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Preconditioning Appears to Play Significant Role in Recovery from Hip Replacement

Posted on: 11/30/1999
Although hip arthroplasties, or replacements, have been done for quite a while now, doctors and researchers are still debating the best ways to do the replacements. A minimally invasive approach to replacing hips has been developed, meaning that incisions are smaller and thought to provide a quicker and more efficient recovery from surgery.

Studies have been done about the different approaches to replacing hips with some surgeons saying that a minimally invasive total hip replacement is better than the traditional one, and other doctors disagreeing. However, it still isn't known what benefits a minimally invasive procedure would have on the patients. The authors of this study wanted to investigate how patient education, accelerated rehabilitation, and improved pain control affected patient recuperation following surgery. To do this, they enrolled 94 patients who were going to undergo hip replacement. The patients were divided into four groups. Twenty-five patients (group A) received the standard surgery and participated in the standard post-surgery protocol; 23 (group B) received the small incision and used the standard protocol; 25 (group C) received the standard incision and used the accelerated protocol; and 21 (group D) received the small incision and used the accelerated protocol.

Patients were not allowed to participate if they had a body mass index of over 30 kg/m2 or if they had any cognitive impairment or psychiatric illnesses. The patients were between 18 and 75 years old and had been diagnosed with osteoarthritis.

Before the surgery, the patients in standard protocol groups were given information about the replacement and the patient-controlled analgesia, a method that allows the patient to give him or herself pain medication through an intravenous with the push of a button, was explained. They were told they would be walking with help every day, beginning the day after surgery. Three or four days after surgery, they would be discharged to home or to a rehabilitation center. Any patients who were taking nonsteroidal anti-inflammatories (NSAIDs) were told to stop two weeks before the scheduled surgery. They were not told what size the incision would be.

The patients in the accelerated protocol groups were told that they would be given a "fast track" surgery and they would be receiving pills for pain in addition to an intravenous medication needed. They were told that they would be up walking on the day of the surgery and the importance of early movement was impressed on them. The patients were told that they were more than likely to be able to walk and even climb stairs already by the second day after surgery. On discharge, it was preferred that they go home rather than to a rehab, and that patients would receive physiotherapy to help teach them how to walk (gait training) and for exercises. For medications, the patients were to take celecoxib, a medication often given for arthritis pain. Finally, the patients were told that their surgery would involve a small incision.

When undergoing the surgery, all patients had spinal anesthesia, none had a general anesthetic. All received antibiotics before surgery and a blood thinner for six weeks after surgery. If blood was needed, those who had donated blood for later use were given it; others received blood donated from others. As well, all patients were seen for social service to see if they needed help after surgery. This resulted in some patients who were expected to go home going to rehabilitation instead.

The results showed that the patients in the standard group used their patient-controlled analgesia for at least two days. Other medications could be added if needed. They were visited by a physiotherapist the day after surgery. They sat up in a chair, walked if possible, and attempted to do stairs on the third day if able.

In the accelerated group, the patients took oral pain relievers, as well as celecoxib again, once per day, if they could tolerate it. If intravenous medication was needed, it was available. They were seen by a physical therapist a few hours after surgery when the patients were assisted into a chair or they walked if able. That was repeated twice a day after.

In order to measure the functional outcome of the surgeries, the patients were tested by the linear analog scale assessment, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Short Form-36 (SF-36), the Harris hip score, and the lower extremity functional score.

The researchers found a big difference between the patients in all groups when they were assessed by all scales and patients who were in the accelerated protocol group did have a significantly better outcome, regardless of whether the incision was small or large. The patients in these groups walked earlier and farther than those in the standard protocol. However, there were no differences between groups when assessing the amount of pain medication used, with the exception of the narcotic or opioid medications. The accelerated group used more. There was no difference in patient groups regarding if blood was needed. In terms of hospital stay length, those in the accelerated program were discharged, mostly to home, after an average of 3.5 days, with a range from 2 to 5 days. In the standard group, the average was 4.2 days with a range from 3 to 8 days.

Of interest, the researchers point out that in a survey from 2004, surgeons said that they had changed some of their routine with hip replacements, including giving pain medications before pain is severe, improving patient education, using different types of anesthetic and different surgical equipment, and being more aggressive with the rehabilitation after surgery.

There are some weaknesses in the study. Because there are several differences between the standard and the accelerated protocols, it's not possible to tell if any one specific change had more influence than any other. However, the study does emphasize the importance of patient education, receiving pain medication before it is absolutely needed, and a more aggressive rehabilitation period after surgery.

Aidin Eslam Pour, MD, et al. Minimally Invasive Hip Arthroplasty: What Role Does Patient Preconditioning Play? In The Journal of Bone and Joint Surgery. September 2007. Vol. 89-A. No. 9. Pp. 1919-1927.

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