The Formula for Hip Replacement Success

• At-home support. Make sure patients have a family member, friend or loved one at home who can help them prepare for surgery and assist in their recoveries. The care partner or coach should be knowledgeable about what the surgery will entail, including how to properly prepare for the procedures, the post-op rehabilitation plan, and general expectations and goals during each phase of care. The care partner should play an active role throughout the surgical journey, which includes attending preoperative educational classes with the patient, and taking part in physical and occupational therapy sessions. They should be willing to manage the patient’s post-discharge needs, which may include planning to stay with the patient at home for a few days, filling prescriptions, maintaining awareness of physical limitations and providing transportation to physical therapy and other postoperative appointments.

Most patients want to go home to a familiar environment as soon as possible after surgery. To help them achieve this goal, set the expectation before surgery that they will be well enough to be discharged on the day of surgery. Review their post-discharge care instructions and the support they’ll need to manage challenges they might face while recovering at home. Consistent communication among the healthcare team, including the patient and care partner, is critical to a successful transition to home after discharge.

• Comprehensive education. Informing patients about all aspects of their care during one-on-one education sessions held before surgery gets them more involved in their care, holds them accountable for doing their part to achieve positive outcomes, allows for open communication and provides a comforting environment where patients can ask difficult or personal health-related questions. If holding one-on-one sessions isn’t feasible for your facility, consider running virtual sessions or in-person group classes.

When patients know what to expect during the entire surgical process — such as who’s going to be calling them, what’s going to happen when they walk in the door and what’s going to happen when they go home — they’re less anxious and feel motivated to be physically and mentally prepared for surgery. If you express your reasoning on why you need to know if they smoke or consume drugs and alcohol, they are more likely to be honest with you and stop the harmful behaviors before their surgery.

• Skin antisepsis. Implementing a nasal decolonization and skin antisepsis protocol decreases the rate of SSIs in hip replacement patients. Screen patients for staphylococcus aureus colonization of the nares two to four weeks before surgery. Patients who are carriers should apply mupirocin topical ointment to the nares twice a day and bathe with chlorhexidine gluconate once a day during the week leading up to surgery. Assess patients for compliance with the regimen on the day of surgery.

There is no real consensus on which skin prepping agent is best, but evidence does show that chlorhexidine gluconate (CHG) provides an adequate barrier against staphylococcus aureus bacteria. Give patients CHG wipes and instruct them to apply to their skin pre-operatively before arriving for surgery. The patient should apply them to the front and back of their trunk, arms and legs. Two applications are recommended: the night before the scheduled surgery and the morning of the surgery. Instruct your patients not to bathe and not to use creams, lotions or powders after the applications.

• Pain management. Single-injection nerve blocks with local anesthetics such as lidocaine, bupivacaine, ropivacaine or mepivacaine provide analgesic benefit for several hours. Periarticular injections placed at the surgical site extend the duration of pain relief and have been shown to decrease consumption of postoperative narcotics. These injections can include a long-acting anesthetic or a combination of an NSAID and epinephrine.

Implementing a multimodal pain management protocol provides patients with a combination of several types of medications and delivery routes. The protocol can include peripheral nerve blocks, periarticular injections, limited oral narcotics, non-narcotic medications that are given preoperatively and postoperatively, and non-pharmacological methods such as cryotherapy, which freezes sensory nerves to provide months of pain relief.

The purpose of multimodal pain management is to decrease sensitization of the peripheral and central nervous systems as well as inflammation of tissue that is associated with surgical incision and tissue manipulation. Common preoperative medications include NSAIDs such as COX-2 inhibitors, pregabalin, gabapentin and acetaminophen. Common postoperative medications include NSAIDs, acetaminophen, neuropathic agents such as pregabalin and gabapentin, and narcotics such as oxycodone, morphine and hydromorphone — all of which should be taken by patients only as necessary to treat intolerable breakthrough pain.

Utilizing various combinations of medications provides a synergistic effect for pain relief through various pain pathways while decreasing the side effects of excessive narcotic consumption. The goal is to limit or eliminate the use of opioids, as they can cause nausea and vomiting, reduced gut motility and respiratory depression, among other side effects that can delay discharge and jeopardize positive outcomes. Effective pain relief is shown to improve patients’ postoperative activity, rehabilitation and satisfaction with the surgery. 

• Wound care. Incision healing begins within hours of surgery and continues for two to seven days postoperatively. Patients, as well as their care partner, should be educated about wound care specific to the type of dressing that’s applied. The initial dressing should stay on as long as possible to reduce risk of bacterial contamination and promote cellular wound healing.

Patients should know how to keep the incision clean and dry, when to bathe, and how to spot and report signs and symptoms of infection. Let your patients know what dressing options are available and help them choose one that will suit their lifestyle. Their feedback should be taken into consideration for ease of use, comfort and freedom of movement while wearing the dressing. Many different silver-infused dressings are waterproof and can be left on for seven days or even up to two weeks.

There is an emerging body of research on negative pressure wound therapy (NPWT) that suggests it can decrease wound complications such as dehiscence, infection, seroma and hematoma for high-risk patients. Surgeons may elect for this therapy and can place its system bandage at the end of procedures or during the postoperative period.

• Early mobility. Make sure your patients understand how important it is for them to ambulate soon after their operation. Rapid recovery protocols include aggressive inpatient and outpatient therapy or exercise protocols. The interdisciplinary care team’s involvement in these protocols is critical to rapid recoveries after hip replacement surgery. Patients might need extra encouragement and motivation to get up and moving soon after they’ve arrived in recovery. They must also be reminded about the importance of remaining active after discharge. If the thought of walking for extended periods of time during the recovery period seems too daunting for some patients, recommend that they break it up into walking sessions of five- or 10-minute increments.