Total Hip Joint Replacement Surgery

Total Hip Joint Replacement Surgery
Total Hip Joint Replacement Surgery
A Guide for Patients and Their Caregivers
About Our Joint Replacement Center
You have decided to have total hip replacement surgery. This book
will help guide you through the process. In this book, you will learn
what you need to do before, during, and after your surgery. You will learn
all about hip replacement itself—including the benefits and
the risks. By following the advice in this book, you will have the best
chance of a good and safe recovery.
In this book, we will teach you about what you need to do to get ready for
surgery. One of the most important things you will need to do is find family
or friends who can help you once you leave the hospital. Having a support
person will be a key part of your successful recovery.
You will learn what to expect during your hospital stay, including
the types of machines you will see in your room and the medicines we
will give you. Most hip replacement patients are able to leave
the hospital 1 or 2 days after surgery.
This book will also explain what you can expect as you recover and
what you can do to help yourself get better. Even though surgery is a big step
and you will have some pain as you recover, in the long-term, once you are
better, you should have less pain than you do now.
Remember: we are here to help you and are committed to your recovery.
If you have any questions at any time, please let us know.
Contents
Total Hip Replacement Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Getting Ready for Your Surgery: Things to Do . . . . . . . . . . . . . . . . . . . . . 7
At the Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
After the Hospital: Your Home Recovery . . . . . . . . . . . . . . . . . . . . . . . 17
Physical Therapy Before and After Surgery . . . . . . . . . . . . . . . . . . . . . . 31
Living with Your Hip Replacement in the Long-term . . . . . . . . . . . . . . . . 37
For information only. Not to replace the advice of your health care provider.
Copyright © 2015 Vanderbilt University Medical Center. All rights reserved. HC 1431 (10/2015)
Total Hip Replacement Surgery
The hip
Causes of hip pain
The hip is a ball-and-socket joint made up of
the hip bone (the socket) and the top of the
thigh bone (the ball). Your hip joint supports
the weight of your body; it is one of the largest
joints to do this job.
Arthritis, which means “swelling of the joint,” is
the most common cause of hip pain. There
are two kinds of arthritis—osteoarthritis and
rheumatoid arthritis.
• Osteoarthritis is caused by “wear and tear.”
• A healthy hip joint keeps your hip stable
even when you twist, jump, and move in
different ways.
• Rheumatoid arthritis happens when a
person’s immune system attacks her or his
own joints.
• A healthy hip joint allows you to walk, squat,
turn, run, and jump without pain.
–– cushions the joint
Both osteoarthritis and rheumatoid arthritis
cause pain, swelling, and deformity in the joints.
Arthritis also damages the cartilage in the joint.
When cartilage gets damaged, the bones of the
hip begin making direct contact with each other.
–– absorbs stress
Other causes of hip joint damage include:
–– keeps the bones of the leg and hip from
making direct contact with each other
• injury
• A healthy hip joint has a layer of spongy
tissue in it called “cartilage.” The cartilage:
• the bones in the hip joint not getting
enough blood flow (a condition called
avascular necrosis)
–– allows the ball to move easily in its socket.
• bones that don’t line up or meet the way they
should (called abnormal alignment)
• birth deformity.
-1-
What is total hip replacement surgery?
Total hip replacement surgery is when
damaged bone from the top of the thigh
bone and the socket of the hip bone is replaced
with metal, ceramic, and plastic parts. These
artificial parts become the new hip joint.
What are the benefits of total hip
replacement surgery?
Benefits from total hip replacement surgery include:
• less pain
• more leg strength
In general, this is what happens in surgery:
• easier movement
• For a first-time surgery, the doctor will make
an incision over your hip that starts at the
back of your body.
• better quality of life.
• Damaged hip joint bone is removed.
• The artificial parts are attached to the
remaining, healthy bone. The new parts
are attached with screws, bone cement, or
“press fit.” (Press fit is when the implant
has rough surfaces into which healthy
bone grows.)
• The muscle or bone that is moved out of
the way is fixed with stitches, wire, or cables.
Complex surgeries may involve replacing
missing bone with bone from your own body,
bone from a donor, or extra wires or screws.
• The surgeon will use staples or stitches to
close your incision.
-2-
What are the risks of total hip
replacement surgery?
Risk of hip dislocation
Hip dislocation is when the ball of the new hip
joint moves out of its socket. This is usually
very painful. As long as you move safely after
surgery, the risk of dislocation is low. Even
though you will always have some risk of hip
dislocation after surgery, over time the risk will
be less.
The success rate for hip replacement is very
high. But like all surgery, there are risks.
Risk of blood clots
• The main risk of clots is that they may
loosen and travel from your surgery leg
to your lungs. In the lungs, they may
go unnoticed or cause very bad pain. If
untreated, they can even cause death.
• If your hip moves out of its socket, a surgeon
will move your leg to get the ball back in
the socket. You will be under anesthesia or
sedation so you don’t feel pain.
–– It is important to remember that
dangerous clots are not common as long
as blood thinners or leg compression
devices are used.
• If your hip keeps moving out of its socket,
you may need more surgery.
Risk of infection
–– The risk of these clots causing death is
less than 1 percent.
You will get antibiotics around the time of
the surgery to lower the risk of infection. But
infection can happen soon after the surgery or
even years after the surgery.
• Clots may or may not hurt. Clots can happen
anywhere in your leg from your pelvis to
your feet. You should let your doctor know
when you have pain in any of these areas.
If your hip becomes infected:
• If you have chest pain or feel like you can’t
breathe, let your doctor know immediately.
• you will probably have to have another
surgery to remove infected tissue
• Clots are treated with blood-thinning
medicines and, occasionally, by placing a
filter in your veins.
• you may need to have your artificial joint
removed and replaced. (Replacing the artificial
joint is usually possible, but not always. In the
end, you may be worse off than if you never
had hip surgery, though this is rare.)
Risk of nerve damage
In rare cases, nerves that travel to your thigh,
legs, or feet can be damaged during surgery. If
these nerves do not heal, your ability to walk
could be limited. You may need a brace for your
ankle or for your knee to help you walk.
-3-
Risk of bleeding
Risk of fracture
Rarely, the blood vessels around the hip are
damaged during surgery. This can cause very
heavy bleeding during or after surgery. If this
happens, you may need more surgery or other
procedures to fix the problem.
The bone in the pelvis or thigh bone can
sometimes crack (fracture) during surgery. This
can happen during surgery or even years after.
Fractures are usually treated with metal cables
or a plate. They tend to heal very well.
Sometimes, blood pools in the wound even if no
major blood vessel is damaged. More surgery
(or observation) is required to fix the problem.
Risk of more surgery
Problems that may lead to more surgery are:
• bone forming where it should not
Risk of one leg being longer than the other
• bone around the artificial joint breaking
down during or after surgery
During hip replacement surgery, the surgeon
may need to lengthen your surgery leg to help
prevent hip dislocation. If this happens and the
unequal lengths of your legs bothers you, there
is always the option of getting a “lift” built or
inserted into the shoe of the shorter leg.
• soft tissues in the hip getting irritated by
stitches or the hardware of the artificial
hip joint itself.
It is rare for a total hip replacement to fail before
10 years. But if it does happen, you would need
more surgery.
In most cases, your legs will still be about
the same length with no more than an inch
difference between them.
Risk of death
Risk of limp
Though very rare, some patients have died after
hip replacement surgery. This can be caused by
medical problems you had before surgery or
medical problems that got worse after surgery.
It can also be caused by blood clots traveling to
the lungs, or from stress caused by too much
bleeding.
Sometimes hip replacement surgery creates a
new limp. For those who already had a limp,
they may continue to have one. For some, the
limp they had before surgery eventually goes
away as their muscles become stronger.
Remember: Most people say they walk better
after surgery, even if they have a limp.
Risk of other problems
There are other problems surgery may cause.
Everyone is unique and may respond differently
to hip replacement surgery. Talk with us if you
have questions.
-4-
Remember: Surgery to fix your hip replacement
can be more difficult if you wait until after the
damage has happened.
How long will a total hip replacement last?
Hip replacements typically fail at a rate of
1 percent each year after surgery. This means
that 10 years after surgery, about 90 patients
out of 100 have continued success with their
replaced hip joint; 20 years after surgery, about
80 patients out of 100 have continued success.
Joint replacements wear out faster in younger
and more active people, because the joints get
more wear and tear.
What happens if my new hip joint wears out?
If your new hip joint wears out, you may have
to have revision surgery. Revision surgery has
greatly improved over the years, but, in general:
• revision surgery is usually more difficult than
first-time hip replacement
• the risks of revision surgery are much higher
than first-time hip replacement
Will I know if my hip replacement is failing?
Unfortunately, you may have a failing hip and
not even know it. Diagnosing hip replacement
failure is tricky for several reasons:
• recovery from revision surgery takes longer
• the results of revision surgery are less certain.
• A failing hip replacement usually does not
hurt until you have had very bad damage.
Remember: Even if the results of revision
surgery are not as good as your first-time
surgery, you would still likely have less pain
and better hip function.
• A hip replacement that is loose on an x-ray
may not be painful and may work normally
for a long time. This means you would not
know you had a problem unless you had an
x-ray.
• There is no agreed upon time as to when you
should have repeat x-rays.
• Your insurance company may not pay for
routine screening visits.
Even though it may be hard to know if your hip
replacement is failing, you are not powerless:
• Talk to your doctor and decide how often you
should schedule screenings.
• Contact your insurance company to find
out what screenings they will cover and
how often.
• Tell your doctor immediately if you develop
new pain or swelling in your hip.
-5-
-6-
Getting Ready for Your Surgery: Things to Do
In order to have the best possible surgery, there
are many things you need to do in the month
and weeks before surgery.
Let us know if you don’t have a regular
doctor or dentist
If you do not have a medical doctor or a dentist,
call the surgery scheduler and we will ask a
qualified doctor or dentist to see you.
Get your medical clearances
Before we can schedule your surgery, you
must provide medical clearances saying it
is safe for you to have surgery. We need
medical clearances from:
• the doctor you go to for your regular,
primary care
• Scheduler for Dr. Holt: (615) 936-6909
• Scheduler for Dr. Polkowski: (615) 343-0825
• Scheduler for Dr. Shinar: (615) 343-0825
Medical forms
• any medical specialists you go to, such as
heart or lung doctors.
There are more forms the surgery scheduler will
give you that you will need to fill out. These
forms will ask for information about you, your
personal and medical history, and your current
living situation. Fill out and and return all of
these forms to us right away.
Have your medical clearances faxed to us at
(615) 936-7131.
Get your dental clearances
Your dentist must give you a dental checkup and fill out a clearance form. Our office
needs these dental clearances before we can
schedule your surgery. All dental work must be
finished before your surgery. Have your dental
clearances faxed to us at (615) 936-7131.
Keep track of your clearances and forms
Please note that all of your clearances and forms
are handled by the medical staff and not the
surgeons. If you have any questions about your
forms or want to call to see if we have gotten all
your forms, please call us at ___________
We will also give you a form called “Your
Joint Replacement, Dental Procedures, and
Antibiotics,” that tells you what antibiotics to
take before dental procedures. After you have
had your hip surgery, some doctors and dentists
recommend that you always take antibiotics
before dental procedures.
-7-
Talk to your doctor about your medicines
Exercise to stay strong
If you take rheumatoid arthritis or blood thinner
medicines, it is normal to stop taking these before
your surgery. Ask the doctor who prescribed
them to include a note on your clearance form
saying when you should stop taking these
medicines before surgery, and when it will be safe
for you to start taking it again after surgery. If
your doctor feels that it is unsafe for you to stop
these drugs, we need to know that too.
It is important for you to begin doing exercises
for your hip now before your surgery. The
exercises you need to do before surgery are
shown on pages 32 to 34 in the exercise section
of this book.
You should keep taking all your other medicines
unless your doctor tells you something different.
• improve joint motion
Exercising now will help you:
• build joint strength
• be able to move without tiring as easily
• have a better recovery.
Call us if you get an infection
If you get any kind of infection before your
surgery, you need to call the surgery scheduler
right away. An infection could move into your
joint replacement and cause serious problems. If
you still have infection the day of your surgery,
your surgery will need to be cancelled in order
to keep you safe and healthy.
In addition to the exercises in this book, your
surgeon may want you to do a physical therapy
program before surgery as well.
Eat healthy foods to stay strong
Include fruits, vegetables, and whole grains in
your diet. A healthy diet will help you have a
better recovery.
Call us if you develop:
• an infection of your teeth
• an infection of your fingernails or toenails
• a bladder infection
• a pimple, cut, scratch, boil, abscess, or insect
bite anywhere on your body—especially on
the skin over or around the hip that will be
operated on
• a rash or flaky skin
• a temperature higher than 100.5°F (38.1°C).
-8-
Lose weight if your doctor says you need to
Arrange your home to prevent falls
Start taking steps to lose weight if you need
to. Keeping a healthy weight will improve
your recovery.
For the first few weeks after surgery, you will
likely need to use a walker or cane (or both).
Move your furniture so you have a clear path
and will be able to use your walker or cane
wherever you need to go.
Start planning for your recovery at home
• Pick up any clutter off the floor so you don’t
trip or hurt yourself.
Unless your doctor decides there is a medical
reason for you to go to another facility, you can
expect to go to your home after surgery. Patients
get better faster when they go home to recover
since it is helpful to heal in familiar surroundings.
Start getting your home ready now, and make
your recovery as easy as it can be.
• Remove any area rugs in your home so you
won’t trip over them.
• Tape down all electrical cords so you don’t
trip over them.
• Put shower grab bars in the shower, and put
rubber mats in the bathtub and shower. More
falls happen in the bathroom than any other
room in the house.
Make your home safe and easy to get
around in
Set up your home now so it will be as easy as
possible for you to live in as you recover.
• Consider installing handrails on stairs in or
outside of your house before your surgery.
• Make sure you have a cordless phone or cell
phone that you can reach easily.
• If your bedroom is on an upper-level floor,
think about setting up a bed on the first floor
of your home to use as you recover.
• Cook and freeze meals in advance. Or
buy frozen dinners and canned fruits and
vegetables. This way, you won’t have to
worry about doing a lot of cooking.
• Buy heavy or awkward things now before
your surgery. This might include dish soaps,
detergents, toilet paper, peanut butter, pet
food, and heavy jars or cans.
• Keep the items you use often within
easy reach.
• Get a rolling cart to help you move items
without having to carry them.
Get your walker and your raised commode
You will get a prescription for a walker and
raised commode before surgery. Buy them
before surgery. You will need the walker when
you leave the hospital. If you live far away, you
will also need to have the elevated commode for
your trip home.
• Store the kitchen items you use the most
at counter-top level, above your waist, and
below your shoulders.
Remember: While you are healing after your
surgery, you should not bend down or reach
up high.
-9-
Arrange for a caregiver
Go to your hip replacement class
It is important that you have one or more
caregivers to help you as you recover. Now is
the time to ask family, friends, or others you
know if they can help you once you leave the
hospital. Remember that you will not be able to
drive for 6 weeks after surgery!
This class will help you feel more confident
about your surgery. Bring this book with you to
class. A nurse practitioner will talk about:
• what to expect in the hospital and after you
get home
• what is safe and not safe to do after surgery
After surgery, you will need help with:
• the goals for your recovery
• getting to and from the hospital, physical
therapy, and doctor appointments
• the risks of hip replacement surgery
• the exercises you should do before and after
surgery. These exercises are shown in the
exercise section of this book. Doing these
exercises at home are key to a successful
joint replacement.
• going to the bathroom and showering
• grocery shopping and meals
• keeping the house clean and safe for you
to walk
• caring for small children and pets.
For the first 2 weeks after surgery, it is best if
someone can stay with you at night.
- 10 -
Go to your VPEC appointment
Seven days before surgery do these things
Before your surgery, you will come to Vanderbilt
for what is called a VPEC appointment. This is
a very important appointment: do not to miss it.
At this visit:
Seven days before your surgery, stop taking the
medicines listed below. Do not take them again
until you are no longer taking the blood thinner
we will prescribe for you after surgery. If you
have any questions, contact your doctor, your
nurse practitioner, or your surgeon.
• you will bring a list of all the medicines you
take, including herbal medicines and those
you buy without a prescription
Important: If one of your doctors thinks it is not
safe for you to stop any of these medicines, you
must talk to the surgeon!
• you will give some blood for testing
• you may give some of your urine for testing
• you will talk with an anesthesia nurse
practitioner. Be sure to tell this person if you
drink alcohol regularly
Seven days before surgery, stop taking:
• aspirin
• ibuprofen
• you will find out what medicines you should
not take on the morning of your surgery.
• Advil
• Motrin
Fourteen days before surgery do these things
• Aleve
• Stop drinking any beer, wine, liquor, and all
other alcohol drinks.
• naprosyn
• Stop taking all estrogen hormones.
• any other medicines that contain aspirin,
ibuprofen, or other non-steroidal antiinflammatory drugs (called NSAIDs) that you
buy with or without a prescription.
• Contact your doctor to find out when to stop
taking Coumadin, Plavix, or other bloodthinner medicines, if you take them.
Taking the wrong medicine too close to surgery,
can keep you from having your surgery. It could
also cause complications.
• Stop taking vitamins, supplements, and all
herbals that you buy without a prescription.
- 11 -
Three days before surgery, do these things
The night before surgery, do these things
• Get everything ready to go to the hospital.
Plan to bring only a few clothes, including:
• Remove any nail polish from your fingers
and toes.
–– a short, lightweight robe
• Clean your skin to prevent infection:
–– soft shorts or pants with an elastic
waistband
–– Take a bath or shower.
–– Wait 1 hour. (As you wait, read
the instructions that came with the
chlorhexidine gluconate antiseptic wipes
that we have given you).
–– t-shirts
–– shoes or slippers with a closed back and
non-skid soles
–– After 1 hour, wipe your body with the
antiseptic wipes. Follow the instructions
exactly. Do not let the wipes touch your
eyes, ears, mouth, or genitals. Wipe
around the area to be operated on last.
–– eyeglasses, if you need them, and a
hairbrush.
• Make sure you have packages of antiseptic
wipes to clean yourself the night before
surgery. If you don’t have them, call your
surgeon’s office
–– Let the antiseptic dry on your body. Do
not rinse it off.
–– Dr. Holt’s patients call (615) 322-2428
• Do not apply lotions, moisturizers, powders,
or makeup to your body or face.
–– Dr. Shinar’s and Dr. Polkowski’s patients
call (615) 936-8255.
• Do not eat or drink anything after midnight
on the night before surgery. That means no
gum, hard candy, or water. This is to prevent
stomach upset and vomiting that can be
caused by anesthesia.
The day before surgery, do these things
The day before surgery, one of the surgery
schedulers will call you to make sure you know
what time to come to the hospital. Please give the
surgery scheduler a choice of phone numbers to
call in case the hospital needs to speak with you.
The day of surgery, do these things
• Before you leave for the hospital, follow the
instructions and wipe your body again with
the antiseptic wipes. Fill out the form that
came with the wipes. Bring this form with
you to the hospital. The form will become
part of your medical record.
• You may brush your teeth. But only use a
small amount of water. Spit the water out.
• You may take your morning pills. But take
your pills with no more than one tablespoon
of water.
- 12 -
At the Hospital
Go to the admission desk
We will take you to the Holding Room
When you get to the hospital, go to the patient
admission desk in the main lobby on the first
floor of the hospital at your scheduled time.
After you have checked in, someone will take
you to the Holding Room. One friend or family
member can come with you.
• You will change into a hospital gown. You
will give your clothes and anything else like
dentures, glasses or contact lenses, hairpins, or
jewelry to your support person to take care of
while you are in surgery.
Leave these things at home
• Do not bring your cane, crutches, or walker
when you first come to the hospital (Have
your cane, crutches, or walker brought to you
the last day of your hospital stay when you
will need a walking aide for your trip home.)
• A nurse will clean your skin over the joint that
will be replaced. You may also be shaved there.
• Do not bring large amounts of money or
valuable items, such as jewelry.
• Your surgeon (or the surgeon’s assistants) will
write their initials on your surgical leg.
• We will put an IV into your arm. An IV is a
tube that goes through your skin and puts
medicine directly into your body.
• We may give you some pills to take by mouth
with a tiny sip of water.
• We will take you to the operating room on
a stretcher.
• If you feel anxious or tense at any time, tell
your nurse.
Surgery
From the holding room, we will take you to
surgery. Most joint replacements take between
2½ to 3½ hours. You will not feel any pain during
surgery because we will give you anesthesia.
- 13 -
Anesthesia
Types of anesthesia we may use to keep you from
feeling pain during surgery:
Anesthesia is medicine that keeps you from
feeling pain during surgery. One type of
anesthesia, called “general anesthesia” also
makes you sleep during surgery. Anesthesia
is part of your surgery. We will create a pain
management plan just for you, your needs,
and your medical history. Every patient’s
needs are different.
There are different types of anesthesia we
may use to keep you from feeling pain during
surgery. You may have one or more of the types
of anesthesia listed below:
• Oral and IV pain medicine.
• Spinal: This is a single injection of long-acting
pain medicine that is put in your spinal
column before surgery.
Your anesthesiology teams
• Peripheral nerve block: This is a single
injection that is put next to the nerve(s) that
lead to the surgical site. The goal is to numb
the part of the body having pain. The nerve
block will last for 10 to 24 hours.
Two teams from anesthesiology will work with
your surgical team to help care for you. You will
meet members of your anesthesiology team on
the day of your surgery.
• The Primary Anesthesiology Team is in
charge of your anesthesia during surgery.
• Peripheral nerve catheter: This is when a tube
that delivers medicine is placed in the body
near the nerve(s) that lead to the surgical site.
The tube allows medicine to continuously go
into your body for long-lasting pain relief.
• The Acute Pain Service Team will help your
surgeon create the best pain management
plan for both your surgery and recovery.
• Epidural: This is a tube that is placed in your
back that sends pain medicine into your body
continuously. An epidural may also have a
button for you to push once you wake up. The
button will allow you to get extra relief when
you need it.
General anesthesia
Another option for anesthesia is called “general
anesthesia.” It is called this, because it affects
your entire body, not just the area being operated
on. General anesthesia will make you sleep
through the surgery. Side effects of general
anesthesia include nausea, being sleepy (sedated)
for a longer time after surgery and after you
wake up, and more pain after you wake up.
- 14 -
After surgery we will take you to the
Recovery Room
Pain medicine
We will do everything we can to lower your pain
after surgery. But some pain is simply a part of
recovery. Our goal is to make you as comfortable
as possible while keeping the side effects of any
pain medicine you get as low as possible.
After surgery we will take you to the Recovery
Room. A team of nurses and anesthesia
specialists will watch over you here.
• When you wake up:
To control your pain after surgery, we will
give you:
–– a nurse will help you breathe deeply and
have you cough to clear your lungs
–– you will do ankle pumps to lower the risk
of blood clots
• pills, including pain pills and
anti-inflammatory drugs
–– you will have an IV in your arm so we
can give you medicine as needed
• pain medicine through your IV.
–– you will have an oxygen tube in your
nose to help you breathe.
Other medicines you will need
In addition to pain medicine, you will get:
• Most people stay in the Recovery Room for
several hours after surgery. How long you
are there depends on how your body reacts
to the anesthesia.
• If the nurse feels you are up to it, you may be
allowed to have visitors once you are awake
and your pain is under control.
• antibiotics to help prevent infection
• blood thinners to prevent blood clots
• nausea medicines, if you need them.
Your hospital room
When you are fully awake, we will take you from
the recovery room to a regular hospital room. You
will still have your IV so we can continue to give
you medicines.
- 15 -
Staying safe while you are in the hospital
The length of your hospital stay
How long you will be in the hospital after
surgery will depend on how well you are able
to walk around and how much pain you have.
Most patients leave after 2 nights in the hospital
(Some patients are able to leave the hospital the
day after surgery). But if you have any other
medical issues that slow your recovery, you
may need to stay longer. Your surgical team will
decide exactly how long you need to stay.
Preventing falls
It is very important to stay safe and avoid falls
while you are in the hospital. When you need
to get up or go to the bathroom, always ask for
help from your nurse or another staff member.
Preventing blood clots
To help prevent blood clots:
• we will give you blood thinning medicines
Visitors
You are allowed to have visitors while you are in
the hospital. You may even have 1 person age 18
or older stay with you at night. Each room has a
pull-out bed.
• you will have a machine around your feet or
calves that gently massages them and helps
increase blood flow.
Every day while you are in the hospital, we will
send a sample of your blood to the lab to make
sure your blood is not too thin or to thick.
Getting you ready to leave
A nurse case manager or social worker will
probably visit you while you are in the hospital.
They are members of your healthcare team.
They can help you make plans for the things
you will need to do after you leave the hospital.
This may include arrangements for outpatient
therapy and lab work, home health services, and
other rehab programs or services. You can ask to
speak with the case manager or social worker at
any time during your hospital stay.
Keeping your lungs clear
Because you will be in bed a lot over the next
few days, we will have you breathe deeply
and use a breathing device called an incentive
spirometer. Exercising your lungs will help
prevent pneumonia.
Make sure you have a ride home
You must have someone pick you up at the time
you are released from the hospital. You will not
be allowed to drive yourself home. And you will
not be allowed to leave the hospital alone.
Am I allowed to take a taxi or a bus home?
No. You must have someone pick you up.
- 16 -
After the Hospital: Your Home Recovery
Incision care
Fighting infection
Bandages and ointments
• Always wash your hands before and after
you touch your incision.
• If your incision is draining, keep the incision
covered with clean, dry gauze or a bandage.
• Do not get into a bathtub, pool, spa, river, or
lake until 6 weeks after surgery.
• If your incision is dry, you do not need to
cover it unless you have pets that will be
around you.
• Call your surgeon if your incision:
–– gets redder
–– swells
• Do not put any cream or ointment on your
incision while it heals.
–– feels warm or begins to hurt
–– begins to drain
–– separates at the edges.
Showering
• Call your surgeon if you have a temperature
higher than 101.5°F (38.6°C).
As you are recovering, you should shower
instead of taking a bath. Do not take a bath for 6
weeks after surgery.
Removing your staples
• If your incision is draining, wear a bandage
over the incision when you shower.
Once your incision has healed, your doctor,
nurse, or physical therapist will take your
staples out. Staples are usually removed about
2 weeks after surgery.
• If the incision is dry, you can shower without
a bandage. It is okay for the shower water to
run over your incision.
• When you are done with your shower, gently
pat your incision dry with a towel.
- 17 -
Reducing swelling
Controlling pain
• Exercise 3 times a day.
You will have pain during your recovery. It is a
normal part of the healing process. With time,
you should have less pain than you had before
surgery.
• Walk every day. Try to walk a little longer
each day.
• When you lie down during the day, you may
put pillows lengthwise under your leg. This
will keep your leg higher than your heart,
which will help reduce swelling.
• Ice, exercise, and keeping your leg raised can
help lower your pain.
• When you left the hospital, we probably gave
you a prescription for pain medicine. While
you may need prescription pain medicine at
first, it is best to start decreasing how much
you take as soon as you can. After a couple
of weeks, call your doctor to find out how to
begin taking less prescription pain medicine.
• Use ice packs on your incision to lower
swelling. Always wrap the ice in a towel or
washcloth. Leave it on for 20 minutes at a
time, several times a day.
Preventing blood clots
• Try taking non-prescription acetaminophen
(Tylenol), which is very good at lowering
pain. If you take acetaminophen, take it alone.
Do not take it with your pain medicine.
Surgery may cause the blood flow in your legs
to slow down. This could cause a blood clot that
may stay in your leg or move to your lungs.
Blood clots can be serious. If you have one, you
will need to go back to the hospital for treatment.
To lower your risk of a blood clot:
• walk and do your exercises, including your
ankle pump exercises
• wear your T.E.D. (anti-clot) hose, if we have
told you to use them
• take your blood thinning medicine exactly
like you have been told.
- 18 -
Understanding your medicines
Your blood-thinning medicine
• If your doctor has prescribed a blood thinner
to prevent blood clots, you will take this
medicine for about 4 weeks.
Your pain medicines
• Take your pain medicine exactly the way
your doctor has told you.
• Pain medicine can make you constipated.
Drinking plenty of water and eating more
fiber (found in foods like fruits, vegetables,
and whole grains) will help you stay regular.
• Blood thinners need to be taken at the same
time of day, every day. Always take your
blood thinner exactly the way your doctor
has told you. Never skip a dose. Never take
a double dose.
• Acetaminophen and NSAIDs like ibuprofen,
Motrin, Aleve, and Advil are very good at
lowering your pain after surgery. But only
take the NSAIDs if your doctor says it is okay.
• If you forget to take a dose of your blood
thinner one day, call your doctor for
instructions. Mark the missed dose in a
diary or on a calendar.
• If you are taking blood thinner medicine, you
may need to complete it before you can take
NSAIDs. Talk to your doctor about this.
• Tell your doctor about every medicine you
take (even over-the-counter drugs). Other
medicines can change the way your blood
thinner works. Your blood thinner can also
change the way your other medicines work.
• If you are going to need a refill of your
medicine, call our office at least a few days
before you need the refill to make sure you
don’t run out. Sometimes you may have to
wait 24 hours for a refill. We can’t give refills
at night or on weekends.
• Products that contain aspirin may lower
your blood’s ability to form clots. These
products may increase your risk of bleeding
when you also are taking a blood thinner.
• Talk to your doctor or pharmacist before you
take these medicines with your blood thinner:
• If you still need prescription pain medicine
after 6 weeks, we will refer you to your
regular doctor.
–– aspirin
–– ibuprofen
–– most NSAIDs (although Celebrex is okay)
–– cold medicines
–– estrogen
–– vitamins
–– herbals.
• Your doctor may prescribe aspirin as a blood
thinner instead of a prescription blood
thinner. If you are told to take aspirin, you
will take it 2 times a day for 6 weeks.
- 19 -
Testing your blood when you are on blood thinners
While you are on blood thinners, call your doctor
immediately if you have:
Blood thinners cause blood to clot slower. But
blood that is too thin can make you bleed too
much if you cut yourself. If your blood is too
thin, you might also bleed inside. You will have
regular tests to make sure your blood is thin
enough but not too thin.
• nosebleeds
• feelings of being dizzy or like you will
pass out
• red or brown urine
• skin rash
• You will need to get your blood tested every
Monday and Thursday as early as possible on
those days. If you do not get your test results
by 3:00 p.m., call our office.
• sudden change in the color of your
bowel movements
• a headache or severe stomach pain
• If your test results show that your blood
might bleed or clot too much, we will likely
change the dosage of your medicine.
• blood in your saliva
• bruises that get larger
• bleeding gums
Staying safe while taking blood thinners
• been unable to eat for several days
• Do not drink beer, wine, or other alcoholic
beverages. Alcohol thins the blood.
• vomiting or diarrhea that lasts more
than 1 day.
• Avoid getting cuts: Use an electric razor, not
a razor with a blade.
• Eat a normal balanced diet, including fruits,
vegetables, and whole grains.
• Use waxed dental floss. Do not use toothpicks.
• Wear shoes or non-skid slippers in the house.
• Be careful when you trim your toenails. Do
not trim corns or calluses yourself.
• Always wear shoes outdoors.
• Avoid getting bruises: Do not do any
activities and sports in which you could
easily be hurt.
- 20 -
Using your walker safely
Using your cane safely
After surgery, you will likely use a walker to get
around at first.
When you’re ready, you may change from a
walker to a cane. Before you switch to a new
walking aid, check with you doctor or physical
therapist to make sure it is safe for you to do so.
Using a walker to walk:
• Hold the cane in the hand opposite the
hip replacement leg (unless we tell you
something different).
• At first, move the walker a few inches in front
of you before you take a step.
• Lean on the walker so it supports you. Step
into the center of the walker with your
surgery leg. Then step forward with your
good leg. Repeat.
• Put all your weight on your good leg. Find
your balance. Move the cane and your
surgery leg forward.
• Support your weight on both the cane and
surgery leg. Then step through with your
good leg, putting all your weight on your
foot. Then take the next step.
• As you get more comfortable, you’ll be able to
move the walker as you step.
Using a walker to step up a curb
• Move your feet and your walker as close to
the curb as possible.
• Put your weight on both legs, and then lift the
walker onto the curb.
• Step on the curb with your good leg. Use the
walker to support your weight; then bring up
your surgery leg.
Using a walker to step down a curb
• Move your feet and the walker as close to the
curb as possible.
• Lower the walker onto the ground, keeping
its back legs against the curb.
• Using the walker to support your weight,
lower your surgery leg. Then step down with
your good leg.
- 21 -
Preventing hip dislocation
Increasing your activity as you recover
Your new hip cannot bend and turn as much as
a natural hip. You will need to move differently
now than you did before surgery to help keep
your new hip from popping out of place. We
will work with you and show you how to move
your hip safely.
• Follow your surgeon and physical therapist’s
advice about increasing your level of activity.
Do not try to do too much all at once.
For at least 6 months after surgery:
• Your physical therapist can help you know
when you are ready to walk without your
walker or cane.
• Accept offers of help from friends and
family, especially during your first few
weeks at home.
• don’t bend over at the waist.
• don’t sit with your hips lower than your knees.
• Three months after surgery, most people
with a new joint can walk without a cane or
walker, and are able to do most of the things
they want to do.
• don’t cross your surgery leg over your
good leg
• always sit with your thighs apart.
• Make walking a part of your daily routine.
Slowly increase the amount of walking
you do around your home. Members of
your health care team can help you create a
walking program that’s safe for you.
• To move easily, you must walk with a smooth
motion. Watch yourself in a mirror while you
walk around it. Make sure you’re walking
heal to toe, and with equal weight (and time)
on each foot.
Sticking with your recovery program will help
you get back to doing the things you enjoy.
Talk with your doctor about the activities that
you want to go back to. Your doctor will tell
you when and how you can safely return to
activities, such as swimming and gardening.
Remember: Even after you have healed from
surgery, you will have some activity restrictions
for the rest of your life. This is to protect your
hip. Safe and unsafe activities are listed on
pages 38 and 39 of this book.
- 22 -
A few tips:
Getting in and out of bed
• A firm bed is better than a soft bed, if you
have a choice.
Your surgery leg should enter the bed first and
leave the bed last. If you need to, change your
sheets and pillows so your bed so the pillow is
on the other end of the bed and you can get in
with your surgery leg first.
• Avoid a bed that is too low to the floor. Some
people choose to raise their bed on blocks. • A satin garment or pillowcase placed under
your bottom will help you slide your bottom
in and out of bed.
1. Sit down on your bed
• Stand with your back to the bed. Back up
to the bed until the back of your good knee
touches the bed.
• Keep the foot on your surgery leg forward.
• Hold the crossbar of your walker with one
hand. Reach back for the bed with the other
hand. Don’t twist.
• Lower your buttocks onto the bed.
2. Support yourself
• Support yourself as you sit down. Put both
your hands on the bed behind you for support.
• Lean backward onto the bed.
3. Carefully lie down
• Swing one leg, then the other, from the floor
onto the bed. If you have a “leg lifter” you
may want to use it. As you move your legs,
use your elbows and hands to lower your
upper body onto the bed. Move your body as
a unit—don’t twist.
• Get comfortable.
• Do not reach to the end of the bed to pull the
blankets up. Use a reacher to pull them up.
• Keep your walker in reach from the bed.
- 23 -
Lying down in bed
Sitting
• Find a position that keeps your hip safe
and comfortable.
Protect your hip when you are seated. Sit with
your knees lower than or level with your hips.
To help you do this:
• Follow your surgeon’s instructions about
which side to sleep on.
• sit in chairs with high seats.
• If you lie or sleep on your side, always put
a pillow between your knees. This will help
keep your hips in a safe position. (You may
need 2 pillows to keep your knees separated.)
• place a firm pillow on the seat of a chair if
you need to raise it.
• Keep the angle of your hip no more than 90
degrees. Don’t move your knees and chest too
far from each other.
• Do not cross your legs or ankles.
- 24 -
Sitting down in a chair
While you are healing, stay safe when you sit down. Be careful and take your time.
1. Back up until you feel the chair touching you.
2. Reach for the armrests. Keep your surgery leg slightly out in front. Lower yourself without leaning forward.
3. Sit, then lean back in the chair. Keep your hips higher than your knees.
To stand up, reverse these steps.
- 25 -
Going up and down stairs
Getting in and out of a car (Remember you must
not drive for 6 weeks)
• Always remember: safety first.
• Getting in a car on the passenger side
• Go up the stairs leading with your good foot
first. Go down the stairs leading with your
surgery foot first. Remember: “The good goes
up, the bad goes down.”
–– Push the car seat as far back as you can
and recline the seat if possible.
–– Back up to the car until you feel it touch
the back of your legs.
• Use handrails if you can.
–– Reach back for the car seat with one
hand. Keep the other hand on your
walker or crutches. Keep your surgery leg
straight in front of you. Lower your head
and sit carefully.
• Climb one step at a time.
• Be careful, and take your time.
–– Turn your body into the car as you lift
your legs into the car. You will need to
use your arms to lift your legs both in
and out of the car. Someone else could
lift them for you.
–– Return the seat back to an upright position.
–– Fasten your seat belt across your hips.
• Getting out of a car on the passenger side
–– To get out of the car, reverse the process
described above.
–– Recline the car seat if possible. Turn and
lift your legs out of the car. Keep your
head down as you push off the seat back
with one hand while the other hand is in
the center of your walker.
–– Use your walker or crutches to stand up.
A few tips:
• Avoid sports cars and cars with bucket seats.
It is hard to sit down so low.
• A plastic trash bag or satin pillowcase on the
car seat is helpful for sliding and turning.
- 26 -
Using the bathroom
Getting dressed
• Use a commode chair or elevated toilet seat to
raise the height of your toilet.
Putting on socks
• Back up to the toilet until you feel it touching
the back of your knees.
• You will need a sock-aide (a tool that allows
you to put on socks or stockings when you
can’t reach your feet).
• Carefully reach back for the armrests with
both hands.
• Sit down to dress.
• Fit the ankle of your sock over the open end
of the sock-aid. Make sure the heel of the sock
is against the back of your shoe and the toe is
tight against the end. Bring the ankle of the
sock as far up the sock-aid as possible. Don’t
cover the knots at the end.
• Keep your surgery leg in front of you as you
bend the other leg to lower yourself to the
toilet seat.
• Reverse the process for getting up from
the toilet. Use the armrests to push up to a
standing position, or use one arm to push up
from the armrest while holding onto your
walker with the other hand in the center of
your walker.
• While holding onto the rope, drop the sockaide to the floor. Slide your foot into the sockaid and pull on the ropes to bring the sock
over your foot.
• To take off the sock, use the screw on the end
of a reacher to push the sock over your heel.
Showering
• For at least a month after your surgery, you
should shower instead of bathe. You can sit
on a bath bench or shower chair if you like.
• Install grab bars in your shower or tub for
support as you get in and out.
• Installing a hand-held shower attachment is
also a good idea.
• Use a long-handled sponge to wash hard-toreach areas.
• Use a rubber-backed bathroom mat to help
keep the floor dry.
- 27 -
Putting on pants
More tips as you heal
• Use your reacher to help you put on
your pants.
Be sure to explain to your entire family what
you must do to be safe.
• Sit down. Use the reacher claw to grasp the
waistband and lower the pants to the floor.
• Always keep a cell phone or cordless phone
with you in case you are alone and need help.
• Put your pant on your surgery leg first. Then
use the reacher to hold the waistband open to
step in with the opposite leg.
• Use a walker basket or shopping bag so you
can carry items with you when you use
your walker.
• Use the reacher to pull the waistband above
your knees. Then use your hands to bring the
pants as far up your legs as you can while still
sitting.
• Keep a night light on in hallways and in
the bathroom.
• Keep your reacher close by to pick up things
you drop so you don’t have to bend over.
• Stand up with the walker. After you have
your balance, pull your pants over your hips.
• Sit in tall chairs that have armrests. It will be
easier to get up. Avoid chairs that rock, roll,
or glide.
• To undress, stand up to push the pants over
your hips.
• Allow extra time when you get up from
sitting or lying down. It will keep you from
getting dizzy.
• Sit down. Remove pants from your good leg
first. Use the reacher to push the garment off.
Repeat with your surgery leg.
• Be careful around your dog or cat because
pets may jump.
A few tips:
• Elastic waist pants work great. They will stay
at your thighs while you are standing and
will not fall to the floor as you are getting
your balance.
• Don’t walk outside in icy or snowy conditions.
• To save energy: Put your underwear and
pants on while you are sitting. Then stand up
just once to pull both over your hips at the
same time.
- 28 -
Sexual activity
You may go back to sexual activity 6 weeks after
surgery when your surgical incision has healed
and you can move your hip.
• You may need to make some position changes
to avoid dislocating your hip.
• Talk with your surgeon or your physical
therapist if you have questions about safe
positions during sex.
- 29 -
Traveling
• For the first 3 months after your surgery, avoid
long trips. (Talk to your doctor if you have to
travel within 3 months after your surgery.)
• Traveling increases the risk of getting a blood
clot. If you do need to travel, talk to your
doctor. Tell your doctor if you or anyone in
your family has ever had a blood clot. You
may need to take a blood thinning medicine.
• When you are away from home, please
remember to call a doctor if you think you
may be getting an infection.
Flying in a plane
• When making reservations, ask for bulk head
seating. You will have more room.
• Ask for an aisle seat. It’s easier to get into and
out of.
• Ask for early boarding so you won’t be
bumped into or feel so rushed.
• Ask for a wheelchair for going to and from
the gate. Call the airline 6 hours before your
flight to make sure a wheelchair will be there
for you.
Riding in a car
Like long plane trips, it is important to move
around during a long car trip to prevent blood
clots. On a road trip, get out of the car every
45 to 60 minutes and walk around at least
2 to 3 minutes.
• Plan for more time at the security check. As
you approach, tell one the staff that you have
had a hip replacement. A security person will
likely take you a few steps away and check
you with a wand. It is simple and no cause for
alarm. It does take a few extra minutes.
• If you are on a long plane flight, it is important
that you get up and move around every hour
or so if possible. When you sit in one place for
a long time, your blood does not move as well
through your body. This can lead to a blood
clot, which can be very serious.
- 30 -
Physical Therapy Before and After Surgery
Physical therapy before and after surgery will help you get the most out of your surgery. It is
important to keep all your physical therapy appointments and to do all the exercises your therapist
tells you to. Be sure to take your pain medicine 30 minutes before you exercise. Your physical therapy
will include exercises:
• to increase your joint motion
• to make you stronger so you don’t tire as easily
• to improve your balance
• to help you walk as normally as possible.
Before surgery
After surgery
Before surgery, you will do the 9 exercises listed
below. There are 3 exercises to improve your
arm strength and 6 exercises for your legs and
hips that you can do while lying down. These
exercises are pictured and described on pages
32 to 34. Your physical therapist will also show
you how to do them.
After surgery, you will do the 11 exercises listed
below. You will continue doing the 6 hip and leg
exercises you did before surgery. You will do 5
new standing exercises as well. These exercises
are described on pages 33 to 36. Your physical
therapist will also show you how to do them.
• Heel slides
• Biceps curls
• Abduction/Adduction exercise
• Triceps curls
• Ankle pumps
• Seated press-ups
• Quadriceps sets
• Heel slides
• Gluteal sets
• Abduction/Adduction exercise
• Internal and external rotation exercise
• Ankle pumps
• Standing hip extension
• Quadriceps sets
• Standing hip adduction
• Gluteal sets
• Resisted hip extension
• Internal and external rotation exercise
• Resisted hip abduction
• Standing hip flexion
- 31 -
Arm exercises to do before hip surgery
These exercises will help you build strength in your upper body before your surgery. Your physical
therapist or surgeon may also tell you to use weights when doing these exercises.
Biceps curls
• Sit up straight in a chair. Keep your elbow
close to your body and your wrist straight.
• Bend your arm, moving your hand up to your
shoulder. Then slowly lower your arm.
Triceps curls
• Sit, leaning forward from the waist.
• Bend your elbow so that your forearm is
parallel to the floor. Then straighten your
elbow as you extend your arm behind you.
Seated press-ups
• Sit in a sturdy chair with armrests.
• With palms flat on the armrests, press down
to lift your buttocks from the chair. Hold for a
few seconds.
• Bend your elbows to slowly ease back down.
- 32 -
Leg and hip exercises for before and after hip surgery (do these lying down)
These 6 exercises can be done in bed. They help improve blood flow or build strength. Your physical
therapist may give you special instructions. Otherwise, repeat each exercise 10 times. Do each exercise
at least 3 times a day.
Heel slides
• Keep the heel of your surgery leg on the bed.
Then slide the heel toward your buttocks as
far as you comfortably can.
• Hold for 5 seconds. The slide your heel back.
Abduction/adduction
• Start with your feet slightly apart. Keeping
your knee and foot pointing toward the
ceiling, slowly slide your surgery leg out to
the side.
• Slide your leg back toward the midline of
your body.
Ankle pumps
• Point, then flex, both feet.
• Doing this 10 to 30 times each hour helps
prevent blood clots in your legs.
- 33 -
Quadriceps sets
• Lie in bed with your legs straight. Tighten the
front thigh muscle of your surgery leg while
pressing the back of your knee down into
the bed.
• Hold for 5 seconds, then relax your leg.
Gluteal sets
• Squeeze your buttocks together tightly. Your
hips will rise slightly off the bed.
• Hold for 5 seconds, then release.
Internal/external rotation
Lie down on your back. Gently turn your legs
and feet in and out.
- 34 -
More exercises you should do after surgery (do these standing up)
These exercises will be done standing up. They will help build your strength after you have had your
surgery.
Standing hip extension
From standing: hold on to a chair or wall for
support. Begin with your feet together. Then
bring your surgery leg back as far as possible.
Standing hip abduction
Begin standing with your feet together. Hold
on to a chair or put your hand on a wall for
support. Gently lift your surgery leg out to side.
Then bring it back to meet your other leg.
- 35 -
Resisted hip extension
Begin standing with your feet slightly apart with
one end of the tubing wrapped around your
surgical leg and the opposite end of the tubing
attached to a stable object (such as a table leg).
Hold on to the table or other secure object that is
in front of you. Lift your surgical leg behind you
while keeping the knee straight.
Resisted hip abduction
Stand next to a table with your feet slightly
apart and your good leg closest to the table.
Attach one end of the tubing around the ankle
of your surgical leg. Attach the other end of
the tubing around one of the table legs. Lift
your surgical leg straight out to the side, while
keeping your knee straight.
Standing hip flexion
With one foot on several-inch step, raise your
surgery leg. Allow your knee to bend, and raise
your hip to a right angle.
- 36 -
Living with Your Hip Replacement in the Long-term
Risk of infection
Antibiotics for surgical or dental procedures
Once you have an artificial hip, you are never
completely safe from infection. You must always
be careful to prevent and treat infections. If
you do get an infection, it could travel to your
artificial hip. This could lead to a stay in the
hospital and possibly more surgery. For the rest
of your life, do not ignore any infection. Always
contact your doctor if you think you might have
any type of infection—even if it is a small one.
The American Academy of Orthopaedic
Surgeons and the American Dental Association
have developed these guidelines for antibiotic
use. Your dentists and doctors will use their own
judgment in deciding if you need antibiotics to
prevent infection.
• For two years after your hip replacement,
you will need antibiotics before all dental
procedures, including dental work and
cleaning. The bacteria commonly found in the
mouth may travel through the bloodstream
and settle in your artificial hip.
Dental and medical procedures
• Always talk to your joint replacement surgeon
before you have any other major surgery.
• For two years after your hip replacement,
you will also need antibiotics before medical
procedures that are invasive, including
colonoscopy, cytoscopy, bronchoscopy, or other
procedures that are called invasive.
• Always tell the doctors or dentists who
treat you that you have a joint replacement.
You will need to take extra precautions
before having surgery and other medical
and dental procedures.
• After 2 years, you may or may not need
antibiotics for certain medical and dental
procedures. Some doctors say joint
replacement patients should take antibiotics
for these procedures for the rest of their lives.
Talk to your joint replacement surgeon.
- 37 -
Sports and activities after physical rehab
These activities are safe:
• Ballroom dancing
After your hip rehab, you should have
improved motion and be strong enough to
return to your daily activities. There are many
activities and sports you will still be able to do
after you have adjusted to your new hip. But
there are some things you should never do.
• Bowling
• Cross-country skiing
• Cycling
• Elliptical
Exercise, but be cautious. If you do more than
you should, you could hurt your hip. For
the rest of your life, you have a risk of bone
breakage, hip loosening, and hip dislocation—
especially if you do too much.
• Golf
• Hiking
• Low-impact aerobics
• Rowing
The lists on these two pages will tell you what
is safe or not safe for you to do. Follow these
guidelines for the rest of your life.
• Sailing
• Speed walking
• Swimming
• Table tennis
• Tennis doubles
• Treadmill walking
• Walking
• Water aerobics
• Weight machines
- 38 -
These activities are safe with experience:
These activities ARE NOT safe:
• Ballet dancing
• Baseball
• Calisthenics
• Basketball
• Downhill skiing
• Football
• Fencing
• Handball
• Horseback riding
• Jogging
• Ice skating
• Karate
• In–line skating
• Lacrosse
• Jazz dancing
• Racquetball
• Pilates
• Snowboarding
• Rock climbing
• Soccer
• Softball
• Volleyball
• Water skiing
- 39 -
Notes
- 40 -
Notes
- 41 -
Notes
- 42 -
Notes
- 44 -
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