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The Birmingham Hip Resurfacing
This is where the worn surface of the hip joint (most often the result of Osteoarthritis) is removed. The amount of bone removed is usually very small and is replaced with a metal-on-metal lining, which is covered by a substance called Hydroxyapatite to help secure the prostheses in place. This is called the Birmingham Hip Resurfacing (BHR).
An incision is made into the buttock and access is gained to the hip joint. The prosthesis chosen is the one closest possible to the normal size of the hip (small people have small joints and large people have large joints, as you would expect). Great care is taken to keep the wound as small and as neat as possible.
The reason such careful attention is paid to the size of the replacement part is because it means there will be less chance of dislocation, the risk being very minimal anyway (less than 1%), which decreases over time and by six weeks post-surgery this risk is really quite insignificant.
Prior to Surgery
After your initial consultation with me, a mutually convenient date will be set for your operation. It is important for you to be as fit and healthy as possible before your surgery. If you put some work in beforehand to build up your muscle strength this will help with your recovery post-surgery. You also need to make sure your blood pressure isn't too high, that you are not grossly overweight, try and stop smoking and do not have any kind of infection (including problems with your teeth). Infections will, more often than not, cause your operation to be postponed because infections are known to make their way to a replaced joint and infect it.
If you are taking any regular medication, including hormone replacement therapy, continue with this but if you take Aspirin daily it is suggested you stop this approximately two weeks before your operation, because Aspirin thins the blood and causes increased bleeding during and after surgery.
Although I understand it may be difficult to lose weight and stop smoking it really is important for you to attempt to do so. Increased weight puts a huge burden on the hip joints and makes recovery slow and difficult. Smoking also delays bone healing. So it is for these reasons that I ask people to try to get their weight under control and to stop smoking. I also advise people to try and eat a healthy diet, one that is low in fat and sugar, but high in vegetables and fruit. Alcohol also needs to be considered and drunk in moderation.
In readiness for the operation it will be necessary for you to have some routine blood tests taken. A small sample of your blood is taken so that units of blood matched to your own are available should they be necessary. You will also be checked to make sure you are not anaemic and other risk factors are kept to a minimum. Having your blood sample taken is a very simple procedure and only takes a few minutes. You may also need to have an ECG (heart tracing) performed and a chest x-ray, but this will depend on your age and general level of fitness. Some younger people do not need these tests taken.
The Day of your Operation
So the dreaded day dawns and yes, I know you will be nervous and dreading the prospect of the operation. This is why I always try and admit my private patients to hospital on the day of their surgery. I ask you not to eat anything for six hours beforehand and not to drink anything for three to four hours prior to surgery. If you are a National Health patient you will be admitted the day before your surgery, so that all the necessary pre-operative tests can be performed.
In the private sector you will come into hospital a few hours before your operation. You will then be required to fill out various forms. Once this has been done you will be shown to your own room, with an en-suite bathroom. You are then asked to shower or bathe and will be given a theatre gown. You will also be given an elasticated stocking to wear, which is to prevent the risk of deep venous thrombosis (DVT) and needs to be worn for at least four weeks. Deep vein thrombosis is a serious risk factor but is routinely treated with daily injections of Clexane, which minimises the risk. Very rarely if a deep venous thrombosis develops, it is possible to develop a pulmonary embolism (clot in the lungs). This is a very rare but life threatening condition but can be treated successfully with drugs to thin your blood.
You will also be asked if you are allergic to anything, including drugs, food and metal. If you are allergic to anything this will be marked on an armband and will need to be worn so that anyone who is caring for you will know of your allergies or sensitivities.
My Consultant Anaesthetist colleague and I will see you before the operation. If you are taking any drugs, please bring them with you and show them to the Consultant Anaesthetist. The operation is done under a general anaesthetic. Depending upon the size of your bones, it is usually carried out in an hour, or less if you have small bones. I have a fully trained and experienced team who work with me regularly, comprising a Consultant Anaesthetist, surgical nurses and assistants.
As mentioned earlier, the operation scar is kept to a minimum and is usually about 15cm (6") long. When it is healed it will leave a faint white line, as close to the crease in your buttock as possible, so that it is hardly visible. After your surgery it is customary to be taken to a recovery room and you will stay there until the staff are confident you are fully awake and comfortable.
After Your Operation
When you start to come round from the anaesthetic you will be aware of an oxygen mask around your nose and mouth, a wedge pillow between your legs to keep them apart, elasticated stockings on both legs to help to prevent a deep vein thrombosis developing, a drip going into your vein to replace fluids, a cuff on your arm to measure your blood pressure, a sensor on your fingertip to record your pulse and oxygen level. The bottom of your bed may be raised. You will have a pain-controlling device attached to your wrist, which you can operate yourself, but is controlled so that you cannot give yourself too much analgesia. Sometimes it is necessary to place a drain in the wound but this is only there for a day or so.
After you have woken up completely you will be taken back to your room/ward where nurses will look after you. There is always a qualified doctor on call 24 hours a day, should it be necessary for you to have medical attention, which is a fairly rare occurrence. The anaesthetist will call in and make sure your pain control is adequate. I will call in and see you on a regular basis to ensure your progress is satisfactory.
There is a lot of physiotherapy to do after your operation to build your muscle strength up, which will have wasted away as your hip pain has become worse. As it is essential for you to do this physiotherapy, pain control is used so you can endure the exercises. If you are in pain please let the nurses know and they will do all they can to help sort this out for you.
When you are in bed you will need to lie on your back with the backrest raised and the wedge between your legs, whether you are awake or asleep, but this is only until the second night, when it will be discarded. The drip into your arm will be discontinued once you are eating and drinking normally.
Your wound is checked and the dressing changed by the nurses every day. When you go home you will have staples in your skin and these will need to be removed by the District Nurse or your GP's Practice Nurse. The hospital will provide you with the tool to remove these staples. It will be necessary for you to make an appointment to have this carried out at approximately 14 days after your operation.
Your hip will be checked with an x-ray in the first few days after the operation to make sure it is in place. It is important for you to bring your x-rays with you when you are seen for check-ups after your operation.
After two or three days you will be able to sleep on your un-operated side but you will have to have a pillow between your legs.
Physiotherapy will begin the day after your operation and a Physiotherapist will see you twice a day. You will be shown how to walk properly, which is very important for the development of your muscles and for you to get the best out of your new hip. You will be given exercises to do and will progress from a Zimmer frame to two walking sticks before you leave hospital. You will also have to demonstrate that you can manage to walk up and down some stairs before you are allowed home. You will not be in hospital for any longer than seven days (sometimes less depending on your progress). You will also be shown how to get in and out of a car safely. You will not be discharged until you can, as a minimum, get in and out of bed unaided and manage some stairs.
Regular walking, together with the exercises you have been shown by the Physiotherapist, are the key to you getting the most out of your hip. Building up the strength of your muscles is critical if you are to walk unaided, confidently and without a limp.
You will be given assistance from the occupational therapist/nurse/physiotherapist with dressing, washing and picking-up aids. They will help you to use these aids so that your are as independent as possible. You may, however, have trouble getting your elasticated (TED) stockings on and off and you may need the help of a relative or friend for this.
When You Go Home
People often feel much more tired after an operation than beforehand. If this happens to you it is important for you to rest and eat a well balanced diet, again high in fibre and low in sugar and fat.
The other problems you may encounter are swelling of the thighs, knees and ankles but this will disappear after approximately three weeks. You are going to have bruising around your operation site and this will last for about four weeks, but aching over the site of the surgery can last for two months. Sometimes you will hear a 'clunking' in the operated hip - don't worry - this will slowly go away once the capsule and muscles have repaired around your hip. It goes away slowly and has usually gone after three months. Sometimes it recurs in very hot weather but again will only last for a short time.
Slowly, you will recover. You will need two walking sticks around the house for two weeks and you should increase your walking tolerance as much as possible over this time, making sure you are safe and do not fall. After three weeks you should be able to walk using just one stick indoors but you are advised to use two sticks when outdoors until you are about four to five weeks post-surgery. By this time you should be walking approximately half a mile a day and may feel confident enough to walk without sticks in the house and only one stick outside.
I usually advise you not to return to driving until six weeks after your operation. Some people feel confident and fit enough to do so sooner but if you do return to driving earlier than this, but probably not until you are four weeks post-surgery, you must check with your insurance company to see if you will be insured to drive and you must be confident you can manage an emergency stop.
You are seen for review at approximately six weeks after your operation and by this time you should have discarded your sticks. You will also probably feel comfortable enough to sleep on your operated side around this time. You should by now be able to manage to put on your own socks and shoes.
Until you are seen for your second follow-up appointment, which is three months after your surgery, I ask you to avoid crossing your legs; lifting anything heavy; twisting; squatting and extreme movements of your new hip. It is also important that you do not lift your knees higher than the level of your hip and please do not go back to golf, skiing or similar pastimes which involve extreme flexibility of your hip until you have reached this three month milestone.
You will be seen again at six and twelve months post-operatively and if you live abroad I will ask you to have x-rays taken locally at all of these stages and send them to me, so that I may check on your progress this way. By the first anniversary of your operation I will discharge you from my care.
Frequently Asked Questions
Q What's the difference between a total hip replacement and a resurfacing procedure?
A A total hip replacement is a much more invasive operation in that the top of your femur, or thighbone, the size of a golf ball, has to be removed so that the prosthesis, or false joint, may be fitted. When a resurfacing is performed, the arthritic bone is simply shaved away and the new ball and socket, or prosthesis, is fitted over your existing bone and cemented into place.
Q How many of this type of operation has Mr O'Hara performed?
A In excess of 500.
Q How long will I be in hospital?
A Approximately 7 nights. If you live locally I ask you to pop along to have a blood sample taken for cross-matching purposes, so that if I need to give you a blood transfusion I have blood perfectly compatible with your own available. However, if you live out of the area, I admit you the day before so the blood sample may be taken and cross-matched. You are then admitted on the day of your operation. I don't believe in admitting you the day before, as no matter how nice a hospital is nobody wants to stay there longer than absolutely necessary and apart from having to do the paperwork and maybe some minor tests, such as an x-ray or ECG (but only on much older patients), there is nothing to be done and people tend to just worry about their forthcoming surgery unnecessarily. The operation is then carried out and approximately 24-36 hours later you will be mobilised, using a Zimmer frame. The Physiotherapists will visit you in your room and start you on a course of exercises. You will not be discharged until you can manage to go up and down some stairs using two sticks.
Q What sort of anaesthetic will I have?
A The operation is performed under a general anaesthetic, which is administered by a Consultant Anaesthetist, who is fully conversant with hip surgery and who will be happy to talk to you when you are admitted to hospital if you have any particular fears, concerns, or worries.
Q Do I need physiotherapy after I have been discharged from hospital?
A No, not usually. The best things to do are: as much walking as possible, to cycle (if you can) and when your wound has healed to go swimming. All of these are wonderful exercises to tone up your muscles, which will have wasted somewhat due to the development of pain and lack of use of your leg.
Q How long will I be off work?
A Usually about six weeks. It is also worth remembering that in the small print of most insurance policies there is a clause that says you will not be insured to drive for six weeks following surgery involving a general anaesthetic. It's at about this time you will be fit to return to work, although some people with sedentary jobs do manage to return earlier.
Q Do I need to make any special arrangements at home?
A It's always a good idea to have somebody who can look after you in the first few days/weeks. Making cups of tea and coffee can be difficult when still using a crutch or stick. Sometimes it is useful to have a tall stool, with non-slip feet, in the kitchen to rest against when making a drink: this leaves your hands free to deal with the kettle, cup, etc., and you will then be able to take your cup and walk with your stick, back to your chair. You may also need help with putting socks and shoes on in the first few weeks - bending down that far often causes problems initially. This includes the elasticated TED stockings, which can prove difficult if you live on your own.
Q How long will it be before I am " back to normal "?
A Everybody differs, but after the first six weeks, if you continue with your walking and if possible other exercises, you will see a slow and gradual improvement and by six months things will be going pretty well for you.
Q How often do I see the surgeon after my operation?
A You will be seen at six weeks post-operation, a further six weeks, i.e. three months post surgery, six months and a year after your operation, at which time, if all is well, you will be discharged from our care.