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Before Surgery

Dr. Swanson will evaluate you in his office to determine if you are a candidate for the minimally invasive technique. Nearly every patient undergoing total hip replacement with Dr. Swanson is a candidate for the minimally invasive technique as the incision length used is based on patient size and weight and may vary from 3 inches in the very thin, petite patient to 5 inches in the large, heavy patient. Most patients require a 3 ½ to 4 inch incision. At this time Dr. Swanson will explain the technique, including its potential risks and complications. In contrast to other minimally invasive techniques being developed (such as the “2 incision technique”), ninety-nine percent of patients requiring a hip replacement are candidates for this minimally invasive procedure. Surgeries are generally scheduled 2-3 months in advance, due to Dr. Swanson's schedule.

Insurance and x-rays

If Dr Swanson does not have your latest x-rays, forward a copy of the most recent x-rays to his office. Dr Swanson will review your x-rays and submit his report to the insurance company. Dr Swanson's staff will handle the insurance authorization.

Preoperative Medical Clearance

All patients over 50, and younger patients with any health problems, will be required to get clearance from a medical doctor prior to surgery. Dr. Swanson’s staff will help you arrange your pre-operative medical appointments either with your regular medical doctor or with one of our pre-op medical doctors; they will also give you the paperwork to take to your medical doctor when you schedule your surgery. Call and schedule an appointment to be seen 4-5 weeks prior to surgery. Take the instruction form entitled “Preoperative Medical Consultation” to your doctor at time of your appointment. A young person without health complication may only be required to have the standard hospital admission tests that should be done within 30 days of surgery.

Autologous Blood Donation

Only rarely is a blood transfusion necessary for  standard, mini-incision total hip replacement. Additionally, the blood supply is now considered quite safe with regard to HIV, hepatitis, and other infectious agents. However, if you are having both hips replaced within 6 weeks of each other, Dr Swanson may recommend that you donate blood for your surgery. You can begin donation 6 weeks prior to surgery. Most private insurance companies do not cover the cost, which can be a few hundred dollars per unit of blood. Additionally, if your blood is not needed for your surgery, it will be discarded; it cannot be used for other patients. Dr. Swanson’s staff will give you  an order sheet to bring with you to the blood bank. United Blood Service will transfer the donated blood to the hospital. By donating early in the 6-week period, your body will have time to rebuild your blood count prior to surgery. Drink plenty of water 1-2 hours before giving blood, as it will help hasten the procedure and prevent light-headedness after donation. Schedule 1½ hour to complete your blood donation. If you are donating out of state, special arrangements for blood transportation must be arranged. There will be an extra cost for the transportation.

Iron and Vitamin C

You should use an iron supplement prior to blood donation or if otherwise directed by Dr. Swanson or your medical doctor) to  replenish your body’s iron stores as it produces new red blood cells. Take an over-the-counter iron supplement such as Ferrous Sulfate,  Ferrous Gluconate, 325 milligrams 3 times daily beginning the first day of donation and continue until surgery. Vitamin C, 1000-1500 milligrams each day is recommended to facilitate iron absorption by your gastro-intestinal tract. Many people find iron to be constipating. The use of a gentle laxative such as Colace, Senokot, or Manna Cleanse may be helpful. Ferrous Gluconate is  used by many people who cannot tolerate Ferrous Sulfate. Product literature states that it is more easily absorbed by the body and does not cause constipation. In any event, don’t overlook this aspect as you will be stronger and have more energy post-operatively if you avoid anemia.

Anti-inflammatory Medication, Aspirin, and other Blood Thinning Agents

Do not take any aspirin or anti-inflammatory medications for 10 days prior to surgery (and that means NOT EVEN ONE PILL). These include Aleve, Advil, Motrin, ibuprofen, Naprosyn, Mobic, Voltaren, Relafen, Daypro, etc. All of these medications thin the blood and may cause excessive bleeding during surgery. Other blood thinners, such as Coumadin (warfarin), Plavix, or Persantine will also need to be stopped prior to surgery. Ask Dr. Swanson how long before surgery to stop these medications. In general, Coumadin must be stopped 3-4 days prior to surgery, and Plavix 10 days prior to surgery. Vitamin E and other herbal supplements, such as St. John’s Wort, Kava-Kava and Ginko Biloba may also cause thinning of the blood and should be discontinued prior to surgery. Any herbal supplementation should be discussed with Dr Swanson or his staff.

Pre-Op Instructions and Hospital Orders

Three to five days prior to surgery, you will meet with one of Dr. Swanson’s assistants for an orthopedic History and Physical examination. Bring a list of your medications and the milligram dosages you take with you. Also, bring a copy of your medical history, including all medical problems, prior surgeries, and previous surgical problems, to this appointment. Call the office where pre-surgery tests were done to make sure they were forwarded to Dr Swanson’s office prior to this appointment, or pick up the results and bring them in yourself. If your pre-operative tests are unavailable or your medical clearance has not been completed, your surgery may be postponed.


Spring Valley Hospital Pre-Admission

Dr Swanson does surgery at Spring Valley Hospital in Las Vegas. Spring Valley has an excellent rating with JCAHO. He has established a team that he works with consistently. At the time of your History and Physical appointment you will be given instructions regarding your preadmissions appointment at Spring Valley Hospital.  Bring all of the information listed below.

Only a few insurance payers are not contracted with Spring Valley Hospital. In this case, Dr. Swanson will try to work with the hospital administration to allow your surgery while not having you pay any more out of pocket than if you had stayed in your insurance network. If this is not possible, your surgery may be scheduled at an alternative hospital. Dr. Swanson’s team will take care of obtaining insurance authorization at an alternative hospital.  Dr. Swanson’s team will take care of obtaining insurance authorization at the appropriate hospital.  

The Pre-admit process may take about 90 minutes. Please bring the following items:

• Physician Admission/Pre-operative Order Form
• Insurance card(s)
• Picture ID (Driver’s license or Military ID, etc)
• List of current medications
• Pre-Anesthesia form completed
• Autologous Donation Card (if self donation done)
  

Day of surgery

A specific time (usually two hours before surgery) will be given for your hospital arrival. One of Dr. Swanson’s staff will call you the night before surgery for confirmation. If preceding cases take less than expected, your surgery may be moved up slightly. Conversely, if preceding cases take longer than expected, your surgery may be slightly delayed. Try to remain calm if your surgery does not begin right on schedule. Remember, to ensure the best results possible, Dr. Swanson will not rush your surgery or any other patient’s surgery. Therefore, it is imperative that you can be patient and understand that any delay in your surgery is due to additional care taken with surgeries preceding yours, just as Dr. Swanson will do with your surgery.

You should have nothing to eat or drink (even water) after midnight the night before surgery. Your stomach must be completely empty for surgery to minimize the risk of stomach contents entering the lungs while anesthetized. If you are on medication for your heart, lungs, blood pressure, or other medical problems, take them with a sip of water the morning of surgery. Diabetes medication generally should not be taken the morning of surgery.

After checking into the hospital you will be prepared for surgery. Blood may be drawn, an IV started for intravenous fluids, and you will sign a surgical consent. An anesthesiologist will ask you questions about your health, medical problems, and previous anesthesia. Most patients choose a “general anesthesia” where you are asleep through the entire procedure. The anesthesiologist’s job is to make sure that you are safe throughout the entire case. He will be with you, carefully monitoring your vital functions, during the entire procedure.

Surgery

Minimally invasive total hip replacement takes approximately one hour to perform. Once completed, you will wake up in the recovery room where there will be several nurses and other personnel attending to you to make sure that you are comfortable. For your comfort, a timy catheter will infuse novacaine into your hip slowly over the first 48 hours. You will also receive a pain medication pump (PCA-Patient Controlled Analgesia) to allow you to administer yourself pain medicine through your IV as needed. We will do everything possible to ensure that you are not in pain after surgery.

After Surgery

Once the surgery is completed you will wake up in the recovery room. The nurses will seem very busy, taking your vital signs and blood pressure, monitoring any drainage from the surgical site, checking the functioning of your leg, and making sure that you are comfortable. When you are awake and feeling comfortable you will be transported to the orthopedic ward for the next 2-3 days. You may be allowed to sit up on the edge of the bed for dinner the evening of surgery and even take a few steps on your new hip if your desire.

The first day after surgery a physical therapist will visit. You will begin strengthening your muscles and work on getting in and out of bed, in and out of a chair, and will start walking. You usually are encouraged to place full weight on the hip from day one. The therapists teach you precautions to follow to prevent dislocation. These are most important during the first 6 weeks after surgery and are much less rigid than those used with older total hip replacement techniques. 

Almost all patients go home by the 3rd post-operative day. Most are getting in and out of bed independently, up to the bathroom, and walking the hallway with the aid of a walker or crutches, or even a cane. A home nurse and home physical therapist will assist you and assess your progress 3 times weekly once you leave.

Rarely, a patient may need to go to a rehabilitation center for a few days after leaving the hospital. This only happens if  your walking and general mobility is not considered safe for discharge by the 3rd or 4th post-operative day, or if no one is able to stay with you (or at least check on you daily) for the first few days after you leave the hospital.

Recovery at Home

Once home you will continue to work on exercises learned in the hospital. You can walk as much as you find comfortable, but should follow the dislocation precautions closely. When able to walk without the use of the walker or crutches you will progress to a cane (used in the hand opposite the side of the surgery). When you are getting around without a limp the cane may be discontinued, particularly for short walks around the house. The home nurse will be available to assist you with your first shower or bath after you arrive home.

The home nurse will generally remove your sutures or staples 10-12 days after the surgery. The home therapist will monitor your exercises. If all is going well you may not need the services of either one for more than 1-2 weeks.

Dislocation Precautions

Since use of the “Capsular Noose” procedure, developed by Dr. Swanson in 2002, dislocation of the artificial hip is unlikely. However, during the early post-operative period while soft tissues are healing, you should be careful to avoid extreme positions, especially turning the knee inward when your hip is flexed (such as while sitting down). Always remember, as long as you can see the inside part of the knee on the opposite side, dislocation is extremely likely, even with bending over.

The physical therapist will teach you stretching exercises to help cross your ankle over the opposite knee for handling shoes, socks, clipping toenails, etc. Always keep the knee rotated outward when you bend the hip past 90 degrees (such as reaching for something on the floor when sitting in a chair).

As a general rule, it is always safe to flex the hip past a 90 degree angle if you have rotated the knee outward enough that you can see the inside part of the knee—keep this rule in your mind at all times; it will eventually become automatic when you bend over.

Additionally, you will be given specific exercises by a Physical Therapist to help strengthen and stretch the muscles around the joint. Do these exercises regularly, at least 3 times daily, during the first 6 weeks after surgery. Stretching exercises are also important, particularly rotating the knee outward. You will be taught to sit in a chair with your feet together and press the knees outward while bending forward a bit. You will also begin to slide the operated ankle up the opposite leg with the knee rotated outward to eventually enable a “figure-4” position to allow easy access to your feet. Remember, as long as the knee is rotated outward, it is very difficult to dislocate the hip.

Blood Clot Prevention

Graduated compression stockings (TED’s is a common name) are used to prevent blood clots in the legs – called deep venous thrombosis (DVT). Patients are required to wear them for 6 weeks post-operatively to keep the blood from pooling in the veins of the legs when inactive. They also help prevent post-operative swelling of the legs. The type that is issued at the hospital has holes at the tip of the stocking to allow staff to check blood circulation in the foot. You may buy additional compression stockings at a medical supply store. You may wish to buy the closed-toe variety, which many patients find more comfortable. Your leg must be measured for correct fit. After hospital discharge, TEDS can be removed a few hours at a time for comfort, but you should try to wear them as much as reasonably possible. At four weeks post-op you may begin to remove your TEDS at night. You will require assistance to put on or remove your TEDS. When planning for help post-operatively, keep in mind that if you plan on removing your TEDS at night you will need someone to help you at least twice daily.

You will also take an adult aspirin twice daily for 6 weeks. Aspirin is a mild blood thinner that helps prevent blood clots in the legs.  Patients at  higher risk for blood clots may require home injections for 4-6 weeks. You or a family member will be taught how to administer these injections prior to leaving the hospital. Additionally, you should try to move your ankles up and down frequently (“ankle pumps”) as this exercise promotes circulation in the legs.

Weight Bearing Restrictions

Due to excellent primary fixation of the total hip components, you will be allowed immediate full weight bearing as tolerated on your new hip. You will be up and taking a few steps the day of or the day after surgery with a walker or crutches and the help of a hospital physical therapist. Two or three days after surgery, you may find yourself able to do one or two laps around the nurses’ station once or twice daily and work on ascending and descending stairs if necessary. The hospital physical therapist will continue working with you on walking until you are released from the hospital. Once home, you should continue walking and performing the exercises learned in the hospital, initially under the supervision of the home physical therapist. In general, weight bearing “as tolerated” means putting your full weight on the extremity, with or without the use of walking aids (walker, crutches or a cane). Walking should be kept within reasonable limits. You will be using a walker or crutches initially and advancing to a cane or no support at all when able to walk without a limp. If you will be allowed only partial weight bearing, you can walk over a bathroom scale to see how many pounds you are actually bearing. The hospital PT will order a walker for you prior to discharge from the hospital. Most insurance companies will pay for your walker. You may want to check with your insurance company to confirm this. Otherwise, you will have to make arrangements to buy or borrow one to take to the hospital upon discharge and for use at home. Many people attach carrying bags or baskets to their walker to make carrying things with them easier.

Post-operative Appointment

At 5-6 weeks you will have an appointment to see Dr. Swanson in his office. By that time most patients are getting around independently without any significant discomfort, and almost all are off pain pills. Several things usually happen after the 5-6 week visit:

• You can quit wearing your elastic stockings
• You can discontinue the aspirin and iron pills (unless taking them for other reasons)
• The primary dislocation precaution (keep hip rolled slightly outward when bending at the waist or flexing the hip) will be reviewed with you.  You should remember this simple precaution for the rest of your life
• You may begin a stationary bike program for the next 6 weeks if needed to loosen up the hip so you can better get your shoes and socks on, clip your toenails, etc.

After this first post-op visit, Dr. Swanson or one of his staff will see you at intervals of 3 months, 6 months, 1 year, and yearly thereafter for routine checks. Of course, if you are having any problems you will be seen more frequently. Because Dr. Swanson is in high demand and extremely busy, you may not see him for every post-operative visit. If you are having any problems, you will see Dr. Swanson; but more often, when things are progressing smoothly, you may see Dr. Swanson’s fellow or Physician’s Assistant for some of your visits. Dr. Swanson apologizes for not being able to see you for every post-operative visit; however, this policy minimizes patient wait times while allowing patients with serious problems Dr. Swanson’s attention.

Note: Often, due to patient add-ons or other unforeseen events, Dr. Swanson may be running behind. Bring reading material or “time passers” to your appointment in case there is a wait. If you are doing well and are there for a routine post-operative check, you may be seen by Dr. Swanson’s fellow or Physician’s Assistant; this will allow for a much shorter wait in many cases. However, Dr. Swanson will always see you at your request, although the wait may be a bit longer and he will see you if you are having any significant problem with the hip.

Disclaimer:The information provided here is intended to educate the reader about certain medical conditions and certain possible treatment. It is not a substitute for examination, diagnosis, and medical care provided by a licensed and qualified health professional. If you believe you, your child, or someone you know, suffer from the conditions described herein, please see your health care provider immediately. Do not attempt to treat yourself, your child or anyone else without proper medical supervision.

©2008 Todd Swanson, M.D.
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The minimally invasive total hip replacement was developed by Dr. Swanson after being introduced to the concept in early 1997. Dr. Swanson began using the technique in May of 1997 and has continued to make improvements that now allow reliable surgery and reproducibly good results in most patients. Standardization of the technique has allowed teaching to other surgeons. Numerous physicians and orthopedic companies have shown interest in promoting “minimally invasive surgery” for total hip replacements.

The minimally invasive technique utilizes a 3-4 inch incision, much smaller than the 8-10 inch approach historically used for hip replacement. Patients require less anesthesia and pain medication, and mobilize more quickly. This results in both quicker recovery for the patient and a lower incidence of complications.

Patients typically recover from minimally invasive surgery in about half the time it takes to recover from standard incision surgery (6 weeks vs. 12 weeks).

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