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Hip replacement surgery takes a team effort

by Donna D’Amour

As we age we often hear friends or family complaining of a bad hip, making it difficult to get up from a chair, in or out of a car, or to manage stairs comfortably. Some parts of our bodies, particularly joints such as our knees and hips, can wear out while we still have a lot of years left in us. Fortunately, doctors are able to replace these parts to allow us to carry on doing things we want to do. But they can’t do it alone.

Each surgery takes a team effort with the patient being an active participant. Recent hip replacement patient Pat Paul, age 87, says she was monitored by her orthopedic surgeon every six months for five years. “I had a real pain in my left foot. The doctor checked things out and told me the problem was that I had one leg shorter than the other. He also indicated to me that my left hip was at a Level 4 and my right hip was at a Level 2. He recommended that I get the left hip replaced,” she says.

Treatment starts with an assessment. Alissa Decker, program manager of the Orthopedic Assessment Clinic attached to the Veterans Memorial Building in Halifax, says, “You would come in and meet with a nurse case manager and a physiotherapist who would do an assessment to see how you are managing your life. How much pain you are having; how it is impacting your daily activities and your quality of life. They would look at your X-rays to discover your arthritis level. It can range from 1 to 4, with 1 being mild and 4 being severe.”

“What the person’s expectations are, often determines the need for surgery,” says Deidre Curiston, physiotherapist, Pre-habilitation Clinic. “We see people who have jobs such as carpenters. They still have to be able to work in a more physical job. Their work life may be impacted by their arthritis. They might be ready to have a hip replacement to allow them to be active and to function longer. Whereas somebody who is not active, might be just puttering around the house, might be able to manage their pain and in terms of their activity level, they might not be that impacted.”

Decker says you could have a person with Level 4 arthritis who can cope without surgery and a person with Level 2 arthritis who needs surgery to keep doing what they usually do. Each patient is different.

“We see people in their 40s upwards to 80s and 90s having their hips replaced. Some people have early onset arthritis. People in their 40s with level 4 arthritis still have a long work life left, are still very active and the pain can greatly impact their activity,” says Decker. “We try to hold people off since that new hip has a shelf life. Generally it lasts a range of 10 to 15 to 20 years; each individual is different. If they have surgery at a younger age, at some point, they would have to have the original replacement hip, replaced.”

Part of the team working with patients with hip and knee problems: Deidre Curiston, physiotherapist, Pre-habilitation Clinic, Alissa Decker, program manager, Orthopedic Assessment Clinic, and Michelle Biso, case manager RN, Pre-habilitation Clinic.

Photo credit: Donna D’Amour

The assessment clinic and wellness model offers arthritis patients a number of options, before considering surgery. “We want people to be as active as possible, do the appropriate exercises, manage their weight, try different bracings, take medications to manage pain, as well as modifying activities,” Decker says. “Surgery is the last resort.”

“My cardiologist also had to be consulted. I had had open heart surgery to repair a leaking valve a few years before. After giving me both an echocardiogram and an electrocardiogram, he gave his approval.”

Most people have a hip replaced because of osteoarthritis. Deidre Curiston says. “Arthritis runs in families, but there are other factors as well: the way we use our joints; previous injury, which can cause the hip to deteriorate more quickly; extra body weight, which is also a risk factor for developing osteoarthritis.”

She says people think of the deterioration of cartilage, but the entire joint deteriorates: the bone underneath the joint, the muscles surrounding the joint, the lining of the joint, as well as the cartilage. Cartilage acts like a shock absorber between the hip joint, when it is broken down or missing, the bone on bone movement causes pain.

Factors affecting the need for surgery include, X-ray results, a person’s lifestyle, their function, how well they get up and down from a chair, how their walking is affected, how bad their pain is. Staff want to make sure patients are aware of the many possible options for treatment before surgery is considered.

“Education and activity is the first line of intervention,” says Curiston. “It should be the first thing that we try, and a lot of people get better from their arthritis just from that.” She says education about pain management, weight management and an appropriate exercise routine really helps. “The wrong type of exercise can aggravate the joint. We tell people to do activities that put less weight or less stress on the joint: water activity, where your body weight is supported by water; seated activities such as using an exercise bike or an elliptical machine, where your whole body weight is not going through your leg. Tai Chi and walking are also recommended.”

She asks people to do 150 minutes each week of such exercise. She says physiotherapists can work on getting the joints moving better, having the biomechanics working better. “You do the activity and strengthen the muscles around the joint to protect the joint.”

Once the decision is made to go ahead with hip replacement surgery there is a wealth of education available to make the experience as pleasant as possible. Preparation is key.

“Discharge planning needs to start the moment you decide to go this route because you are going to need to be prepared,” says Michelle Biso, Orthopedic Assessment Clinic Pre-habilitation RN case manager. Biso provides two types of programs. “We have a pre-habilitation program for people who are on the surgical wait list. The team includes myself as a nurse, Deidre the physiotherapist, an occupational therapist, a nutritionist, as well as resources through a social worker. We support the patient. We do an assessment and they take an eight-week class of education and exercise with us. Two days a week they have an hour of exercise each class and one hour of education.”

Biso says that if those with osteoarthritis don’t get out often, they may not be able to do the things they used to. Some people may have depression from not getting out. The environment in the class helps people relax. It’s a learning situation but also a social gathering. Peers learn from each other as well as from the instructors. Some participants may have already had surgery and can share their experience.

The second program is a pre-surgical class at the Orthopedic Assessment Clinic in Halifax as well as one in Dartmouth General and Cobequid. “We talk about what to expect before, during, and after surgery. It optimizes their outcomes.”

In keeping with the team approach, patients are asked to bring a “coach” along to the session. This can be a friend or family member who will see them through recovery.

Patient Pat Paul was very impressed with the day-long pre-surgery series of interviews ending with the pre-surgical class. She met with the pharmacist to review her medications and explain any changes pre- and post-surgery; a nurse who took her vital signs, and reviewed her medical history; an anesthesiologist where Pat requested a spinal anesthetic, which she was told was given in most hip replacement surgeries. Pat also asked that she not be given hydromorphone and was assured there were alternative pain medications available. After tests including EKG, blood, urine and X-rays, she went to the pre-surgical education class. In one segment, they actually passed around the titanium joint that would replace the natural joint.

“The ball and socket are replaced in a total hip replacement, which is what we see most often,” says Biso. “The ball part is the top of the femoral head and the stem goes inside the femur (thigh bone); the socket goes into the part of the pelvis called the acetabulum. Joints can be made of different materials; titanium is commonly used. They can be a combination of metal or ceramic or metal and plastic. The rough exterior of the new joint encourages new bone tissue to adhere to it.”

Most patients are released from hospital the day after surgery, but some might stay longer if medical issues arise. “They have to be able to get up and down from a chair and walk a distance that is reasonable for their home situation. If they have stairs at home, they need to be able to get up and down the stairs with minimal assistance or supervision, so we know they are going to be safe at home,” says Curiston.

Pat Paul says she was fine when she got home because she had someone staying with her. “I’m pretty agile so I often do things others would not do. I was making meals, doing my daily exercises.”

“Hip replacements are very successful procedures,” says Curiston. She says most people have had so much pain prior to surgery, they are happy the pain is gone. They can move the joint much better, they can tolerate putting weight through the joint, they can walk further. Their level of activity is greatly improved.  Most people are happy with the outcome.

In 2018, there were 1,625 hip replacement surgeries in Nova Scotia. “Our goal is to increase that number and there has been a lot of funding to provide four new surgeons across the province, a new anesthesia and new operating room times,” says Decker. Wait times have gone down considerably as a result. Some people have surgery after six to eight months, some prefer a particular surgeon who may have a longer wait time. “The goal is to meet the six-month wait time set by the Canadian Institute for Health Improvement.”

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