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Anterior Approach Hip Replacement

A total hip arthroplasty, or hip replacement surgery may be your best option for long-term relief of symptoms from arthritis.  Other conditions that may warrant a hip replacement include avascular necrosis of the hip, hip dysplasia and post-traumatic arthritis of the hip.  At Joint Pain Orthopedics, the procedure is usually done through a minimally invasive, direct anterior approach to the hip.  This allows the surgeon to avoid cutting into muscle and allows for a more rapid recovery when compared to conventional hip replacement surgeries done using different surgical approaches.  The surgery can be performed under a spinal anesthetic in most patients.  After surgery, we have an extensive protocol that has been developed to allow for rapid recovery and improved pain control.  Benefits of having a procedure such as an anterior total hip replacement done by a surgeon who performs a high volume of joint replacement surgeries, such as a joint replacement specialist, may include a lower complication rate.  Dr. Christopher Jimenez has undergone extensive orthopedic training at the University of Utah under the direction of leaders in the field of joint replacement surgeries, including Dr. Chris Peters.  In addition to this, he undertook a 1-year joint replacement fellowship in California where he performed surgeries with and learned from Dr. Joel Matta, who is a well-known surgeon throughout the world and is widely regarded as a pioneer in the direct anterior approach hip replacement.  Dr. Edward McPherson was also instrumental to the development and education of Dr. Jimenez as he is widely regarded as an expert when it comes to revision joint replacement surgeries.  This has given Dr. Jimenez the education, experience and ability to manage even the most complex joint replacements and revision surgeries.  Joint Pain Orthopedics manages patients from Texas cities such as Austin, San Antonio and San Marcos to name a few.


How long will I be in the hospital?

            This varies depending on each patient’s health status and fitness level.  Select patients may be candidates for surgery in an outpatient setting or perhaps in a surgery center, meaning they may not even have to stay in the hospital after surgery.  Others can remain in the hospital for 1 night to allow for adequate mobilization and stabilization of long-term medical problems.  In rare cases, a longer hospitalization may be required.


When is a hip replacement surgery the best option for you?

            Pain and dysfunction associated with arthritis can limit your ability to walk long distances, sit for an extended time or even sleep.  It can even cause a decline in sexual function.  The time may be right for a hip replacement when you experience symptoms that don’t respond well to measures such as rest, medication or even injections.  It is time to stop taking time off of work or isolating yourself from others and avoiding the things you used to like to do.  A hip replacement surgery can help tremendously.

  1. Wiklund, I. & Romanus, B. A comparison of quality of life before and after arthroplasty in patients who had arthrosis of the hip joint. J Bone Joint Surg Am 73, 765–769 (1991).


How can you improve your chances of having a successful hip replacement surgery?

            You want to put yourself in the best position possible to be successful after a hip replacement surgery.  As a patient you want this experience to be a one-time deal that goes without complication.  There are certain risk factors that would increase the risk profile of a candidate for hip replacement surgery.  In some cases these risks may be mitigated, or modified, so that we decrease your risk for major complications after surgery.  Uncontrolled diabetes, severe obesity, smoking, malnutrition and anemia are a few of those factors.  If you have any of these risk factors, don’t delay in seeing us.  We can help you navigate how to improve this and help with your pain in the meantime.

  1. Alamanda, V. K. & Springer, B. D. Perioperative and Modifiable Risk Factors for Periprosthetic Joint Infections (PJI) and Recommended Guidelines. 1–7 (2018). doi:10.1007/s12178-018-9494-z


Do you need to see your primary care doctor before your hip replacement surgery?

            We want to ensure that you have the optimal experience with your hip replacement surgery.  Long-standing medical problems should be well controlled prior to your surgery.  We will routinely ask that your primary care physician and possibly other specialists involved in the long-term management of your health needs provide clearance for you to proceed with a hip replacement surgery.


Where do you go after hip replacement surgery?

            The thought of returning to your home after a hip replacement surgery and managing life yourself can be a daunting process and cause for un-needed anxiety and stress.  These concerns about bathing, cooking and getting around at home are all valid concerns; however, the majority of people that undergo this surgery will be safe for discharge home.  In many cases people have been in a debilitated state of life prior to undergoing the surgery that they have developed ways to cope with such bad joints.  Very soon after the surgery they likely will find they are in a better state of function and pain when compared to the pre-surgery state of living.

            You might have relatives or friends who had joint replacement surgery in the past that went directly to the skilled nursing facility or inpatient rehabilitation after discharge from a hospital.  Interestingly, there are no studies showing that this practice leads to better outcomes.  In fact there is evidence that you are more likely to have complications such as infections, wound problems and returns to the emergency room if you go to a facility rather than returning home after surgery.  People who go directly home rather than a rehab or skilled nursing facility often achieve a faster recovery.  It may be appropriate for a small percentage of patients to go to a rehab or skilled nursing facility after surgery for safety concerns.

            Is it safe to discharge home if you live by yourself?  This is a frequent question encountered in our clinic.  This topic has been researched and studies indicate that in many circumstances it is safe to discharge home if you live by yourself.  Home health services may be a great option as you can have a physical therapist come to your house for the first week or two to allow you to gain the strength and confidence needed to drive.  Ridesharing apps and food delivery services that are available from a phone also make this a reasonable option.  There are personal caregivers that are available if you feel this will be required.  Ask the staff at Joint Pain Orthopedics for more information.

  1. MHS, M. C. F. M. et al. Discharge to Inpatient Facilities After Total Hip Arthroplasty is Associated with Increased Postdischarge Morbidity. Journal of Arthroplasty 32, S144–S149.e1 (2017).
  2. Fleischman, A. N., Austin, M. S., Purtill, J. J., Parvizi, J. & Hozack, W. J. Patients Living Alone Can Be Safely Discharged Directly Home After Total Joint Arthroplasty. J Bone Joint Surg Am 100, 99–106 (2018).


What kind of help will you need after hip replacement surgery?

            The patient should arrange for a person or a team of people to assist them in the immediate post-operative period.  Patients that live alone may want to ask a family member, friend, neighbor or church members for time and help for the first week or two after the hip replacement surgery.  It is also possible to set up a personal assistant if help is not readily available.


How can you prepare your household for hip replacement surgery?   

            Be sure to let family, friends and neighbors know that you are having surgery.  You can cook extra meals and freeze them or use delivery services for food.  Arrange for someone to look after your pets while you are recovering.  If this isn’t feasible, then it may be a good idea to kennel your pet for a short period of time.  Remove any rugs, cords or obstacles that may cause you to trip and fall down at home.


Preoperative education and labs

            Joint Pain Orthopedics requires you to partake in class that is intended to teach you more about the hip replacement surgery and what to expect after.  These classes may be taught in the hospital where you will have a nurse and physical therapist instruct the class.  It is advised to have someone with you that will assist with your post-operative care.

            You may be required to undergo lab studies prior to your surgery to ensure you don’t require optimization of any abnormal parameters.  This may be coordinated with your primary care provider and/or the facility you will have your surgery at.


What should you expect on the day of surgery?

            You will be expected to be at the surgery facility a few hours before the scheduled time of your procedure.  You likely will be allowed to have clear liquids up until 2 hours before the surgical procedure; however, check with your surgery coordinator to be certain.  You will receive several different medications before surgery to enhance your surgical recovery.  You will also meet members of the surgical team, including the anesthetist and the nurse from the operating room.


Why do you use a spinal anesthetic?

            A spinal anesthetic is the preferred anesthetic used in total joint replacement surgeries.  Several studies have been conducted on the safety and benefits of this sort of anesthetic as compared to a general anesthetic.  There is a documented decrease in risk for major adverse events after the procedure when a spinal anesthetic is used.  A few of these are lower rate of blood clots, lower pain scores after surgery, lower rates of nausea and lower rates of confusion after surgery.  Our goal is to ensure you have an optimal experience with your hip replacement surgery.

  1. Basques, B. A., Toy, J. O., Bohl, D. D., Golinvaux, N. S. & Grauer, J. N. General Compared with Spinal Anesthesia for Total Hip Arthroplasty. J Bone Joint Surg Am 97, 455–461 (2015).


What happens during my surgery and how long does it take?

            The hip replacement surgery will usually be performed through the anterior approach, which is a surgical approach to the hip that allows the surgery to be performed without removing or damaging muscle around the hip joint.  A specialized table called the Hana table will be used for the procedure.  The goal of the surgery is to remove the diseased and arthritic portions of your hip joint and replace them with an implant that is made of titanium, ceramic and polyethylene.  Some patients may require the use of bone cement to accomplish their surgery, while others will have a prosthesis inserted that their body will eventually adhere too.  The surgeon’s goal should be to restore your hip back to it’s native state and to make your legs as even as possible.  We use advanced technology called radiographic navigation for this procedure, which gives us the ability to position the implants in the optimal position and match the length of your other extremity.  The surgical procedure usually takes 45-90 minutes in an experienced surgeon’s hands.  The length of the procedure depends on the level of deformity and difficulty of the case.


Why you should choose a surgeon with high surgical volume and advanced training in hip replacement surgeries?

            Joint Pain Orthopedic surgeons all have advanced surgical training in addition to the standard residency training that is required performing orthopedic surgery.  Standard training would give a surgeon the ability and know how to operate on several musculoskeletal issues ranging from spine surgery to bunion surgery and joint replacements.  Having a surgeon undergo a year or more of extra training in a specific subspecialty, i.e. hip replacements and revision surgeries, gives a surgeon a deep understanding of the surgical anatomy and relevant techniques that will be required of a hip replacement specialist.  Having the combination of a surgeon that is fellowship trained in joint replacement surgeries who performs a high volume of joint replacement surgeries is a great benefit to you as the patient.  There are several studies that have demonstrated a positive correlation between having a surgeon who specializes in hip replacement surgeries and having a lower chance of having major complications after total hip replacement surgery.  Dr. Christopher Jimenez has the advanced training in anterior hip replacement after completing a fellowship with world-renowned surgeons, Dr. Joel Matta and Dr. Edward McPherson.

  1. Koltsov, J. C. B., Marx, R. G., Bachner, E., McLawhorn, A. S. & Lyman, S. Risk-Based Hospital and Surgeon-Volume Categories for Total Hip Arthroplasty. J Bone Joint Surg Am 100, 1203–1208 (2018).


What kind of medications will you be on after your surgery?

            The Joint Pain Ortho Rapid Recovery plan has been developed with you in mind.  There are several different medications used that are non-opioid (narcotic) that will target pain and swelling from multiple different points.  This cocktail of medications may include an anti-inflammatory, non-opioid painkillers and nerve medications to name a few.  Opioid medication may be required for some patients; however, our goal is to make you comfortable to the point that these are unnecessary.  During the procedure the surgeon will infiltrate the tissue with a combination of medications that should provide excellent pain control for up to several days after the procedure.  Additionally, mobilization soon after a hip replacement has been shown to improve the perception of pain.  Cold therapy units may also enhance your recovery from a pain control and swelling standpoint.

Additional medications such as stool softeners and nausea medications may also be provided to decrease the possibility of complications after your surgery.  Deep venous thrombosis (DVT), or blood clots, has traditionally been a major concern for patients undergoing this surgery.  Your surgeon and or your healthcare team will decide what is the optimal medication to take to decrease this risk for you.  Mechanical compression devices may also be provided to further decrease your risk for DVT.  Additionally, rapid mobilization and ambulation further decreases the risk of DVT.


What kind of durable medical equipment will I need for my surgery?

            We would like for you to have a front-wheeled walker and a cane.  I generally do not advise you to have a walker with 4 wheels, as these require the use of hand-operated brakes.  The transition off of assistive devices can be accomplished once you have no residual gait abnormality after surgery.  Cold therapy units are also available for purchase.  Cold therapy has been shown to improve pain and swelling in the immediate post-operative period.  Sequential compression devices are also available for purchase.  These devices may reduce your risk for DVT, or blood clots, after surgery.  Some patients with really low toilet seats may want to purchase a riser to assist with rising from the seated position.  Additionally, some patients may benefit from the use of a shower chair.  A long-handled shoehorn has also proven useful for some patients that have difficulty putting on shoes.


When can you drive an automobile?

            A patient is generally safe to drive an automobile in about 1-2 weeks after undergoing a hip replacement procedure.  I generally advise that you should have stopped all opioid drugs that may delay your response time.  You should have the ability to slam on the brakes to avoid the car in front of you before you drive. 

  1. van der Velden, C. A., Tolk, J. J., Janssen, R. P. A. & Reijman, M. When is it safe to resume driving after total hip and total knee arthroplasty? Bone Joint J 99-B, 566–576 (2017).
  2. Batra, A., Gogos, S. & Nizam, I. When do patients drive after minimally invasive anterior hip replacements? A single surgeon experience of 212 hip arthroplasties. SICOT-J 4, 51 (2018).


Can you go through airport security with a hip replacement?

            It is safe to say that with enhanced security measures at airports nowadays your joint prosthesis is likely to set off the metal detector.  TSA prefers that you inform the security officer about the presence of hip replacement prosthesis at the time of screening.  A card stating that you have a prosthetic joint may be presented to the officer if you prefer not to say this out loud.  Feel free to watch the video describing this process below.

  1. Johnson, A. J., Naziri, Q., Hooper, H. A. & Mont, M. A. Detection of Total Hip Prostheses at Airport Security Checkpoints: How Has Heightened Security Affected Patients? J Bone Joint Surg Am 94, e44–1–4 (2012).



What should you do about showers and the dressing after hip replacement?

            We will routinely have what is called an occlusive dressing placed on your leg at the time of surgery.  This dressing is intended to prevent any leakage or contamination of the incision.  The intent of this dressing is to avoid the need for frequent dressing changes that could contaminate the incision.  In fact, it is designed so that you keep this on until your follow up appointment.  Most people can shower with this dressing on; however, we encourage you to place a secondary barrier to decrease the risk of penetration of the dressing with water.  If the dressing happens to get saturated, call the clinic for further instructions.  The incision should ideally not be left to soak in water.  Submerging your incision under water, as in bathing, should be avoided for 4-6 weeks after the surgery.  Ask your surgeon or a member of their team for specific instructions about their protocol.


When can I go back to work?

            Most patient should be able to return to work between 2-12 weeks after surgery.  The timing of return to work largely depends on the type of work you perform where people with heavy workloads such as construction will be closer to the 12-week goal.  Those with sedentary jobs such as desk jobs may be able to return to work much sooner.

  1. McGonagle, L. et al. Factors influencing return to work after hip and knee arthroplasty. Journal of Orthopaedics and Traumatology 1–9 (2019). doi:10.1186/s10195-018-0515-x


How long will it take to recover from hip replacement surgery?

            This depends on your definition of recovery.  To some patients, this means, “When will I be able to walk?”  Patients should expect to be up and walking with a physical therapist within a couple of hours after the surgery.  In general, patients should expect to be up and walking the day of surgery.  Rehabilitation after a hip replacement can vary depending on each patient’s goals and expectations.


Will I have precautions after surgery?

            This depends on the surgical approach used by your surgeon.  Dr. Jimenez uses the anterior approach for most hip replacement surgeries.  Using this approach usually means that you have no precautions after the surgery.  You should also be placing full weight on your leg.  In some circumstances a posterior based approach may be used where you may not be able to cross your legs, in-toe your foot or bend your hip past 90 degrees.  Complex hip replacements or complications may necessitate the need for protected weight bearing after surgery.  I would advise patients to refrain from performing high impact activity for at least the first 3 months after surgery.  This includes activities such as running and jumping.