ANDREW A. SHINAR, MD
VANDERBILT ORTHOPAEDIC INSTITUTE
ARTHRITIS & JOINT REPLACEMENT CENTER
Medical Center East, South Tower, Suite 4200
Nashville, TN 37232-8774
(615) 343-0825

 INTRODUCTION

The purpose of this form is to instruct you on the major aspects of your hip replacement surgery, inspire you to ask questions, and inform you of its major risks. We intend this form to neither frighten you, nor to cover up your fears. We hope that it can ensure that you understand the procedure well, and thereby relieve the fears you might have. It is not meant to be complete with regard to every detail of the surgery or its risks. If you would like more information, please ask Dr. Shinar, or his assistants.
Modern hip replacements were developed in the late 1950s, and have gone through many changes in technique, implants, and post-operative care since then. Consequently, a wide variety of methods are used today, and not all the answers are available as to which methods are best. However, since the basic technique has been around for over three decades, we all now benefit from this experience, and understand the procedure and its risks quite well for most surgeries.

 BEFORE THE SURGERY

Medicines

• You should stop all aspirin seven days before the surgery.
• Stop all older “non-steroidal” anti-inflammatory drugs (such as Advil, Motrin, Alleve, Naprosyn, etc.) three days prior to the operation.
• You may continue to take the newer anti-inflammatories (such as Celebrex, Vioxx, and Bextra) up to the day of your surgery.
• If you take coumadin or other blood thinners (such as Plavix), please contact your medical doctor to find when it is safe to discontinue these drugs. If your medical doctor feels it is unsafe to stop these drugs, you must inform Dr. Shinar of this, preferably a week before your surgery.
• If you are unsure whether any drugs you take fall in these categories, contact Dr. Shinar or your medical doctor.
• All other medications should be continued unless your medical doctor instructs you otherwise. You should ensure that you bring a list of all your medications and their doses to the hospital with you.
• If you drink alcohol regularly, you must inform Dr. Shinar and your medical doctor.

Medical Clearance

• If you have not seen your medical doctor recently, you should make an appointment with him/her as soon as possible. Your surgery can then be performed once your medical doctor clears you for it.
• If you have recently seen your medical doctor, you should have him/her send a note to Dr. Shinar stating that you are medically fit for your surgery.
• If there is a question as to whether you have been seen recently enough, call your medical doctor.
• If you see a medical specialist (e.g., a heart or lung doctor), have him/her also send a note to Dr. Shinar stating that you are medically fit for your surgery.
• If you have no medical doctor and no medical problems, let Dr. Shinar know.
• If you have no medical doctor and you do have medical problems, let Dr. Shinar know this, and he will refer you to a medical doctor.
• You must inform Dr. Shinar immediately about any infection anywhere on your body, especially in the skin over your hip. This can include a pimple or scratch, or infection in your fingernails, toenails, teeth, or urine.
• If you have any ongoing dental problems or even old infections, you must see your dentist before the operation, and have him/her contact Dr. Shinar.

No one is in absolutely perfect health. Our goals before the surgery are to ensure that your condition is good as it can reasonably be, and that in this condition, you stand the best chance of safely undergoing the surgery.

Pre-operative Hospital Visit

• You will have blood drawn for testing.
• You will meet an anesthetist. Discuss with him/her your options regarding spinal, general, or epidural anesthesia. All are adequate for Dr. Shinar’s needs. Your pain control after the surgery can be greatly improved with an epidural. Ask which medications you should take the morning of your surgery.
• Prior to the surgery, you may meet Dr. Shinar’s assistants, physical therapists, social workers, and others involved with the process. It is a true team effort.

 THE SURGERY

The procedure involves replacing the top of your thigh bone and the socket of your pelvis bone with metal and plastic parts that then act as a new hip joint. The parts are fixed into your bones with screws, precise fit (“press fit”), and/or bone cement. The muscles or bone that is moved out of the way is repaired with sutures, wire, or cables. Complex problems may involve bone graft from your own bone, bone graft using donated bone (“allograft”), and/or extra wires or screws. The incision is centered over the top of your thigh, and is repaired with staples. For a first time surgery, it is likely that your incision will be 3-5” in length.

 IN-HOSPITAL CARE

Dr. Shinar or one of his assistants will see you in the hospital each day. (If not, you should let the nurses know.)

The medical care while you are in the hospital involves:

• Controlling your pain with pills, or medicine through your veins or epidural
• Following your blood count (replenishing your blood supply, if needed)
• Thinning your blood with drugs and pumping of your feet (with special boots) to help prevent clots
• Receiving antibiotic medicines to help prevent infection
• Managing your pre-existing medical problems (often with the assistance of medical doctors)

Most often, the post-operative stay goes uneventfully. Occasionally, though, patients need a urinary catheter for more than a day, more than a few blood transfusions, or a tube in their stomach and fluid given in their veins if their bowels do not work properly. Rarely, patients experience gout, ulcers, healing problems, and other difficulties.
The physical therapy after the surgery mainly involves safely getting in and out of bed in the hospital, learning how to safely move your hip, and learning how to safely walk with the support of a walker or crutches. The physical therapists will guide you in a variety of exercises.

 GOING HOME

• The stay in the hospital is usually about 3 days. A social worker will determine how much help you need at home, and will contact your insurance company to see what help is covered.
• Occasionally, the rehabilitation doctors and social workers will determine whether you need to go to a rehabilitation facility or short-term nursing home. On going home, you will receive a prescription for pain medication, and instructions regarding a follow-up appointment with Dr. Shinar.
• Most likely, Dr. Shinar will prescribe blood thinners (coumadin or other) when you leave the hospital, and may monitor the medication’s effect with blood tests. If coumadin is the medication you are receiving, you must make sure that your blood is drawn at home or at a hospital or lab within 3 to 4 days after your discharge. You must also make sure that Dr. Shinar’s assistant or your medical doctor receives the results of your blood tests, and changes the dose of coumadin as needed.
• Staples are removed between 1 and 3 weeks after surgery, either in Dr. Shinar’s office or by a nurse who comes to your home.

 RISKS OF HIP REPLACEMENT

Though the success rate with hip replacement is very high, all surgery involves risks, and there is no guarantee that your surgery will be as successful as you and Dr. Shinar wish it to be.

The main risks include:

1. Blood Clots: Clots in your leg veins are very common when blood thinners are not used, but dangerous ones are uncommon when blood thinners or leg compression devices are used. They may hurt or may be silent, and can occur anywhere from your pelvis to your feet. You should let your doctor know when you have pain in any of these regions. The clots can rarely cause long-term problems with the return of blood from your leg to your body, but the main danger with them is that they may dislodge from your leg veins and travel to your lungs. In the lungs, they can be silent, cause severe pain, or even cause your death. If you feel chest pain or breathing difficulties, you should let your doctor know immediately. The risk of these clots causing death has been drastically reduced, and is much less than 1%. The treatment for these clots when they occur is more thinning of the blood with medications, and occasionally with placement of a filter in your veins.
2. Dislocation: The ball of the new hip joint may become dislodged from the socket, which is usually quite painful. The risk of this occurring is lessened with proper safe movements of your legs after the surgery. You will never be completely free of this risk, but the risk decreases with time. If it occurs, a surgeon will manipulate your leg under anesthesia or sedation to place the ball back in the socket. Occasionally, the hip replacement needs to be revised to correct this condition if it keeps occurring.
3. Infection: Antibiotics given around the time of the surgery greatly decrease this risk, but it still can occur soon after the surgery or even years after the surgery. It is usually treated with another surgery to remove infected tissue or to remove the prosthesis. If removed, the prosthesis can sometimes be replaced, but sometimes cannot. In the end, you may be worse off than if you never had surgery, though this is an uncommon result.
4. Nerve Injury: The nerve to your leg and feet, or the nerve to your thigh can rarely be damaged by the surgery. These nerves may or may not recover by themselves. If they do not, you may need a brace for your ankle or for your knee to walk, and your walking ability could be limited.
5. Bleeding: Rarely, the blood vessels around the hip are damaged by the surgery and excessive bleeding occurs after or during the surgery, requiring either surgery or special procedures under X-ray control to correct the problem. Occasionally, blood gathers in the wound even if no major blood vessel is damaged and further surgery (or observation) is required to correct the problem.
6. Unequal Leg Lengths: The length of your legs usually is within 1 inch after surgery, but it may be necessary for Dr. Shinar to lengthen your leg during the hip surgery to help prevent dislocation of your hip. If the unequal lengths are bothersome, a lift can be built or inserted into the shoe of your shorter leg.
7. Limp: The limp that most people have before the surgery usually persists until the muscles become stronger after surgery. It sometimes never goes away, and sometimes the surgery creates a new limp. Most people, however, note that the way they walk is greatly improved by the surgery.
8. Fracture: The bone in the pelvis or thigh bone can crack when placing the new hip, when preparing for it, or even years after the surgery. Fractures usually are treated with metal cables or a plate, and usually heal very well.
9. Need for Further Surgery: Though uncommon, hip replacements occasionally fail before ten years. Some other problems can also make further surgery necessary, including: bone forming where it should not, breaking of the bone around the prosthesis (during or after surgery), and irritation of the soft tissues by wire or sutures.
10. Death: Though very rarely, patients have died following hip replacements. This can be due to underlying medical or heart problems that surface or become worse after the surgery. It can also be due to blood clots traveling to the lungs as mentioned above, or from the stress placed on the body by more than the usual amount of bleeding.
11. Other Problems: This list is meant to cover only the major problems most frequently encountered. Just as everyone is unique, so are many problems.
    At this point, it is important to remind you that though complications are numerous and common, most are minor, and the surgery is -much more often than not- very effective in reducing pain and improving function. We would not be recommending it to you if it were not.

 REVISION SURGERY

Replacing a previously placed prosthesis is much more difficult and less uniform in nature. Each case has its own unique problems and risks. In all cases, the risks are much greater than the risks with first-time surgery. The recovery is usually longer, and the results are less certain. You would likely not proceed as quickly in therapy or weight bearing as with first time surgeries.
Revision surgery, however, has greatly improved over the years, and even if the outcome is not always as good as with first-time surgery, great improvement in pain and function often results.OUTSIDE THE HOSPITAL
As mentioned, you are never completely safe from the risks of dislocation or infection.

Measures that you can take to help prevent them include:

• Avoiding low soft chairs or sofas
• Avoiding sports that include the risk of falling or twisting
• Avoiding other conditions that increase your risk of falling (dogs on leashes, walking on icy steps, etc.)
• Telling your doctor immediately of any possible infection anywhere on your body. Also let Dr. Shinar know.
• Receiving antibiotics before any dental, urinary, or rectal procedure for two years. You will require pre-procedure antibiotics for a longer period if you have a disease that compromises your immune system. (Call Dr. Shinar if there are any questions.) Always mention to any doctor performing an invasive procedure on you that you have a hip replacement.

 LONG-TERM

Hip replacements usually fail by a gradual process that can occur silently 5 to 25 years after the surgery. Pain is often not present until significant destruction has taken place. Revision surgery can be made more difficult by waiting until after this destruction has occurred. On the other hand, many hip replacements that are loose on x-rays are not painful and function normally for a long time. No uniform protocol as to when you should have repeat x-rays has been universally agreed upon, and your insurance company may not pay for a routine screening visit. Check with Dr. Shinar as to when he wishes you to return to have screening x-rays taken, and check with your insurance company prior to returning. If you develop new pain in your hip, notify Dr. Shinar immediately.

 Contact us!

Vanderbilt Orthopaedic Institute
Medical Center East, South Tower, Suite 4200
Nashville, TN 37232-8774

Carolyn Aubrey
615-343-0825
615-322-7556 (Fax)
carolyn.aubrey@vanderbilt.edu