Accelerated Recovery After Modern Hip Replacement

What are Total Hip Replacements and ERAS Programs?

Total hip replacement is the definitive treatment for severe degenerative joint disease of the hip, which can arise from numerous conditions, including, but not limited to:

• Osteoarthritis
• Avascular necrosis
• Rheumatoid arthritis
• Post-traumatic conditions

Called one of the most successful surgeries of the century, total hip replacements have become a very common surgery in the United States, with approximately 544,000 total hip replacements being performed in the US in 2022.  In the past, total hip replacement often required a lengthy recovery process with prolonged hospitalization and rehabilitation after the inpatient hospital stay, frequently in a skilled nursing facility or inpatient rehabilitation center.  Over the past several years, orthopaedic surgeons have worked with other health care team members to develop new techniques to accelerate the recovery process following total hip replacement.  These Enhanced Recovery After Surgery (ERAS) programs have resulted in a much shorter recovery following total hip replacement and allow many patients to return home the same day as their surgery.

ERAS programs are not a single technique but rather a coordinated way of navigating patients through the hip replacement process including the orthopaedic surgeon, the anesthesiologist, nurses, physical therapy team and the patients family to help maximize recovery, reduce hospital stay, lower cost of care, and enhance the patient experience while at the same time, improving patient safety and outcomes.  The process carries through three main phases of care, preoperative optimization, intraoperative efficiency and minimally invasive techniques, as well as postoperative rehabilitation.

Preoperative Optimization for Accelerated Recovery After Modern Hip Replacement

There are three main areas of focus for preoperative patient optimization, including education and counseling, physical preparedness and nutrition, and discharge planning. Patient education includes information provided by the surgeon, surgical scheduler and nurse navigator to help the patient understand the procedure itself, to discuss and understand expectations for recovery milestones, pain management planning, and to understand potential risks of the surgery.  Having a good understanding of the surgery and plan for postoperative pain management and recovery helps to empower patients to manage their recovery, as well helps to minimize anxiety for patients and their families. 

Physical preparedness encourages patients to continue their activity level to the best of their ability prior to surgery in order to maintain strength in the muscles that help drive the hip, including lower leg muscles and core muscles in the spine and stomach, which allow patients to walk efficiently.  Patients are also encouraged to maintain a healthy diet leading up to surgery including working to have a high protein diet that will prime their body for healing following the surgery.  Patients are also recommended to cut back or stop risk factors such as smoking or excessive alcohol intake that have been shown to delay recovery and increase the risk for complications. 

Discharge planning is the final crucial step in preoperative optimization, which involves understanding expectations for recovery, and assembling a team of family, friends, and neighbors who can help the patient in recovery following surgery. Care teams such as this do not typically physically help to move the patient but rather assist the patient with medications, meals and encouragement.  This team can also help communicate with the medical team if concerns arise during the postoperative recovery period.

Intraoperative Efficiency and Minimally Invasive Surgical (MIS) Techniques

Surgical techniques have evolved over time to allow surgeons to access the hip joint and perform total hip replacement with less damage to soft tissues.  The direct anterior approach has become a popular approach among surgeons and patients, as it allows surgeons to access the hip by going between muscles, rather than having to cut muscles or tendons. Many modern approaches for performing total hip replacement no longer require patients to adhere to postoperative restrictions, such as those recommending patients not bend over too far or sit in deep chairs. Going hand in hand with improved surgical techniques are advanced anesthesia techniques that may utilize shorter acting medications that allow patients to wake up and “feel normal” more quickly, all of which facilitate early mobilization.  Nerve blocks and or infiltration of local anesthetics in the hip joint during surgery also help to minimize pain to allow early mobilization and minimize the number of narcotics, which can cause nausea, constipation, and confusion, all of which hinder recovery.

Postoperative Rehabilitation for Accelerated Recovery After Modern Hip Replacement

The combination of efficient surgical approach and advanced anesthesia techniques allows patients to begin walking within hours of their surgery with assistance from the recovery room nursing and therapy team. Early motion helps to minimize complications like blood clots and empowers patients to start their recovery process to get back to feeling “normal.” Multimodal pain management strategies will be used to help maintain pain at tolerable levels. This technique uses many different types of medications, often including Tylenol, NSAIDs, nerve medications, steroids and anti-depressants, to minimize or even eliminate the need for narcotics, which cause side-effects as described above and can become addictive.

These techniques allow many patients to go home the same day as their surgery when discharge criteria are met, including adequate pain control and the ability to demonstrate to the physical therapy team that they can safely navigate their home environment. Patients who do stay in the hospital are typically able to return home the morning after their surgery. Once home, patients are encouraged to walk short distances frequently and may receive a set of home exercises to perform. Many patients can recover by simply walking and performing home exercises, without the need for formal physical therapy.  Additionally, most patients are back to driving approximately 3 weeks after surgery and are feeling quite well by that time.  However, it takes approximately 3-6 months to completely recover from hip replacement surgery.

Advantages and Considerations for ERAS

The advantages of ERAS are many, including:

• Reduced pain for patients
• Less time in the hospital, which lowers the risk of complications
• Higher overall rate of patient satisfaction. 
• Allowing patients to return to work, hobbies and an active healthy lifestyle sooner. 

Although the benefits of ERAS are substantial, these protocols may not be appropriate for all patients. Patients with significant medical comorbidities, cognitive impairment, or patients lacking social support at home may require a more traditional pathway with a longer hospitalization, including a potential discharge to a nursing facility for a few weeks.

Conclusion

Rapid recovery following total hip replacement has transformed the patient experience. By optimizing every phase of care (preoperative, intraoperative, postoperative) through advanced surgical techniques, sophisticated pain control, and early mobilization, this protocol decreases the physical and psychological stress of surgery. It represents a commitment to efficient, high-quality, person-centered care, enabling patients to move beyond chronic pain, while reclaiming their mobility and independence in record time. To schedule a consultation with myself or one of my colleagues, visit our Appointments page today.