Although hip replacement surgery is great at relieving pain and restoring mobility, dislocation is a common complication of the procedure. The risk of this is highest in patients who have had a second hip replacement, and that procedure is known as “revision surgery.”

Now, though, research conducted by Dr. Geoffrey Westrich and colleagues at Hospital for Special Surgery, in New York City, and other joint replacement centers indicates that a newer type of artificial hip known as a “modular dual mobility” implant could be a good choice for patients who need a revision surgery.

The study represents good news for patients who need to have their original hip replacement taken out.

Their study was presented at the annual meeting of the American Association of Hip and Knee Surgeons in Dallas.

“Although the concept of dual mobility was originally developed in France in the 1970s, the technology is relatively new in the United States,” said Westrich, director of research of the Adult Reconstruction and Joint Replacement Service at HSS. “Our study found that the newer technology with modular dual mobility components offered increased stability, lowering the risk of dislocation, without compromising hip range of motion in patients having a revision surgery.” (See “Better Hip Replacements.”)

“Currently, there are few large-scale outcome studies on the modular dual mobility device in revision hip replacement,” Westrich said. “We set out to determine the rate of dislocation and the need for another surgery following revision hip replacement using this implant.”

The investigators’ study included 370 patients who underwent revision hip replacement with the dual mobility implant between April 2011 and April 2017. The average patient age at the time of surgery was 65.8 years. Clinical, radiographic and patient reported-outcome information was collected.

To be included in the final report, patients needed to be seen for follow-up for at least two years after their surgery, and the average follow-up was 3.3 years. “At the latest follow-up, we found that surgery with the dual mobility implant resulted in a very low rate of instability for the revision patients, namely 2.9 percent, with good functional improvement and a low rate of reoperation,” Westrich noted. “While longer-term follow-up is needed to fully assess the newer device, in our study there was clearly a benefit provided by the dual mobility implant in the first few years following revision surgery.”

A release from the society quotes study lead author Stavros G. Memtsoudis, M.D., PhD., director of critical care services in the Department of Anesthesiology and senior scientist at the Hospital for Special Surgery in New York, as saying, “Patients need to be aware that there are ways to treat their pain during and after surgery in addition to opioids. If the doctor prescribes more than one type of medicine for your pain, it may reduce your need for opioids.”

Opioids are powerful pain medications but have many unwanted side effects. They can cause nausea, vomiting and drowsiness, which can hinder a patient’s recovery from surgery. This has prompted more interest in offering patients multimodal therapies to manage pain while also reducing the amount of opioids prescribed. “Opioids may have a role to play during and immediately after surgery, but we’ve been relying on them too much,” Dr. Memtsoudis said.

Researchers used Premiere Perspective, a nationwide database that includes information on joint replacement surgeries performed at 546 hospitals, to examine types of analgesics (pain relievers) used between 2006 to 2016 in 512,393 hip replacement and 1,028,069 knee replacement patients. They compared patients who received opioids alone during surgery, on the day of surgery, or during recovery to those who received multimodal therapy, meaning opioids and one or more additional pain management methods, such as peripheral nerve block, acetaminophen, gabapentin/pregabalin, non-steroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors or ketamine. These multimodal techniques are increasingly being used in knee and hip replacements to improve pain control — in the study, multimodal pain therapy was used in 85.6 percent of cases.

Patients undergoing total hip replacement who received more than two methods of pain relief in addition to opioids had up to an 18.5 percent decrease in opioid prescriptions after surgery, 19 percent fewer respiratory complications, 26 percent fewer gastrointestinal complications and a 12 percent decrease in hospital length of stay, compared to patients receiving opioids alone. While total knee replacement patients who received more than two methods of pain relief in addition to opioids had up to an 18.5 percent decrease in opioid prescriptions, 6 percent fewer respiratory complications, 18 percent fewer gastrointestinal complications and a 9 percent decrease in hospital length of stay. However, using multiple analgesics did not lead to decreased hospitalization costs.

NSAIDs and COX-2 inhibitors used in a multimodal regimen seemed to be the most effective modalities, with the greatest reduction in opioid prescriptions and complication risk. Additionally, using a peripheral nerve block in a multimodal regimen was also found to be effective in reducing complications and opioid prescriptions. However, Dr. Memtsoudis noted, “This study does not answer the question of what combinations of analgesic approaches are best — we would need to conduct a much more complicated analysis, because there are so many potential combinations of drugs to consider. But our findings do encourage the combined use of multiple analgesic modalities during and after surgery. Each of these drugs work on different parts of the pain pathway, so by using more than one medicine, we are attacking pain on many different levels.”

The authors note that future studies are needed to identify the maximum number of analgesic methods effective in improving outcomes. “We think three or four is probably the maximum — more than that may only increase drug-related side effects,” said Dr. Memtsoudis. “Future studies are needed to identify optimal multimodal regimens and patient subgroups most likely to benefit from each combination.”

What no one told us was what happens emotionally after hip replacement surgery. In addition, nothing was said in the handouts or hospital class we took to prepare for the surgery about the narcotics prescribed post-surgery.

As a caregiver, you will be told about helping the patient stand and sit, providing physical support with using the bathroom, showering, grooming, dressing, shopping, cleaning, cooking, doing laundry and errands, your duty to manage the finances, keep track of medical appointments and medications, and encourage physical therapy exercises daily. But no one will say your spouse may experience a roller coaster of moods or withdrawal symptoms coming off pain meds. These tips are a heads up for patient and caregiver as a team.

-Issue: Depression

Depression can be triggered by the anesthesia from surgery, pain medications, pain itself, and restricted movement. Add to this the universal desire to get back in shape as soon as possible. Many people assume if they do everything the doctor and physical therapist say to do – and then some – they will get better faster. When that doesn’t happen due to a variety of individual factors, the caregiver may have to deal with massive disappointment and their spouse’s feelings of inadequacy. Even though my husband was ahead of the curve in recovering skills, it didn’t happen as fast as he thought it should. Bottom line: bodies heal at different rates and no one should compare their progress to other people’s experiences unless perhaps that person is your genetic twin.

Action: Inform your doctor

Inform your surgeon you are feeling depressed. Surgeons generally don’t receive or react well to feedback that is “nonmedical.” But the brain is a medical organ that controls the rest of the body and must be considered in any invasive surgery. If your surgeon is not responsive, tell your general doctor. You may be prescribed an antidepressant. If already on one, your dose may need to be altered temporarily, especially given the amount of pain medication in the mix. Post-surgical depression is not abnormal and it will pass; but it may need to be tempered by medication. Also, surf Internet forums on patients’ experiences and you will likely find you are somewhere in the middle of the extremes.

–Issue: Anxiety

Each day can be a roller coaster ride. At first my husband wanted to do everything himself so he could be independent faster. Then he would have more pain from his activity level and feel anxious that it was too much pain and something must be wrong. Some days he even questioned the wisdom of getting the operation as it seemed to be taking too long to feel better. This happened at two weeks, three weeks, and so on. It also turned out that he had a strong reaction to his pain medication: Oxycodone with Acetaminophen. His reaction was the opposite of what we expected. As an opiate, one would think it would calm you down, but it made him more anxious and aggressive.

-Action: Inform your doctor

As with depression, medication may need to be prescribed for anxiety, or adjusted, in order to deal with both the trauma to the body and the alarm bells going off in the brain. The body was not only sliced open, but bone was replaced by metal. It would be great if patients could have a week by week description of average pain levels and skill progression.

Issue: Opioids

Oxycodone with Acetaminophen is probably the most common pain medication prescribed post-hip surgery. A strong narcotic pain reliever, Oxycodone does not stop pain but increases tolerance to pain. Acetaminophen is non-narcotic and relieves pain by elevating the threshold to sensing pain.

My husband was prescribed 80 325mg pills for the first two weeks, 80 for the second two weeks, and 60 for the third two weeks, taking one to two pills every four to six hours. We both freaked out a little watching a news program targeting addiction to opioids, and reviewing the coverage of Prince’s death, which was allegedly caused by an opioid addiction due to severe hip pain.

Dr. Jim Duffey, an orthopedic surgeon and partner at Premier Orthopedics in Colorado Springs, says the body does develop a dependence on the narcotic and will go through withdrawal when that amount of opioids are used post-surgery. He uses a combination of pain treatments to avoid overreliance on narcotics, one of which is implanting a catheter within the incision under the skin that steadily releases a regional anesthesia that numbs the site (he uses ON-Q Pain Relief System). In addition, Tylenol (Acetaminophen) can be effective, particularly when given intravenously, which is more potent.

A Harvard Magazine article by John Lauerman points out that not enough recognition is given to post-surgical depression and the effects of stopping opioid medications. At that point, there is often more residual pain than the patient realized, and withdrawal can include trouble sleeping, anxiety, and dark thoughts.

Action: Talk to your doctor before surgery

“Most MDs (especially surgeons) are horrible at discussing these things with their patients,” says Dr. Jeffrey Foote, cofounder and director of Center for Motivation and Change, which specializes in substance abuse treatment. Side effects and complications of pain medications should be explained prior to surgery. Ask about the possibilities of addiction. How many pills are too many? Ask about withdrawal and how to taper off or about the possibility of opioid substitutes.

Issue: Constipation

We knew constipation is a side effect of both opioids and anesthetic and has to be treated aggressively. We had been told to use over the counter medications, to try warm prune juice, to drink lots of liquids – but nothing worked, not even suppositories. During this time, my husband ate less and less and I worried he was getting inadequate nutrition for healing.

Action: Ask a nurse (or trust me)

Nurses, who are perhaps more aware of dealing with constipation in patients, are a great resource for details like this. Get a laxative with Senna (Sennosides). That, finally, did the trick.

Note: At seven weeks post-op, my husband alternates between using a cane and walking tall and going without the cane and limping. The surgeon said the limp generally resolves between four and six months post-surgery. He is off all narcotics but takes some Tylenol every day. We are excitedly planning activities we could not do for the last two years because of his hip pain. The one thing that surprises him is how clearly he feels the rod and cup, the new bionic parts in his body.

Judy Kirkwood writes articles for print and web publications – national, regional, and local; is a contributing writer to Simply the Best and Boca Raton Observer magazines in South Florida; and plays on the beach and in the pool year-round. Visit her on Facebook @JudysFlorida and please visit www.JudysFlorida.com.