With advanced minimally invasive surgery, multimodal pain management, and comprehensive blood management protocols the need for a hospital stay has become almost unnecessary. We almost never transfuse patients and patients are comfortable and are able to walk independently very rapidly after surgery.
All patients will be discharged with a detailed written protocol that contains all of the instructions that they have been previously taught. This pamphlet allows you or your caregiver to review instructions if you forget anything. The written instructions apply to the first 6 weeks which we call phase I of your recovery. All of your medication will have been filled in advance of discharge.
Click the headings below to learn more about what to expect after your procedure and instructions you should follow.
Therefore anyone who lives within 4 hours drive from Columbia is typically discharged after only one night in the hospital. Your Caregiver can then drive you home. I recommend that you sit in the passenger seat of a mid sized or larger sedan with the seat reclined for the ride. This is no different than sitting in a recliner at home. You will be on oral blood thinner and should do your ankle pump exercises every hour. Getting out to walk periodically is optional. If you purchase a car charger, you can use your ice machine while riding.
People that live eight or more hours away may opt to fly instead. Most airlines will give you the bulkhead seat if you are handicapped and arrive early. You do not need a slip; they will take your word for it when you arrive on crutches. Be sure to pack your ice machine in your check-in luggage, but bring your medications on board with you. Carts are always available to transfer you at airports.
People who live more than 4 hours drive away are usually kept in the hospital a second night for their convenience. That way they can get an early start on their travels the following morning. If you are flying, I would recommend booking one night after hospital discharge at the Marriott Courtyard or Residence Inn close to the hospital or near the airport. That way, you will have some leeway in case your stay is prolonged due to some minor medical issue.
The Columbia Airport is small, attractive and efficient and is about 40 minutes from the hospital and 30 minutes from our office. But often only small planes fly out of here. You will often have to climb steps to get into the plane, but you will be capable of this. The other option is to fly out of the major Charlotte airport. It is about 1 hour and 15 minutes drive from the hospital and 1-½ hours from our office.
Selected healthy patients can also opt for outpatient surgery at our surgery center. Currently we only have a contract with Blue Cross for this option. You will stay in the surgery facility for about 8 hours. When your anesthesia has worn off, you have voided, and you have walked with the therapist you are discharged home. Local Columbia metro patients can go directly to their home. Patients from outside the area will need to stay at the Marriot Residence Inn with a caregiver for one night or two nights if they live more than 4 hours drive away. A home health nurse will visit you the evening after the surgery and in the morning. She can administer a shot of morphine or run a bag of fluid if needed. This is rarely required.
Our protocol is very effective and patients are usually very comfortable. Every patient responds differently to medications. We follow a multimodal protocol that can be adjusted, as needed depending on individual patient response. We combine numerous agents to limit postoperative pain and keep our patients as comfortable as possible. The person who has taken a lot of narcotics before surgery is the hardest hit with pain afterwards.
On the other hand, sometimes people feel so comfortable that they stop all the medications when they leave the hospital and then pain catches up. We generally recommend 3-5 days of long-acting narcotic after surgery together with occasional short-acting narcotic as needed. In addition, round the clock Tylenol for 1 week and an anti-inflammatory medication for at least 2 weeks is recommended. An ice machine should be used regularly for 1 week.
True allergy to narcotics is rare indeed. Common side effects include nausea, itching, constipation, and mental changes. Some people are more sensitive to these side effects. They still need narcotics for surgery. Our protocol includes medications to limit these side effects. If narcotic dosage is decreased, side effects lessen, but pain increases. The patient must choose the right balance.
Switching from one specific narcotic to another is generally less effective than adjusting dosage. All narcotics cause these side effects; they are dose dependent effects. Certainly you need narcotics while you travel home. After 3-5 days surgical pain is usually to a point where narcotics are not needed on a regular basis.
You should be up out of bed the full day. If you are tired you can take a nap. Otherwise you should not be in bed. You should basically hang around the house like a very lazy weekend day. You should get up and walk around frequently with you crutches. You can read watch TV or use the computer. You will be on narcotics for about 3-5 days after discharge, so your thinking may be muddled and you may be a bit groggy.
You should walk for exercise twice daily. At first, in the hospital, you are walking several hundred feet. You should gradually increase the walking distance at home until you are walking one to 1-1/2 miles a day by week 6. You will be able to climb stairs as well. Most people are able to start going foot over foot with the rail by 4-6 weeks. Most patients use crutches for 2 weeks and then a cane in the opposite hand for another 2 weeks.
Don’t try to advance more rapidly than our instructions recommend. You won’t heal faster with more exercise; you will just risk hurting yourself. We have seen patient break their wound open, severely strain their weakened muscles or even get a stress fracture with too much activity too early. If you don’t do much, there will be no harm; there will be plenty of time for vigorous exercise when you are more fully healed. No impact activities or lifting more than 50 pounds are allowed for the first 6 months; thereafter restrictions are lifted.
As soon as you have stopped taking narcotics, you may drive. You should use an automatic car with the right foot on the gas pedal. If your right leg was operated on, you need to be comfortable using the left leg on the brake for about 6 weeks. This is because in an emergency, it is difficult to slam the foot of the operated leg on the brake hard and fast enough. Most people can resume normal driving at 6 weeks.
Most people return to office work at 2 weeks after surgery. For doctors, dentists and others who spend time standing and walking, a lighter schedule is recommended starting at 2 weeks after surgery. Pilots can return to flying at 6 weeks. People who have jobs that require walking can do this at 6 weeks. Deep bending squatting heavy lifting and impact activities (running, jumping, sports) and heavy labor are not allowed for 6 months.
Some people will require a modified slowed down program of recovery. Typically this is required in people who have weaker bone, severe under lying deformities or significant bone loss prior to surgery. I can resurface most bad hips, but in the more challenging cases, a slower initial program is required to avoid complications. Most patients who fit in this group will still have an excellent outcome and be able to fully participate in impact sports after 6 months just like the more ideal candidates. The slow down program involves 6 weeks of crutches, one month of a cane, and limited walking until 6 months.
We do a complete bone strength analysis with a DEXA scan before surgery. We also measure vitamin D levels on all patients. About 40 % of the population is deficient. Long-term deficiency weakens the bones. In young men who are found to have low bone density we recommend having your doctor check your testosterone level and consider supplementing it if it is low. Our research has shown us that low bone density is the one factor that is most strongly linked to the two most common early complications of hip resurfacing: femoral neck fracture and femoral head collapse (some call this necrosis). We call these early femoral failures because femoral neck fractures always occur within 6 months of surgery and head collapse is almost always seen by the 1-year x-ray.
The only other factor that we have found to be linked to early femoral failures is body mass index (BMI) over 30. It does not matter if BMI is elevated because of fat or muscle. In my first group of 373 resurfacings we had about 2% early femoral failures. In the last one thousand, we have had one single case. This 20-fold improvement has been achieved by research into the causes of these complications and development of patient stratification protocols; NOT by patient selection. Many experts recommend doing resurfacing only on the “best candidates” (patient selection). We have instead taken the approach to modify patient management to allow all patients to benefit from resurfacing. Because we have nearly eliminated these complications, we have even expanded the indications for resurfacing to nearly all age patients.
Basically, the protocol is to measure the DEXA scan. If patients have a T score in the operated femoral neck less than 0, then they are given an oral bisphosphonate drug weekly for 6 months. If the T score is less than -1.5, we recommend a one-year bisphosphonate course as well as a longer period on crutches. If the BMI is 30 or greater we also recommend a 6onth course of bisphosphonates. There are other alternatives to bisphosphonates if you cannot tolerate these, but sometimes insurance companies are reluctant to pay their higher costs.
A raised toilet seat and seats built up with blankets are helpful for a few weeks until muscle strength starts returning. It is more difficult to rise from a lower seated position at first. Even though the hip bearings that we employ are larger and more stable, extreme bending past 900 is still best avoided for the first 6 months until the hip ligaments are healed. It is safe to put on shoes and socks whenever you are comfortable to bend your hip enough provided you keep your knees apart when bending over.
Pillows between the legs are not required, but many people find this more comfortable. Laying on the incision causes no harm, but will be uncomfortable at first. After 6 weeks, bending past 900 is allowed, but deep squats and flexion exercised should be avoided until 6 months after surgery. After 6 months only extreme forceful flexion of the knee towards the opposite shoulder should be avoided.
Rehab / PT
I strongly recommend against stays in an inpatient rehab facility. The only time that I think this is required is in patients who are unable to arrange for any help at home, or those that have severe compounding disabilities that make walking with crutches extremely difficult. It has been shown that patients going to rehab units have a significantly higher risk of infection. Sick people tend to congregate in these units; it is best to stay away from them. If you need extra help that family and friends are not available for, home health aides can be hired from a home health agency to come assist you. In the Columbia area this costs about $17 / hour with a 3-hour daily minimum; insurance does not cover this.
Formal Physical Therapy is not required after you leave the hospital. The exercises are easy to perform on your own. We teach them to you in the hospital and send you home with an instruction sheet. At 6 weeks we advance you to the phase II program which is also easy to learn and to perform without supervision. If you see me in the office for the 6-week follow-up, we will instruct you in the phase II exercises, if you choose remote follow-up, you will arrange for a one-time visit with a PT to learn the phase II program. If you insist, I will provide you with a physical therapy prescription for more than one visit after 6 weeks. In the typical case extra PT is a waste of money, in some special circumstances it can be helpful.
I use a posterior approach. The incision is just back from the side of the hip. You will not sit on your scar. My total hip incision is 3 inches and my resurfacing incision is 4 inches in length in 95% of patients. Patients with BMI >35 or with old hip scars or with more complex anatomy sometimes require longer incisions. We use only internal stiches. This leaves a nicer scar and avoids suture/staple removal. We apply a 10-day antibacterial silver sealed dressing. This should only be removed early if it peels off or there is excessive drainage. You can shower over this dressing, but should not soak it in a tub.
After this initial dressing is removed (10 days after surgery) you may shower with your skin exposed. You should pat it dry and apply a small amount of bactroban (mupirocin) ointment daily until the wound is fully sealed and no scab or drainage occurs. If there is any drainage, the draining area should be kept covered by gauze dressing. You should notify us if there is any drainage after 2 weeks. Bruising and some redness are normal for a few weeks, if you are concerned, call us and e-mail us a picture. In rare cases there is a lot of early drainage. If this occurs, the initial silver dressing may become overwhelmed and require removal.
In this case you should apply bactroban daily, together with a thick gauze dressing. If drainage does not resolve after 3 days please call us for further instructions. Although minor wound problems are common and can be easily managed, serious deep infections are very rare (< 2/1000 cases in our practice). Even with these rare cases, the implant can usually be salvaged with aggressive management. After 6 weeks the wound is usually healed enough to allow soaking in a tub or swimming.
After 6 weeks you may also apply any creams or ointment that you desire. Although there are many advertised wound-healing creams, there is no good evidence to support this practice. Your incision will gradually fade over a period of 1-year, if you apply a special lotion it will not change this natural process. Due to subcutaneous fat atrophy at the incisional site, a small depression is usually present after all swelling has resolved at 6-12 months after surgery. This a cosmetic issue that sometimes bothers women. We have found no way to prevent it. It is not a sign of underlying muscle atrophy. We have done MRI scans in many patients and the gluteus maximus is always similar in size to the opposite side. Massage around the operated hip can be resumed after 6 weeks.
Every patient’s recovery is different; therefore we can only give you a general description of what is normal. If you are concerned that you may be having a complication, please don’t hesitate to call us at any time. Most questions can be answered over the telephone or via the online patient portal if you prefer. A physician is always on call to handle emergencies, but they will not be able to answer questions about our protocol or instructions, for these you will need to consult my nurse during regular business hours.
On-call doctors are also not authorized to call in any narcotic prescriptions. You will have to go through the inconvenience of going to the ER if you need these and have not planned in advance. Refills for narcotics must be arranged through my nurse during regular business hours. It is rare that refills are required because we provide a generous amount at the time of discharge that almost nobody uses up.
Routine follow-up is at 6 weeks, 1 year, 2 years and every other year thereafter. We can accommodate remote follow-up if everything is going well and return travel is too inconvenient. We prefer to see patients in person at the first 2 visits. The first 2 follow-up visits involve a questionnaire, an exam and an x-ray.
At the 2-year follow-up we request a questionnaire, an x-ray and metal ion levels. All subsequent checks require only a questionnaire and an x-ray. Additional visits or tests are sometimes needed if problems arise. Questionnaires are available online, as are prescriptions for x-rays and physical therapists who perform the exams. We generally do not recommend seeing another doctor.
Please see the Follow-Up section of Columbia Hip Protocol for details. Typically x-rays are less expensive at independent centers rather than high-priced hospitals. Metal ion levels should be done at Quest labs.