removed at 14 days after the surgery. If there is any drainage at all from the hip, we ask that you call us immediately, so we can fix it, or put you on antibiotics. We have not yet had an anterior hip get infected, yet another improvement in the overall complication rate. I believe this has to do with the relatively “atraumatic surgery”, and the excellent blood supply in the anterior aspect of the hip. Of course any operation, can get infected, and we want you to watch the hip wound daily in the mirror to make sure it stays dry and does not get very red!
The vast majority of patients DO NOT NEED formal physical therapy after this procedure. We give you some general exercises to do at home or your favorite health club, and have seen better results this way as the hip gradually acclimates to the new you. You can shower on post op day two, and swim as soon as the wound is completely healed ( usually two weeks). You can bend down to tie your own shoes, and sit in regular chairs. you can sleep in a regular bed, and DO NOT need to keep a pillow between your knees. I will instruct you to avoid the most challenging YOGA positions for a month or so, just because I am being over-cautious.
The recovery process speeds along from here. Your favorite gym or health club will help, and you may do all exercises and use all machines that feel good. Some patients do TOO MUCH, and develop a new pain after a week or two of none – this is normal – I call it the three steps forward, one step back syndrome – and it is a natural development of the healing process. You should call us in the office if you have ANY questions – we hear the same questions over and over, so Kelly, Gerry, Amanda or one of the doctors can answer you! if I am not available, my partner Dr. Evangelista can see you or answer your questions. He also does the anterior hip procedure.
Patients will have their “stitches” removed at 14 days, either by myself or by Kelly, Amanda, or Rebecca, our PAs. Patients can play easy golf at two weeks. They can play doubles tennis at 3 weeks. Swimming starts as soon as the wound is sealed. While running is possible, we don’t think it’s a great idea, mostly because we don’t know how the hip will hold up over many years- that study has NOT been done yet!. ( Bo Jackson played pro baseball on his hip replacement, the only MLB player to ever do so- and he did need to have the cup re-done after a few years of pounding!)
So that is the nuts and bolts of recovery. We will have you return to the office for an Xray at three months after surgery – just to take a peak and be sure there has not been any changes in the implant positions. The implants are made of porous titanium, and bone will grow into them to make a permanent bond. This takes about three months to be truly connected!. we will then see you again one year later – just to check in and say hello. We really don’t know how many years these modern anterior hips will last. In any given patient, a hip can fail at any time. However, my best guess is that most implants I am using will last 30 years or so, for many patients that means forever. if a change or “revision” operation such as a plastic liner exchange is needed, that could be accomplished through the same minimally invasive approach.
I hope this guide to recovery of the anterior total hip has been helpful to patients. I will add to it and make it better as time goes on. Please ask me if you have any specific questions I have not answered! You may also visit our website at www.ScottsdaleJointCenter.com and click on the “ask the doctor” button. I will get back to you as soon as I can!
Stuart Kozinn MD
Medical Director -Total joint Center Scottsdale Osborn
also visit www.shc.org/ortho
Holly had two hips replaced and works as a fitness/yoga instructor!