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Hip Replacement - A Guide

A hip replacement is a surgical procedure to replace your hip joint with an artificial version. It provides a long-term solution for worn or damaged hip joints caused by injury or disease, such as osteoarthritis, which can cause severe pain and loss of mobility

Introduction
When a hip replacement is necessary
Hip replacement - Preparing
How a hip replacement is performed
Risks of hip replacement surgery
Recovering from hip replacement
Future prospects

Introduction

The purpose of a new hip joint is to:

  • relieve pain,
  • improve the function of your hip,
  • improve your ability to move around, and
  • improve your quality of life.

The hip joint is a ball-and-socket joint. The operation replaces both the natural socket and the rounded ball at the top of the thigh bone with artificial parts (see How it is done). These parts replicate the natural motion of the hip joint.

At least 50,000 hip replacements are carried out each year in Britain, usually on adults aged over 65. Women are more likely to need a hip replacement than men.



Hip resurfacing

An alternative to hip replacement, known as metal-on-metal hip resurfacing, involves replacing the diseased or damaged surfaces in the hip joint with metal parts. Less bone is removed, so less prosthetic (implant) is needed.

Outlook

The outlook fora hip replacement is generally considered to be good. It is a routine operation that offers an end to joint pain, increased mobility and a better quality of life. Hip replacements currently last about 20-30 years.

However, it is a major operation with a fairly long recovery period. Associated problems include wear and tear of the prosthesis in people who are more active, and the device dislocating or loosening.

Hip resurfacing also appears to be beneficial, but there is little information available about the long-term safety and reliability of this method. It is not known precisely how long hip resurfacing parts last, but they are expected to last at least 10 years.

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When a hip replacement is necessary

Hip replacement is the most effective treatment for a hip joint that causes pain and cannot function properly. The most common reasons for surgery are:

  • Osteoarthritis. This is the most common form of arthritis. It occurs when connecting tissue between the joint is damaged, causing bones to rub together painfully.
  • Rheumatoid arthritis.This is caused by the immune system attacking the lining of the joint, resulting in pain and stiffness.
  • Septic arthritis. This form of arthritis occurs when the joint becomes infected.
  • Fracture of the neck of the thigh bone (femur). Thiscauses a loss of blood supply to the rounded head of the bone and may also lead to crumbling of the bone (avascular necrosis).
  • Paget's disease of bone.This affects bone growth and can make bones weak and deformed.
  • Bone tumours.
  • Other joint injuries.

Hip replacements are also sometimes needed in:

  • Late cases of developmental dysplasia of the hip, a condition that prevents the ball and socket hip joint from developing properly. If left untreated, it can cause permanent deformity and walking problems.
  • Hip joint fractures caused by osteoporosis, which causes the bones to become thin and weak. Certain cells within the bone are no longer able to break down old bone and replace it with strong, healthy bone.

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Hip replacement - Preparing

Pre-operative assessment

A couple of weeks before the operation, you will usually be asked to attend a pre-operative assessment clinic to meet your surgeon and other members of the surgical team. They will take your medical history, examine you and organise any tests needed, to make sure you are healthy enough for an anaesthetic and surgery.

They will give you advice on anything you can do to prepare for surgery and ask you about your home circumstances so your discharge from hospital can be planned. If you live alone, have a carer or feel you need extra support, tell the team so that help or support can be arranged before you go into hospital.

Take a list or thepackaging of any medication you are taking. Some rheumatoid arthritis medications suppress the immune system, which can affect healing. For this reason you may be asked to stop taking them before surgery. Your surgeon can advise you about alternative medications.

Exercising before the operation

You can prepare for the operation by staying as active as you can. Strengthening the muscles around your hip will aid your recovery. Youmay be referred to a physiotherapist, who can give you helpful exercises. If you can, keep up any gentle exercise,such aswalking and swimming, in the weeks and months before your operation.

The following exercises can help maintain your muscle strength and movement before surgery:

  • Stand at the bottom of the stairs and put one foot on the second stair. Alternatively, put one footon a kitchen stool.Hold on to the banister or another firm support. Lean forward to bend the top leg while stretching the front of the standing leg. Hold this for about 30 seconds, then repeat with the other leg.
  • Stand on the affected leg for short periods, lifting the good leg off the floor. Concentrate on holding the pelvis level. Use a support as necessary for balance.
  • Lie on your back. Pull one leg up to your chest, keeping the other leg flat down on the bed. Repeat the exercise with the other leg. (Only do this exercise if you have not already had a hip replacement on one side.)
  • Lie on your back. Bend your knee up so that your foot rests flat on the bed, and allow the bent knee to fall out to the side as much as is comfortable.
  • Lie on your stomach and then flat on your back for approximately 20 minutes once or twice a day (early morning or late at night while in bed is often a good time), to stretch the front and back of your hip.

Preparing for yourhospital stay

  • Get informed. Find out as much as you can about what is involved in your operation. Your hospital may provide written information or videos.
  • Arrange help. Arrange for a friend or relative to help you at home for a week or two after you come home from hospital.
  • Sort out transport. Arrange for someone (either a friend or relative or ataxi) to take you to and from the hospital.
  • Prepare your home. Before you go for your operation, put your TV remote control, radio, telephone, medications, tissues, address book and a glass on a table next to where you will spend most of your time when you come out of hospital.
  • Stock up. Buy food that is easy to prepare such as frozen ready meals, cans and staples, such as rice and pasta, or prepare your own dishes to freeze and reheat during your recovery.
  • Clean up. Before going into hospital, have a long bath or shower, cut your nails (taking off any nail polish) and wash your hair. Put on freshly washed clothes. This helps prevent unwanted bacteria coming into hospital with you and complicating your care.

When you go into hospital

You will usually be admitted to hospital the day before your operation (or earlier if you have any additional medical problems such as heart disease). The surgeon and anaesthetist will usually come and see you again to discuss what will happen and give you the opportunity to ask any more questions.

You will not have anything to eat or drink for about six hours before your operation.

Just before surgery, the ward staff will help you to take a bath or shower and put on a surgical gown. You will have to remove make-up, nail polish or jewellery. If you wear glasses or false teeth, these can be removed in the anaesthetic room.

You will then be escorted to theatre by a nurse.

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How a hip replacement is performed

Before your operation, you will receive either a general anaesthetic (where you are put to sleep) or a spinal (epidural) anaesthetic plus sedation, so you do not have to lie awake and listen to the operation.

The procedure

Once you have been anaesthetised, the surgeon removes the existing hip joint completely. The upper part of the femur (thigh bone) is removed and the natural socket for the head of the femur is hollowed out.

A plastic or ceramic socket is fitted into the hollow in the pelvis. A short, angled metal shaft with a smooth ball on its upper end (to fit into the socket) is placed into the hollow of the thigh bone. The plastic cup and the artificial bone head may be pressed into place or fixed with acrylic cement.

Metal-on-metal (MoM) hip resurfacing is carried out in a similar way. The main difference is that much less of the bone is removed as only the joint surfaces are replaced with metal inserts.

Materials used

Both types of hip replacement surgery use the same sort of prosthetic parts, which can be cemented or uncemented:

  • Cemented parts are secured to healthy bone using a special glue.
  • Uncemented parts are made from permeable materialthat has many tiny holes. This allows the bone to grow into it, holding it in place.

Most prosthetic parts are produced using high-density polythene for the socket, titanium alloys for the shaft, and sometimes a separate ball made of an alloy (mixture) of cobalt, chromium and molybdenum. Some surgeons use ceramic parts, which do not wear as quickly as plastic.

The hip replacement operation has become a routine and simple procedure. However,as with all surgery, it carries a degree of risk.

Choosing your prosthesis

There are more than 60 different types of implant or prosthesis. In practice, however, the options are usually limited to around four or five. Your surgeon can advise you on the type they think would suit you best.

NICE only recommends prostheses known to have a 90% chance of lasting at least 10 years. Ask your doctor if you will be getting one of these and, if not, why not.

The National Joint Registry (NJR), which collects details on total hip replacement operations from hospitals in England and Wales, can help you to identify the best performing implants and the most effective type of surgery.

Your specialist

Choose a specialist who regularly performs hip replacements and can discuss their results with you. This is even more important if you arehaving a second or subsequent hip replacement, known as revision hip transplant, which is trickier to perform.

Look for a specialist who will work with you to find the best treatment for you.

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Risks of hip replacement surgery

Loosening of the joint

The most common problem that can arise as a result of a hip replacement is loosening of the joint. This can be caused by the shaft of the prosthesis becoming loose in the hollow of the thigh bone, or due to thinning of the bone around the implant.

Another operation (revision surgery)may benecessary, although this cannot be performed on all patients.

Wear and tear

Another common complication of hip replacement surgery is caused by the wear and tear of the artificial sockets. Particles that have worn off the artificial joint surfaces can be absorbed by surrounding tissue, causing inflammation. Anti-inflammatory drugs may stop the problem. If not, you may be advised to havefurther surgery.

Less common complications

  • Infection. This can be reduced by using antibiotics at the time of surgery and by using 'clean air' ventilation in theatre. However, infection still occurs in less than 1 in100 cases. Deeper infection is serious and requires removal and re-implantation of the joint.
  • Blood clots. These can form in the deep veins of the leg (deep vein thrombosis) due to reduced movement, but can be prevented using special stockings, exercises and medications.
  • Dislocation. In a small number of cases, the artificial hip can come out of its socket. It can be replaced under anaesthetic, but repeated problems require further surgery.
  • Joint stiffening. The soft tissues can harden around the implant, causing reduced mobility. This is not usually painful and can be prevented using medication or radiation therapy (a quick and painless procedure during which controlled doses of radiation are directed at your hip joint).

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Recovering from hip replacement

Looking after your new hip

With care, your new hip should last well. The following tips will help you care for your new hip:

  • Avoid bending your hip more than 90° (a right angle) during any activity.
  • Avoid twisting your hip.
  • Do not swivel on the ball of your foot.
  • When you turn around, take small steps.
  • Do not apply pressure to the wound in the early stages (so avoid lying on your side).
  • Do not cross your legs over each other.
  • Do not force the hip or do anything that makes your hip feel uncomfortable.
  • Avoid low

Orthocard

If you have had a joint replacement or implant in the UK, you can apply for a free Orthocard. This is a credit card-sized, personalised card that you carry around with you to confirm that your replacement or implant exists.

You can show the card to:

  • border control staff -for example at airports, to explain why the security alarm may be activated
  • your GP, dentist or another healthcare professional, so they are aware you have had a joint replacement or implant (as this may affect the medical treatment you receive)

Visit the Joint Action website if you are a patient and would like a free Orthocard or more information

Aftertheoperation, you will be lying flat on your back and may have a pillow between your legs to keep your hip in the correct position. The nursing staff will monitor your condition and you will have a large dressing on your leg to protect the wound.

You may be allowed to have a drink about an hour after you return to the ward and you will also be allowed to have food, depending on your condition.

How soon will I be up and about?

The staff will help you to get up and walk about as quickly as possible after surgery. Some patients are able to get up and walk the same day they had surgery.

It is normal, initially, to experience discomfort while walking and exercising, and your legs and feet may be swollen. You may be given an injection into your abdomen to help prevent blood clots forming in your legs and a short course of antibiotics to help prevent infection.

A physiotherapist may teach you exercises to help strengthen the hip and explain what should and should notbe done after the operation. They will teach you how to bend and sit to avoid damaging your new hip.

When can I go home?

You will usually be in hospital for aroundthree to fivedays. If you are generally fit and well, the surgeon may suggest an accelerated rehabilitation programme, where you start walking on the day of the operation and are discharged within one to three days.

How will I feel when I get home?

Do not be surprised if you feel very tired at first. You have had a major operation and muscles and tissues surrounding your new hip will take time to heal.

You may be eligible for home help and there may be aids that can help you. You may want to arrange to have someone to help you for a week or so.

An occupational therapist should be available to help you. They will assess how physically capable you are and, when you are about to leave hospital, they will assess your circumstances at home.

Your occupational therapist will be able to advise you on how to do daily activities, such as washing yourself, more easily. They will also advise about any equipment you may need to help you to be independent in your daily activities. This may include a raised toilet seat and aids to help you dress.

How soon will the pain go away?

The pain that you may have previously experienced should go immediately, although you can expect to have a different form of pain from the operation, which is only temporary.

Is there anything I should look out for or worry about?

After hip replacement surgery, contact your GP if you notice redness, fluid or an increase in pain in the new joint.

Will I have to go back to hospital?

You will be given an appointment to check up on your progress, usually 6-12 weeks after your hip replacement. The surgeon will want to see you a year later to check that everything is OK, and every five years after that to X-ray your hip and make sure it is not beginning to loosen.

How long will it be before I feel back to normal?

Generally, you should be able to stop using your crutches within four to six weeks and feel more or less normal by three months. You should be able to do all your normal activities.

It is best to avoid extreme movements or sports where there is a risk of falling, such as skiing or riding. Your doctor or a physiotherapist can advise you about this.

When can I drive again?

You can usually drive againafter about six weeks. Your surgeon can advise. It can be tricky getting in and out of your car at first. It isbest to ease yourself in backwards and swing both legs round together.

When can I go back to work?

Thisdepends on your job, but you can usually return to work between 6 and 12 weeks after your operation.

How will it affect my sex life?

If you were finding sex difficult before because of pain, you may find that having the operation gives your sex life a boost. Your surgeon can advise when it is OK to have sex again.As long as you are careful, you should be able to have sex after six to eight weeks. Avoid vigorous sex and more extreme positions.

Will I need another new hip?

Nowadays, most hip implants last for 20 years or more.If you are older, your new hip may last your lifetime. If you are younger, you may need another new hip at some point.

Revision surgery is more complicated and time-consuming for the surgeon to perform than a first hip replacement and complication rates are usually higher. It cannot be performed in every patient. However, it is much more successful than it used to be and most people whocan have it report success for 10 years or more.

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Future prospects

Hip replacement surgery is being improved in several ways:
  • New, stronger materials for prosthetics arebeing developedthat will allow longer wear and better joint mobility.
  • Enhancements are being made to new 'cementless' implants. Patients can be recommended for newer types of joints, such as ceramic-on-ceramic and ceramic-on-plastic.
  • Anew kind of minimally invasive surgery is sometimes used to reduce the size of the surgical incision.
  • Computer-assisted surgeryis being used to generate an image of the hip joint to allow greater visibility and precision.


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