As with all major surgical procedures, complications can occur. Some of the most common complications following hip replacement are:

++ Thrombophlebitis
++ Infection
++ Dislocation
++ Loosening
++ Myositis Ossificans

This is not intended to be a complete list of the possible complications, but it includes the most common problems.

++ Thrombophlebitis
Thrombophlebitis, sometimes called Deep Venous Thrombosis (DVT), can occur after any operation, but 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 within the veins. This may cause the leg to swell, become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they get lodged in the capillaries of the lung and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary = lung, embolism = 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!

Some of the 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 surgery. The chance of getting an infection following total hip replacement is approximately 1%. Some infections may show up very early - 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.

++ Dislocation
Just like your natural hip, an artificial hip can dislocate (where 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 therapist will instruct you very carefully how to avoid activities and positions which may cause a hip dislocation. A hip that dislocates more than once may have to be revised (which means another operation) to make it more stable.

++ Loosening
The major reason that artificial joints eventually fail continues to be a process of loosening where the metal or cement meets the bone. There have been great advances in extending how long an artificial joint will last, but all will eventually loosen and require a revision. 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.

++ 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 process of ossification or the formation of bone. This can lead to a situation where the bone actually can form 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 in the hip joint.

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

The treatment for myositis ossificans may actually begin before you get it. In cases where your surgeon feels that you are at high risk for developing the condition, he may recommend medications such as Indomethacin® be taken following 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 is to prevent the development of myositis ossificans using 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 3-5 days, seem to drastically reduce the risk of developing myositis ossificans. If myositis ossificans forms anyway, 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.

As with any medical treatment, individual results may vary. Only an orthopaedic surgeon can determine whether an orthopaedic implant is an appropriate course of treatment. There are potential risks, and recovery takes time. The performance of the new joint depends on weight, activity level, age and other factors. These need to be discussed with your doctor.

In What Activities May I Participate After I Recover ?

After undergoing hip replacement surgery, it is important you have realistic expectations about the types of activities you may do.

++ Driving
Driving may be resumed in accordance with the type of surgery you had. If the surgery was performed on your right side, your surgeon may give you permission to drive four to six weeks following surgery. If the surgery was with a “mini incision” permission may be given to drive earlier than with a standard incision. In any case you must be able to move the leg easily from the gas pedal to the brake. If you have a manual shift car and the surgery was on the left side, driving permission may be given at about six weeks following the surgery.

++ Sexual Activity
Resumption of sexual activity may be recommended anywhere from four to six weeks following surgery depending on the type of surgery. Your surgeon and physical therapist will discuss positions that maintain appropriate hip precautions.

++ Walking and Stairs
You will be progressed during your physical therapy program from your original walking aid (e.g., walker, crutches) to a cane. Eventually you will use no supportive device as long as there were no other problems encountered requiring long-term use of a walking aid. Eventually you will be allowed to climb stairs step over step. In most cases, patients begin with smaller height steps and gradually progress to standard height steps.

---Work Activities
Determining the date you return to work will depend both on your surgeon and the type of work you do. Some individuals may require modifications of their job, while others may easily return to their previous activities. Those engaged in heavy manual labor may have to discuss the possibility of vocational counseling with their surgeon.

++ Leisure and Sport Activities
There are different risks associated with certain types of leisure and sport activities. Some activities may lead to damage of your artificial joint over time due to wear and tear of the joint. In general, the more vigorous the activity, the higher the risk of damaging the implant, increasing the wear and tear on the implant, or increasing the risk of loosening or dislocating the implant.

Three major categories of activities should be avoided. These include:

++ Activities that cause high impact stresses on the implant.
++ Activities with potentially high risk of injury.
++ Activities that may result in falling or getting tangled with opponents risking dislocation of the joint itself or a fracture of the bone around
      the implant. These types of activities include competitive racquet sports (such as, singles tennis, squash, and racquetball), high impact  
     aerobics, high intensity jogging, water skiing, power gliding, Alpine skiing, mogul skiing, martial arts, rope jumping, and rough contact
     sports (such as football, soccer, lacrosse, basketball, baseball, handball, and volleyball). Therefore, these activities should be avoided.

Lower stress activities such as golf, hiking, walking, biking, stationary skiing (e.g. Nordic Track), and swimming are excellent forms of exercise for individuals with a hip replacement. Others may also be considered for long-term sports or leisure activities including cross country skiing, doubles tennis, table tennis, and bowling.

As with any medical treatment, individual results may vary. Only an orthopaedic surgeon can determine whether an orthopaedic implant is an appropriate course of treatment. There are potential risks, and recovery takes time. The performance of the new joint depends on weight, activity level, age and other factors. These need to be discussed with your doctor.

Understanding Postoperative Pain Medications

Unfortunately, pain following major surgery is inevitable, but there are several very effective methods available to control the pain following surgery.

++ Intravenous injections
Medications to reduce your postoperative pain can be given through your intravenous (I.V.) line. The most common medication used in this manner is morphine (or one of the newer synthetic morphine type drugs.) These injections are usually given by the nurse immediately following surgery until you feel that your pain is being adequately controlled. Be sure to tell your nurse when you need more pain medication. Narcotic medication given by intravenous injection acts quickly, but wears off quickly as well. Any narcotic medication may cause nausea and vomiting. You may need another type of medication that will reduce this side effect of the narcotic pain medications.

++ Patient Controlled Analgesia (PCA)
One of the newest - and most effective - methods of controlling pain after surgery is the PCA pump. This pump is attached to your I.V. line and controlled by a small computer. You will have a button that you can push when you need to have something for pain. The pump delivers a small dose of medication such as morphine directly into your I.V. line. The small computer controls how much medication that you are receiving so that you will not get too much. This frees you of having to call a nurse everytime you need pain medication. You are in control of how much and how often you receive pain medication.

++ Intramuscular injections
In some cases, the old standby of intramuscular injections (shots into the muscle of the buttocks or arm) of pain medication is still the best. The advantages of this type of injection are that the pain relief is longer acting than pain medications given through the I.V. Pain medications injected into the muscles are slowly absorbed into the body over two to three hours. If you are sleepy or groggy after being put under anesthesia, this may be more effective for you until you can focus on controlling the PCA pump.

++ Pills by mouth
Before you go home you will have to switch to pills to control your pain. There are many different types of pain pills that can be prescribed to help control your pain. Generally, most pain pills are not as strong as medications that are injected. They also take about 30 minutes to be absorbed from the stomach and begin to ease your pain. Most pain pills last about 3 or 4 hours, although there are several new long acting pain medications that last up to 8 hours. Your doctor will determine which pain medication is best for you and begin to switch you over to pills before you are scheduled to leave the hospital. You should watch for any signs of allergies to the pain medications, such as a rash or itching, and tell you doctor or nurse if these occur.

++ Epidural Catheter
If you have had surgery using an epidural type of anesthetic, you may receive pain control using a catheter. An epidural anesthetic is a type of spinal block where a needle is inserted into the bony spinal canal and a plastic catheter is inserted into the epidural space between the spinal sac and the vertebra. This catheter can be left in place after surgery so pain medications can be injected straight into the epidural space around the nerves of the spine. This reduces the pain in the lower half of the body (if the catheter is in the low back). One advantage to this type of pain control is that it takes less medication to control your pain. There is also less of an effect on your brain so you are able to think more clearly.

Physical Therapy Postoperative Out-Patient Total Hip Replacement Interventions/Treatment

Once your physical therapist has completed the examination, an intervention/treatment plan will be established. This plan will list the goals you and your therapist think will be helpful in getting you back to your daily activities. Finally, it will include a prognosis, or how much time and how many visits your therapist feels will be needed.

All of the precautions taught in the hospital will continue for approximately six weeks. Your therapist may choose from one or more of the following interventions to facilitate your recuperative process.

++ Exercises
Exercises will be prescribed by your physical therapist for many different reasons.

++ To improve your flexibility
++ To increase your strength
++ To enhance your endurance
++ To increase your balance and coordination
++ To make the performance of your daily activities easier
++ To improve your walking and stair climbing ability
++ Improving Flexibility; to improve your flexibility, your physical therapist may use graded exercises including active movement and
      stretching exercises. These exercises help restore movement while keeping your hip precautions in mind.

++ Strengthening and Stability Exercises
Strengthening and stability exercises will progress during this phase to regain the strength in the muscles around the hip and lower leg, especially the muscles in the front, side, and back of your hip, the muscles in the front and back of your thigh, and your calf muscles. In addition, you will continue to strengthen the trunk, non-operative leg, and arms.

++ Endurance Exercises
Endurance exercises will also be progressed so your muscles may function effectively over longer periods of time. These may include walking, swimming, upper body exerciser, and any other activity which maintains your hip precautions at this time.

++ Weight Bearing Exercises
Weight bearing exercises may increase during this time. You may be asked to shift weight from side to side and front to back, to walk for increasing distances, to go up and down ramps and curbs, and to climb increasing number of stairs. You may also be asked to rise up on your toes or perform modified squats.

++ Postural Exercises
Postural exercises will be incorporated into the program to keep your back and head well aligned and preclude unnecessary stresses on your back as a result of the surgery.

++ Balance and Coordination Exercises
Balance and coordination exercises may be incorporated at this time, especially if your hip replacement was the result of a fall from losing your balance. You may be asked to balance on one leg with your eyes open and closed, walk on uneven or softer surfaces, and do side-to-side walking.

If you have a pool available and are cleared by your surgeon for immersion in water, aquatic exercises may be incorporated into your overall program. Exercises should never be overdone. If you find your leg is swelling late in the day, it may be a sign you are doing too much too quickly. Pain should also be avoided. Pain is an indicator that something is or was too much. A small amount of muscle discomfort with increasing exercise may occur, but it should be reasonable discomfort, not pain.

++ Gait Training
Once you are able to bear full weight on your operated leg, your physical therapist will work with you to fine tune your gait. Retraining may be needed if you developed a limp, as a result of pain prior to the surgery, apprehension, or simply a habit developed over time. The goal is to develop a normal walking pattern where your steps are equal in width and length, and learn to appropriately shift your weight.

++ Functional Activities
Exercises may be included in your program simulating day-to-day activities like stair climbing and partial squatting. You will review all of your self-care and home management activities, as well as all activities related to your job and leisure life. This is done to ensure you are able to do them safely and effectively maintaining any appropriate hip precautions. You will continue to use the elevated toilet seat from six to ten weeks after surgery.

++ Modalities
Ice may be used if there is pain or swelling. Heat may also be used for pain management and for relaxation. Special care must be taken to make sure your skin does not overheat and burn.

++ Other Activities
If the surgery was on your right side, you may be given permission by your surgeon to drive between four and six weeks following surgery. If the surgery was done using a mini-incision technique, permission may be given to drive earlier than with a standard incision. In any case you must be able to move the leg easily from the gas pedal to the brake.

Resumption of sexual activity is usually recommended anywhere from four to six weeks following surgery depending on the type of surgery. Your surgeon and physical therapist will discuss positions that maintain appropriate hip precautions.

++ Home Program
As your condition continually improves, you will be given advanced exercises to do at home, in a pool, or in a gym setting. You may be scheduled to re-check with your physical therapist at regular intervals to make sure you are doing these exercises routinely and safely. During these re-checks, you may be given additional exercises to work on over the next few weeks. Eventually, you will have progressed to a final home program. Once you have been released to full activity, you may be instructed to follow up with a few visits over the next few months to make sure you reach your peak level of performance.

Physical Therapy Postoperative Out-Patient Total Hip Replacement Examination

After your hip replacement surgery, you may be sent home, moved to a rehabilitation facility, or to a long-term care facility.

++ Examination
On your first outpatient visit, your physical therapist will perform a thorough examination to gather as much information as possible about the history of your condition. Quick screening examinations of your heart rate, blood pressure, breathing rate, skin integrity, range of motion of other joints of the body, functional strength of other areas of the body, your overall ability to move, and your learning style may be done during this phase. Other parts of the examination may include assessment of any of the following areas:

++ Ambulation and Elevation Activities
By watching you walk, your physical therapist will analyze your walking pattern and check your assistive device to ensure you are using it correctly and safely. The amount of weight you bear on your leg will also be checked.

++ Balance and Coordination
Your balance and coordination may be assessed to see if any activities in these areas need to be incorporated into this phase of your physical therapy program.

++ Functional Activities
You may be given a questionnaire that helps you describe day-to-day problems you may be having with functional activities (e.g., putting on socks and shoes, dressing or self-care activities, getting in and out of bed, managing your home) as a result of the surgery.

++ Girth
Using a tape measure, your therapist may compare the circumference of your thigh, knee, and calf with the non-operative side. These measures may indicate if any swelling is still present or whether your muscles may have lost size (atrophied) as a result of lack of use or from pain.

++ Leg Length
The lengths of both of your legs will be assessed to see if a lift may be necessary on your shoe.

++ Pain
You may also be asked to rate your pain on a scale from one to ten. This measure helps your physical therapist gauge how much pain you may be experiencing at this stage and how much your pain and symptoms may change with the physical therapy interventions/treatment.

++ Posture
Your physical therapist will check your overall posture, including the alignment of your head, back, pelvis, hips, knees, and ankles.

++ Range of Motion (ROM)
Your therapist will check the ROM in your new hip. These measurements will indicate how far you can move your hip in different directions. Measurements may include forward and back (flexion/extension), side-to-side (abduction/adduction), and rotating (internal or external motions). Movements will be limited so you stay in line with the precautions you were told at the hospital.

++ Skin Status
Palpation or feeling of the soft tissues around the scar area may be done to check the skin for changes in temperature, to determine if any swelling is present, and to see if there are tender points or spasms in the muscles around the hip joint. The scar will also be assessed for healing.

++ Strength
The strength of your muscles will also be tested. The muscles around the hip, the knee, and the ankle will be assessed. These measurements will be initially assessed on your non-operative side and then compared with the operative side. Weakness in key muscles will be addressed with a strengthening program.

Once your examination is complete, a postoperative, out-patient interventions / treatment plan will be established by your case allotted board certified consultant.