Hip replacement: ‘I went home the same day and since then I’ve been flying’
The enhanced recovery procedure sees patients discharged within hours of the operation
The enhanced recovery programme of hip replacement is still relatively new in Ireland. Photograph: iStock
When Dubliner Mark Lawless was told he needed a hip replacement, he also learned it would be done and dusted in just one day.
An estimated 4,500 people have hip replacements in this country every year and the public perception is that patients require several days in hospital following the operation.
Earlier this year, the 49-year-old underwent the enhanced recovery (ER) process of hip replacement which has been available at Cappagh National Orthopaedic Hospital since last summer, when the hospital became the only public hospital in Ireland to offer this same-day service.
The Clondalkin father-of-two, who specialises in international household and personal effects removals, had been experiencing hip-pain since a work-related accident in September, 2012. “I’d just arrived in Zurich from Ireland and was about to start unloading furniture for a house I’d been contracted to do a removal for.
“As I was getting out of the truck, I slipped and landed badly, damaging the cartilage in my hip,” he recalls.
A cortisone injection helped with the pain – but only for a few months. An MRI scan showed damage to the cartilage in his hip and eventually, when a second cortisone injection had no impact, Lawless was told he needed a hip replacement.
He was put on a waiting list for a hip operation at Cappagh. It was 2018 before he met with the consultant who was to carry out the operation, and throughout all of this time, Lawless continued to work, albeit in constant pain. “For me, it was about managing the pain in my mind because I didn’t take painkillers. I have to drive so I only took painkillers when I couldn’t bear the pain any longer. I’m quite a happy fellow, but pain drags you down and puts you in bad form.”
There is a preconception that, following a joint replacement, patients need to stay in bed for several days, says Dr James Cashman, consultant orthopaedic surgeon at Cappagh. However, he says, under the same-day-discharge enhanced recovery programme, patients are up and about and out of hospital within hours of the surgery taking place.
The process, which is still relatively new to Ireland, although commonly available in the US, aims, he says, to reduce pain and improve a patient’s quality of life.
There are actually two kinds of the process – under one, the patient will leave hospital about two days after surgery, instead of the traditional five to six days.
However, under the same-day-discharge process, the patient is released from hospital within hours of the operation.
Same day ER patients, says Cashman, make up a small, but increasing number of hip replacements. They are generally otherwise fit people, who live close to the hospital and have support at home, he explains. “These patients are very carefully selected in terms of their fitness. They also receive extra education about their post-operative programme,” Dr Cashman explains.
Patients are initially seen by the consultant in the hospital’s outpatient department for assessment, he says. “Once they’re booked for surgery, they attend a special pre-assessment clinic at the hospital.”
At the clinic, patients have blood tests and other relevant pre-operative tests. They also meet with nurses, a physiotherapist and an anaesthetist to learn how the enhanced recovery process works. “They will receive a spinal anaesthetic rather than a general anaesthetic before the operation,” says Dr Cashman, adding that patients also learn about the type of pain-reduction medication and physiotherapy they will receive after surgery.
“Involving the patient beforehand, and educating them is very important, because it gets them into the mindset of understanding why they need to get moving so quickly.
“They understand that they won’t have a lot of disability following surgery. At the pre-assessment clinic, they also learn how to walk on two sticks or crutches. People tend to assume they’ll be in bed in a hospital, and that they’ll need rehabilitation following a hip replacement,” he says, adding that with ER this is not the case. “The anaesthetic which the patient receives is short-acting, to cover the duration of the surgery,” he says – same-day-discharge patients receive an anaesthetic which only lasts for two hours.
“The pain medication used is a system of multi-modal pain control,” Dr Cashman explains, adding that, during the operation, the patient gets an injection around the hip joint, which extends their pain control and continues for several hours.
“Patients also receive a mixture of lower-dose painkillers and other drugs after the operation so that they don’t experience a big spike in pain. We treat their pain with a number of different medications, but no high dose of any of them. This is to avoid the use of opiates such as morphine, which can leave the patient dizzy and nauseated and unable to get up and walk. This means they’re more comfortable and can get up and walk more easily.”
Out of bed
As soon as the same-day ER patient’s anaesthetic has worn off, he or she is encouraged to get up and out of bed by the physiotherapist.
Being mobile so soon after the operation reduces the risk of clots, chest infections and urinary retention, which are common conditions following a hip replacement, Dr Cashman explains.
“After a traditional hip or knee replacement, it could take till the following day for a patient to begin moving but in this process they can begin to move up to two hours after surgery,” he says.
“We aim to get them on two walking sticks or crutches rather than a walking frame, If you’re on a Zimmer frame, you’re more disabled than on sticks.”
Both sets of ER hip patients will see the physiotherapist shortly after they wake up in the recovery bay, but those selected for same-day discharge will meet with the physiotherapist up to four times in the hours following their operation, explains Paul Barry, senior physiotherapist leading out on enhanced recovery.
“Same-day-discharge patients will be assessed to establish that they can transfer in and out of bed, can be mobile using two elbow crutches independently, can navigate the stairs and can complete an initial home exercise programme.
“In the initial phases, we’re seeking to help people build confidence in their hip replacement,” he says. Patients quickly understand that they can weight-bear and walk using crutches or sticks.
“We contact them the following day and check whether there have been any issues overnight or if there’s anything they need to clarify. Generally, the feedback is really good and they’re managing well. The advantages are that the patient can recover in the comfort of their own home and feel empowered to take control over their recovery,” he adds.
Lawless attended his pre-assessment clinic for enhanced recovery patients last January. “The pre-assessment clinic took about six hours. I had blood tests and met with the staff including the anaesthetist, the physiotherapist and the nurse, and learned about what would happen.
“They were very reassuring. They spoke very clearly and kept it very simple,” he recalls.
His operation took place on the morning of February 26th. “When I woke up, I got pain medication and before lunch the physio had me standing up and walking across the room with two crutches. He returned in the afternoon and I did more exercises, and walked from the ward onto a stairs. I went up and down the stairs before walking back to the room.
“I got more pain medication, and they went through it all with me. The consultant came in to see me and answer any questions I had, and the pharmacist went through my medication with me,” he says, adding that he also met with the nurses and the physiotherapist about his home recovery programme.
“The physio went into detail about the kind of exercises I was to do and how to do them, and gave me a folder of illustrated exercises.
“I went home the same day and since then I’ve been flying,” he says, adding that within four days he was walking for 10 minutes with two crutches. Within three weeks, he was walking for up to an hour on just one crutch.
Lawless hopes to be back at work by mid-April and says he’s had no pain apart from a “slight stiffness which I get rid of by walking and doing the exercises recommended by the physio”.
“I stuck to the plan regarding the exercise. I’m delighted with it and I’m extremely grateful to the team in Cappagh for the care I received.”