Total Hip Replacement
Whether you have just begun exploring treatment options or have already decided to undergo hip replacement surgery, this information will help you understand the benefits and limitations of total hip replacement. The information provided here is, in general, an attempt to describe how a normal hip works, the causes of hip pain, what to expect from hip replacement surgery, and what exercises and activities will help restore your mobility and strength and enable you to return to everyday activities. However, your operating joint replacement surgeon is best to answer queries related to you, as each person is unique and the treatment requirement may differ from one individual to another based on their current clinical condition, lifestyle requirement and a lot of other factors best assessed by your operating surgeon.
If your hip has been damaged by arthritis, a fracture, or other conditions, common activities such as walking or getting in and out of a chair may be painful and difficult. Your hip may be stiff, and it may be hard to put on your shoes and socks. You may even feel uncomfortable while resting.
If medications, changes in your everyday activities, and the use of walking supports do not adequately help your symptoms, you may consider hip replacement surgery in discussion with your joint replacement surgeon. Hip replacement surgery is a safe and effective procedure that can relieve your pain, increase motion, and help you get back to enjoying normal everyday activities.
First performed in 1960, hip replacement surgery is one of the most successful operations in all of medicine. Since 1960, improvements in joint replacement surgical techniques and technology have greatly increased the effectiveness of total hip replacement. According to the Agency for Healthcare Research and Quality, more than 1.5 million total hip replacements are performed each year globally.
The hip is one of the body's largest joints. It is a ball-and-socket joint. This arrangement gives the hip a large amount of motion needed for daily activities like walking, squatting, and climbing stairs. The socket is formed by the acetabulum, which is a part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).
The bony surfaces of the ball and socket are covered with articular cartilage, a smooth tissue that cushions the ends of the bones and enables them to move easily.
A thin tissue called synovial membrane surrounds the hip joint. In a healthy hip, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost all friction during hip movement.
Bands of tissue called ligaments connect the ball to the socket and provide stability to the joint.
Normal hip anatomy
Common causes of hip pain
The most common cause of chronic hip pain and disability is arthritis. Osteoarthritis, rheumatoid arthritis, and post- traumatic arthritis are the most common forms of this disease which has more than 100 different types.
- Osteoarthritis: This is an age-related "wear and tear" type of arthritis. It usually occurs in people 50 years of age and older and often in individuals with a family history of arthritis. The cartilage cushioning the bones of the hip wears away. The bones then start rubbing against each other causing hip pain and stiffness. Osteoarthritis may also be caused or accelerated by irregularities in how the hip developed in childhood.
- Rheumatoid arthritis: This is an autoimmune disease in which the synovial membrane becomes inflamed and thickened. This chronic inflammation can damage the cartilage leading to pain and stiffness. Rheumatoid arthritis is the most common type of a group of disorders termed "inflammatory arthritis."
- Post-traumatic arthritis: This can follow a serious hip injury or fracture. The cartilage may become damaged and lead to hip pain and stiffness over time.
- Avascular necrosis: An injury to the hip such as a dislocation or fracture, may limit the blood supply to the femoral head. This is called avascular necrosis (also commonly referred to as "osteonecrosis"). The lack of blood may cause the surface of the bone to collapse and result in arthritis. Some diseases can also cause avascular necrosis.
- Childhood hip disease: Some infants and children have hip problems. Even though the problems are successfully treated during childhood, they may still cause arthritis later on in life. This happens because the hip may not grow normally and the joint surfaces are affected.
In hip osteoarthritis, the smooth articular cartilage wears away and becomes thin and rough.
In a total hip replacement (also called total hip arthroplasty), the damaged bone and cartilage are removed and replaced with prosthetic components.
- The damaged femoral head is removed and replaced with a metal stem that is placed into the hollow centre of the femur. The femoral stem may be either cemented or "press fit" i.e. fixed without using cement, into the bone.
- A metal or ceramic ball is placed on the upper part of the stem. This ball replaces the damaged femoral head that was removed.
- The damaged cartilage surface of the socket is removed and replaced with a metal socket. Screws or cement are sometimes used to hold the socket in place.
- A plastic, ceramic, or metal spacer is inserted between the new ball and the socket to allow for a smooth gliding surface.
(Left) The individual components of a total hip replacement. (Centre) The components merged into an implant. (Right) The implant as it fits into the hip.
Is hip replacement surgery for you?
The decision to have a hip replacement surgery should be a cooperative one made by you, your family, your primary
care doctor or family physician, and your joint replacement surgeon. The process of making this decision typically
begins with a referral by your family physician to a joint replacement surgeon (who is a qualified and trained
orthopaedic surgeon on joint replacement procedures) for an initial evaluation.
Candidates for surgery
There are no absolute age or weight restrictions for total hip replacements.
Recommendations for surgery are based on a patient's pain and disability, not age. Most patients who undergo total hip replacement are between the age of 50 and 80, but orthopaedic surgeons evaluate patients individually. Total hip replacements have been performed successfully at all ages, from a young teenager with juvenile arthritis to an elderly patient with degenerative arthritis.
When is surgery recommended?
There are several reasons why your doctor may recommend a hip replacement surgery. People who benefit from a hip replacement surgery often have:
- Hip pain that limits everyday activities such as walking or bending.
- Hip pain that continues while resting, either in the day or at night.
- Stiffness in the hip that limits the ability to move or lift the leg.
- Inadequate pain relief from anti-inflammatory or painkiller medicines, physical therapy, or walking supports.
The orthopaedic evaluation
An evaluation with a joint replacement surgeon consists of several components:
- Medical history: Your joint replacement surgeon will gather information about your general health and ask questions about the extent of your hip pain and how it affects your ability to perform everyday activities.
- Physical examination: This will assess hip mobility, strength, and alignment.
- X-rays: These images help to determine the extent of damage or deformity in your hip.
- Other tests: Occasionally other tests such as a magnetic resonance imaging (MRI) scan, may be needed to determine the condition of the bone and soft tissues of your hip.
(Left) In this X-ray of a normal hip, the space between the ball and socket indicates healthy cartilage. (Right) This X-ray of an arthritic hip shows severe loss of joint space.
Hip Joint with arthritis
Deciding to have hip replacement surgery
Talk to your doctor
Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether a hip replacement surgery is the best method to relieve your pain and improve your mobility. Other treatment options such as medications, physical therapy, or other types of surgery may also be considered.
In addition, your orthopaedic surgeon will explain the potential risks and complications of a hip replacement surgery including those related to the surgery itself and those that can occur over time after your surgery.
Never hesitate to ask your doctor questions about things you do not understand. The more you know, the better you will be able to manage the changes that hip replacement surgery will make in your life.
An important factor in deciding whether to have hip replacement surgery is understanding what the procedure can and cannot do. Most people who undergo hip replacement surgery experience a dramatic reduction of hip pain and a significant improvement in their ability to perform the common activities of daily living.
With normal use and activity, the material between the head and the socket of every hip replacement implant begins to wear. Excessive activity or being overweight may speed up this normal wear and cause the hip replacement to loosen and become painful. Therefore, most surgeons advise optimum high-impact activities such as running, jogging, jumping, or other high-impact sport depending upon your general conditions.
Realistic activities following total hip replacement include unlimited walking, swimming, golf, driving, hiking, biking, dancing, and other low-impact sports.
With appropriate activity modification, hip replacements can last for many years.
Preparing for surgery
If you decide to have hip replacement surgery, your orthopaedic surgeon may ask you to have a complete physical examination by your primary care doctor or physician before your surgical procedure. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such as a cardiologist, before the surgery.
Several tests, such as blood and urine samples, an electrocardiogram (EKG), and chest X-rays, may be needed to help plan your surgery.
Preparing your skin
Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for treatment to improve your skin before surgery.
You may be advised to donate your own blood prior to surgery. It will be stored in the event that you may need blood after surgery.
Tell your orthopaedic surgeon about the medications you are taking. He or she or your primary care doctor will advise you which medications you should stop taking and which you can continue to take before surgery.
If you are overweight, your doctor may advise you to lose some weight before surgery to minimise the stress on your new hip and possibly decrease the risks of surgery.
Although infections after hip replacement are not common, an infection can occur if bacteria enter your bloodstream. Because bacteria can enter the bloodstream during dental procedures, major dental procedures (such as tooth extractions and periodontal work) should be completed before your hip replacement surgery. Routine cleaning of your teeth should be delayed for several weeks after surgery.
Individuals with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing required treatment before having surgery.
Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several days or weeks with tasks such as cooking, shopping, bathing, and laundry.
If you live alone, your orthopaedic surgeon's office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at your home. A short stay in an extended care facility during your recovery after surgery also may be arranged.
Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:
- Securely fastened safety bars or handrails in your shower or bath.
- Secure handrails along all stairways.
- A stable chair for your early recovery with a firm seat cushion (that allows your knees to remain lower than your hips), a firm back, and two arms.
- A raised toilet seat.
- A stable shower bench or chair for bathing.
- A long-handled sponge and shower hose.
- A dressing stick, a sock aid, and a long-handled shoe horn for putting on and taking off shoes and socks without excessively bending your new hip.
- A reacher that will allow you to grab objects without excessive bending of your hips.
- Firm pillows for your chairs, sofas, and car that enable you to sit with your knees lower than your hips.
- Removal of all loose carpets and electrical cords from the areas where you walk in your home.
You will most likely be admitted to the hospital on the day or one day prior to your surgery.
After admission, you will be evaluated by a member of the anaesthesia team. The most common types of anaesthesia are general anaesthesia (you are put to sleep) or spinal, epidural, or regional nerve block anaesthesia (you are awake but your body is numb from the waist down). The anaesthesia team, with your operating surgeon’s input, will determine which type of anaesthesia will be best for you.
Many different types of designs and materials are currently used in artificial hip joints. All of them consist of two basic components: the ball component (made of highly polished strong metal or ceramic material) with a femoral stem for the thighbone and the socket component (a durable cup of plastic, ceramic or metal, which may have an outer metal shell).
The prosthetic components may be "press fit" into the bone to allow your bone to grow onto the components or they may be cemented into place. The decision to press fit or to cement the components is based on a number of factors, such as the quality and strength of your bone. A combination of a cemented stem and a non-cemented socket or vice versa may also be used depending upon the overall planned outcome and your clinical needs.
Your orthopaedic surgeon will choose the type of prosthesis that best meets your needs.
(Left) A standard non-cemented femoral component. (Centre) A close-up of this component showing the surface for bone growth. (Right) The standard cemented femoral component.
(Left) The acetabular component shows plastic (polyethene) liner inside the metal shell and metal or ceramic head. (Right) The porous surface of this acetabular component allows for bone ingrowth. The holes around the cup are used if screws are needed to hold the cup in place.
The surgical procedure takes a few hours. Your orthopaedic surgeon will remove the damaged cartilage and bone and then position new metal, plastic, or ceramic implants to restore the alignment and function of your hip.
X-rays before and after total hip replacement. In this case, non-cemented components were used.
After surgery, you will be moved to the recovery room where you will remain for several hours while your recovery from anaesthesia is monitored. After you wake up, you will be taken to your hospital room.
Orthopaedic surgeons use different methods to perform hip replacement surgery to have the best post-op outcome. As a result, the precautions you will follow after surgery depends on your surgeon's preference and the way the surgery was done. The success of your surgery will depend in large measure on how well you follow your orthopaedic surgeon's instructions regarding home care during the first few weeks after surgery.
You may have stitches or staples running along your wound or a suture beneath your skin. The stitches or staples will be removed after surgery depending upon your wound healing process.
Avoid getting the wound wet until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing or support stockings.
Some loss of appetite is common for some duration after surgery. A balanced diet, often with an iron supplement is important to promote proper tissue healing and restore muscle strength. Be sure to drink plenty of fluids.
Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most of the normal activities of daily living within 3 to 6 weeks following surgery. You may experience some discomfort with activity, and at night. This is a common occurrence during the first few weeks.
Your activity program should include:
- A graduated walking program to slowly increase your mobility, initially in your home and later outside.
- Resuming other normal household activities such as sitting, standing, and climbing stairs.
- Specific exercises several times a day are needed to restore movement and strengthen your hip. You probably will be able to perform the exercises without help, but you may have a physical therapist help you at home or in a therapy centre during the first few weeks after surgery
Possible complications of surgery
The complication rate following hip replacement surgery is very low. Serious complications such as joint infection occur in less than 1% of patients. Major medical complications such as a heart attack or a stroke occur even less frequently. However, chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur they can prolong or limit full recovery.
Infection may occur superficially in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later.
Minor infections of the wound are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.
Blood clots in the leg veins or pelvis are one of the most common complications of hip replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program which may include blood thinning medications, support hose, inflatable leg coverings, ankle pump exercises, and early mobilisation.
Blood clots may form in one of the deep veins of the body. While blood clots can occur in any deep vein, they most commonly form in the veins of the pelvis, calf, or thigh.
In very few cases after a hip replacement, one leg may feel longer or shorter than the other. Your orthopaedic surgeon will make every effort to make your leg lengths even but may lengthen or shorten your leg slightly in order to maximise the stability and biomechanics of the hip. Some patients may feel more comfortable with a shoe lift after surgery.
Hip implant dislocation:
This occurs when the ball comes out of the socket. The risk of a dislocation is greatest in the first few months after surgery while the tissues are healing. Dislocation is uncommon. If the ball does come out of the socket, a closed reduction usually can put it back into place without the need for more surgery. In situations in which the hip continues to dislocate, further surgery may be necessary.
Loosening and implant wear
Over years, the hip prosthesis may wear out or loosen. This is most often due to everyday activity. It can also result from a biological thinning of the bone called osteolysis. If loosening is painful, a second surgery called a revision may be necessary.
Nerve and blood vessel injury, bleeding, fracture and stiffness can occur. In a small number of patients, some pain can continue or new pain can occur after surgery.
Avoiding problems after surgery
Recognising the signs of a blood clot
Follow your orthopaedic surgeon's instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. He or she may recommend that you continue taking the blood thinning medication you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.
The warning signs of a possible blood clot in your leg include:
- Pain in your calf and leg that is unrelated to your incision.
- Tenderness or redness of your calf.
- New or increased swelling of your thigh, calf, ankle, or foot.
A common cause of infection following hip replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections.
Following surgery, patients with certain risk factors may need to take antibiotics prior to dental work, including dental cleanings, or before any surgical procedure that could allow bacteria to enter your bloodstream. Your orthopaedic surgeon will discuss with you whether taking preventive antibiotics before dental procedures are needed in your situation.
Notify your doctor immediately if you develop any of the following signs of a possible hip replacement infection:
- Persistent fever (higher than 100°F orally).
- Shaking chills.
- Increasing redness, tenderness, or swelling of the hip wound.
- Drainage from the hip wound.
- Increasing hip pain with both activity and rest.
A fall during the first few weeks after surgery can damage your new hip and may result in a need for more surgery. Stairs are a particular hazard until your hip is strong and mobile. You should use a cane, crutches, a walker, or handrails or have someone to help you until you improve your balance, flexibility, and strength.
Your orthopaedic surgeon and physical therapist will help you decide which assistive aides will be required following surgery and when those aides can safely be discontinued.
To assure proper recovery and prevent dislocation of the prosthesis, you may be asked to take special precautions when sitting, bending, or sleeping usually for the first 6 weeks after surgery. These precautions will vary from patient to patient, depending on the surgical approach your surgeon used to perform your hip replacement.
Prior to discharge from the hospital, your surgeon and physical therapist will provide you with any specific precautions you should follow.
How your new hip is different
You may feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending. These differences often diminish with time and most patients find that these are minor compared with the pain and limited function they experienced prior to surgery.
Your new hip may activate metal detectors required for security in airports and some buildings. Tell the security agent about your hip replacement if the alarm is activated. You may ask your orthopaedic surgeon for a card confirming that you have an artificial hip.
Protecting your hip replacement
There are many things you can do to protect your hip replacement and extend the life of your hip implant.
- Participate in a regular light exercise program to maintain proper posture, gait, strength and mobility of your new hip.
- Take special precautions to avoid falls and injuries. If you break a bone in your leg, you may require more surgery.
- Make sure your dentist knows that you have a hip replacement. Talk with your orthopaedic surgeon regarding your need to take antibiotics prior to dental procedures.
- See your orthopaedic surgeon periodically for routine follow-up examinations and X-rays, even if your hip replacement seems to be doing fine.