Hip replacement surgery

This is probably number two in terms of popular surgery for arthritis. The most popular form of arthritis surgery is knee replacement surgery but hip replacement is a close second.

There are people who have arthritis of the knee/s as well as the hip: surgeons prefer to replace the hip first before the knees as a new hip will provide a firm support for a replacement knee.

Hip replacement is often carried out to treat osteoarthritis but can also be done in cases of rheumatoid arthritis, bone tumours and joint injuries.

Around 50,000 hip replacements are performed on adults in the UK each year. More women than men undergo a hip replacement.

There is an alternative procedure called hip resurfacing which involves removing the damaged areas and replacing these with metal parts. This is a less extensive procedure which is popular in people (particularly men) who are younger and fitter.

Hip replacement surgery is discussed in the following manner:

• Why hip replacement surgery?
• Criteria for hip replacement surgery
• Not suitable for hip replacement surgery?
• Benefits of hip replacement surgery
• Disadvantages of hip replacement surgery
• Hip replacement procedure
• Complications of hip replacement surgery
• Recovery from hip replacement surgery
• Alternatives to hip replacement surgery

Why hip replacement surgery?

This is an effective form of surgery for people with osteoarthritis or hips damaged by accident, disease or injury. This is also carried out to treat hip fractures caused by diseases such as osteoporosis.

Surgery for arthritis such as this is usually offered when conventional forms of treatment have failed to work. It is a major operation which means benefits and risks but these will be discussed with you beforehand.

Your GP will refer you to an orthopaedic surgeon for this operation. He or she will assess your condition before adding you to a waiting list. Once your reach the top of that list you will then be given a date and time for surgery.

The aims of hip replacement surgery are to ease the pain caused by arthritis and to enable you to remain active and live a normal life.

Criteria for hip replacement surgery

Your surgeon will examine you and ask you about your general health plus medical history before deciding whether to accept you for surgery.

He or she will use a set of guidelines or criteria for assessing your suitability for a hip replacement. These include your age, your weight, the degree of arthritis and the effect this has had on your quality of life.

Your surgeon will also ask you about your lifestyle.

Do you have a hip replacement now or later?

Some people argue that it is better to undergo surgery when the arthritis is at an early stage but this is countered by arguments which state that this increases the need for revision surgery later on in life.

On the other hand it may be better to wait until your arthritis has reached an advanced stage where it is causing a great deal of pain and problems with mobility.

Not suitable for hip replacement surgery?

Most people are able to have a new hip but there are a few people for who surgery is not advisable. This is usually for health reasons such as a chronic medical condition; obesity or a form of arthritis which is too active thereby increasing the strain on the body during surgery.

Your surgeon will decide if you are suitable or not for this surgery. If you are refused then there will be a good reason for this which is to avoid putting your health at risk.

Plus your surgeon may be able to recommend an alternative procedure or similar forms of treatment. On example is a ‘debridement’ procedure in which the affected joint is cleaned via keyhole surgery (minimally invasive surgery).

Benefits of hip replacement surgery

This is a successful procedure which means freedom from pain and stiffness and improved flexibility and mobility. For many people, a new hip has meant a new lease of life.

The benefits outweigh the risks as the majority of satisfied people will testify to.

The biggest benefit is that of pain relief: many people find that they no longer experience pain which is one of several major issues with arthritis.

Another benefit is an improved range of movement and flexibility which allows the person to perform a range of tasks. They are able to resume many of their normal activities which include sport.

There is no longer any stiffness or impaired movement which means an improved quality of life.

Disadvantages of hip replacement

A replacement hip brings a wide range of benefits but there are a few disadvantages as well.

An artificial joint is never quite the same as a natural joint and tends to have a limited shelf life. These joints usually last for 15 to 20 years which means further surgery will be required around that time.

Your new hip will not have the full range of movement you experienced with your own hip. So it will be difficult or even impossible to perform certain movements such as squatting as this can increase the risk of a dislocation.

Another possibility is finding that you have one leg longer than the other although this is a small difference. But there are special insoles you can wear to correct this difference.

Your new joint can slacken over time which is caused by bone which has thinned around the prosthesis: or the shaft of the prosthesis working itself loose within the hollow of the thigh bone.

An artificial hip is subject to wear and tear in the same way that a natural joint is.

Hip replacement procedure

This procedure involves the removal of the damaged hip joint which is then replaced by an artificial joint or prosthesis. The aim is to replicate the movement of a natural hip joint.

Your hip joint is what we term a ‘ball and socket’joint which means that a spherical (ball shaped) bone fits into a ‘cup’like bone. Both of these parts are replaced with artificial versions during this surgery.

For more information about the human body and anatomy of the joints, visit your joints section.

If you are suitable for a hip replacement then you will be referred to an orthopaedic surgeon by your GP. This applies if you are having surgery on the NHS.

If you choose to go privately then you will need to find a surgeon and private clinic/hospital.

Once you have been seen by the surgeon and he/she agrees to you undergoing this procedure than you will be put on a waiting list. Be prepared to wait for some time before you have surgery.

Pre-admission clinic

But before you undergo this surgery there are few things you need to do beforehand. Your surgeon will mention these during the initial consultation and will provide you with a booklet detailing what you need to do/bring with you on the day of your surgery.

You will be asked to attend a ‘pre-admission’ clinic two weeks before your surgery. This is where you meet the surgeon and members of his/her team and have the chance to ask questions about this procedure.

You will be examined and asked about your medical history. You will also undergo a series of tests such as X-rays and blood tests to check that you are in good shape for anaesthesia and the surgery.

If you are taking any medication for your arthritis then take that with you and ask the surgeon about whether you need to stop taking this before your surgery.

The surgical team will ask you if you have anyone at home who can help you after your surgery. It is important that you think about how you will manage once you are discharged as you will be incapacitated for some time. Arrange for someone at home to help you or if you live alone then mention this to the team.

They can arrange for you to have support before you are admitted to hospital.

Exercise before surgery

You will be encouraged to exercise after surgery but it is equally important that you do so before you go into hospital. The reason for this is that exercise will help to strengthen the muscles around your hip which aids with mobility.

Preparing for surgery

You will have been advised about what to do before you go into hospital which includes:

• Arranging for someone to drive you to and from the hospital
• Arranging for someone to help you at home
• Read up as much as you can about your surgery so that you are better informed.
• Set up a ‘recovery area’ at home: this means a room (or part of a room) in your house where you will spend most of your time, e.g. bedroom. Ensure that you have the TV remote control, radio, medication, painkillers and a phone close at hand.
• Make a note of the name, address and telephone number of your surgeon (and the hospital): do this in case you need to get in touch with him/her before and after your surgery. Keep this handy.
• Buy in plenty of food so that you do not have the worry of going shopping after your surgery. Choose foods which are easy to prepare.
• Arrange time off work with your employer

The day before your surgery, have a bath or shower and ensure that your nails are cut short. Do not eat or drink anything at least 6 hours before your operation.

You will be admitted into hospital the day before your surgery although some people are admitted on the actual day of their operation.

Going into hospital

Pack a small case with your nightwear, toiletries, books/iPod, change of clothes and medication. If you are taking your mobile phone with you then check if you are able to use this whilst in hospital as they can interfere with the medical equipment.

Once at the hospital you will meet with your surgeon and anaesthetist who will discuss the procedure with you. Ask as many questions as you need to.

You will change into a gown and be given a pair of compression stockings to wear to prevent the risk of a blood clot.

The surgery

Hip replacement is either performed under a general anaesthetic or a spinal anaesthetic. So you have the choice of being asleep throughout the surgery or a spinal block which will numb the area below the waist. You will remain awake during the procedure but will be unable to feel anything.

There are two procedures:

• Total (full) hip replacement
• Hip resurfacing

Total hip replacement

The head and part of the thigh bone (femur) is removed and the part of the pelvis which acts as a natural socket is roughened so that it will accept an artificial socket. This socket is fixed into place with cement (acrylic based) or pressed into position.

The artificial socket is comprised of plastic, metal or ceramic. The artificial ball is made from metal or ceramic and is attached to a long metal shaft which fits into this socket.

Basically, the surgeon replaces your natural ball and socket joint with artificial substitutes or prosthesis.

But what tends to be the case now is that one half of the prosthesis, e.g. the socket, or even both parts are put in place without the need for cement. These cement free parts have a series of tiny holes drilled into the surface which encourages new bone to grow onto them, thereby fixing it securely in place.

The most popular form of artificial joint is a metal ball in a plastic socket which is preferred by older, less mobile people.

Range of artificial joints

There are a range of combinations to choose from in regard to the materials used in your artificial joint. These include ‘metal on plastic’,‘ceramic on ceramic’ and ‘ceramic on plastic’.

The advantage of using metal components such as a metal ball or socket is that they longer lasting than the other types of materials such as ceramic or plastic.

Ceramic on plastic type of joints are preferred by younger and physically active people. This also applies to metal joints which are thinner than the plastic variety, enabling a larger than normal ball to be fitted.

This increases the range of movement in the hip which is particularly beneficial for the active or sporty person.

Many artificial joints are comprised of the following materials:

• Titanium alloy for the shaft (long thin rod which fits onto the top of the thigh bone).
• Solid polythene for the socket
• Alloy mixture for the ball

Other joints are composed of ceramic components only.

There are around 60 types of artificial joint but the reality is that you will have four to five joints to choose from. Your surgeon will advise you as to the most suitable joint for you.

Hip resurfacing

This is an alternative procedure which is often performed on younger people. The main reason for that is a reduced risk of dislocation which enables active people to take part in high intensity sports.

This is a less invasive procedure with a quicker recovery period as well as less worry about dislocation.

This is a ‘metal on metal’ procedure in which a metal cap is fitted over the head of the thigh bone. Another metal component or ‘shell’is then fixed into place within the natural socket of the pelvis. This looks similar to the ball and socket joint used in total hip replacement surgery. But the main difference is that most of the natural underlying bone structure is left with hip resurfacing compared to hip replacement.

If you choose this procedure then one advantage is if you need to have a full hip replacement later on. If more of the natural hip ball is left then it will make it easier for the surgeon to perform this surgery at a later date.

Hip resurfacing is not advisable for people with osteoporosis or low bone density.

The outcome is good for younger and fitter people but more research is needed, especially to gauge the long term benefits of this procedure.

What about minimally invasive surgery?

Surgeries for arthritis such as knee replacement have been performed as minimally invasive procedures which appeal to people who want less scarring and a faster recovery.

Minimally invasive surgery has been used in a small number of hip replacements but the results are mixed. It does mean a smaller incision and less risk of damage to surrounding ligaments and tissues.

But this technique has not been around as long as hip replacement which means it is difficult to determine its long term effectiveness.

Complications of hip replacement surgery

Surgery is very safe but all procedures come with a small degree of risk. Hip replacement surgery is classed as a major operation so there are a few risks but these are minor and easily treated.

Your surgeon will discuss these risks with you before you consent to this operation.

Many of the following risks or complications apply to all types of surgery and include:

• Dislocation or a loosening of the hip joint
• Infection
• Blood clots
• Wear and tear on the joint
• Pulmonary embolism

Dislocation of the hip joint occurs in a small percentage of cases and requires the hip being put back in place under an anaesthetic.

Many people are given antibiotics during their operation to prevent the risk of an infection. However, infection occurs in around 1 in 200 cases. This requires the new joint to be removed and the infection treated. A new hip joint is then implanted.

Blood clots (thrombosis) can develop in the legs but can be prevented. Wearing compression stockings can help as can an injection of heparin or warfarin which thins the blood and reduces the risk of a clot.

An artificial joint is still liable to wear and tear in the same way a natural joint is. This is often the case with a plastic joint but ceramic or metal joints are hard wearing and less likely to deteriorate.

Pulmonary embolism is where a blood clot becomes dislodged and travels up to the lungs causing chest pains, difficulty in breathing and the risk of collapse.

Recovery after hip replacement surgery

This starts from when you are taken from the operating theatre to the recovery room through to your rehabilitation at home.

After your surgery You will be taken to a recovery room after your surgery so that the surgical team can monitor your condition. Once they are satisfied with this you will then be returned to your ward.

You will have a couple of suction drains leading to your hip which are designed to remove excess fluid from the surgical incision and aid with healing. You will be placed on an intravenous drip and will have had a catheter inserted to remove urine. Painkillers will be given.

These will be removed after a short period of time, usually 24 to 48 hours later.

Once you are back on the ward your condition will continue to be monitored by the nursing staff. A soft pillow will be placed between your legs to stop you putting any pressure on your new hip.

Become active as soon as possible

Your surgeon will be keen for you to become mobile as soon as possible so you will be able to get up and move around the day after your surgery. Although in some cases you will be encouraged to do this on the day of your operation.

This will mean using a walking frame to start with followed by crutches and then a stick. This will be followed by a series of exercises via the hospital physiotherapist who will advise what you can and cannot do with your new joint.

Physiotherapy in hospital

These exercises will include how to stand up and sit down, getting in and out of bed, using a shower and walking around at home and outside. This will include advice about suitable forms of exercise such as swimming and walking.

The physiotherapist or occupational therapist will discuss ways of making your life easier once back at home. This includes advice on gadgets to use in the kitchen, in the bath or shower and around the home in general.

It is important that you follow this advice to the letter. A failure to do this could mean a dislocation or some other form of damage to your new hip.

Continue with these exercises at home but be careful for the first 8 to 12 weeks to avoid the risk of hip dislocation.

Follow up appointment

You will stay in hospital for a week to 10 days. Any stitches will be removed unless they are the dissolvable kind. You will also be given a date for a follow up appointment at the hospital which will be around 6 to 8 weeks time.

This will be followed by another check up a year later and then every 5 years to monitor the condition of the joint and your health in general. This will involve an X-ray to check that there is no dislocation or loosening of the joint.

At home

Once you arrive home it is important that you get plenty of rest and allow your new hip time to heal. This must be balanced with periods of activity and the exercises recommend by the physiotherapist as these will strengthen your hip muscles.

Use any mobility aids such as a walking stick or crutches until you are fully able to move around on your own. Do not overdo things or be too proud to ask for help. Ask your family or friends for help if need be.

Exercise gently, e.g. walking before gradually building this up. Avoid high impact exercise such as jogging but if you are a keen participant in sports such as these then ask your surgeon or GP for advice.

You may experience some pain and general discomfort during this time but painkillers will relieve this.

You will be able to resume sexual relations 6 to 8 weeks after your surgery.

When can you go back to work? This will depend upon the type of job you have but you can expect to return to work around 6 to 12 weeks following surgery. You may have to wait for longer than this if you have a job which is physically demanding.

Your recovery is a time where you adapt to your new hip joint and resume many of the activities which you had to give up due to your arthritis.

For more information about this and coping with arthritis in general then visit our living with arthritis section.

Warning signs

Most people do not have any problems with their new joint after surgery but if you notice any fluid, redness or have an increase in pain in this joint then contact your GP or hospital.

Seek medical help urgently if you develop chest pains, have difficulty in breathing and/or shortness of breath. These symptoms are an indicator of a pulmonary embolism – a blood clot in the lungs which is dangerous if left untreated.

Alternatives to hip replacement surgery

Hip resurfacing is an option but it is often advised for younger people who are fit and physically active.

This option means a quicker recovery but more information is required as to the long term prognosis of this technique.

Your surgeon will discuss alternatives with you.