Hip Replacement

Introduction

Hip replacement surgery, also called total hip arthroplasty, involves removing a diseased hip joint and replacing it with an artificial joint, called a prosthesis. Hip prostheses consist of a ball component, made of metal or ceramic, and a socket, which has an insert or liner made of plastic, ceramic or metal. The implants used in hip replacement are biocompatible — meaning they're designed to be accepted by your body — and they're made to resist corrosion, degradation and wear.

Hip replacement is typically used for people with hip joint damage from arthritis or an injury. Followed by rehabilitation, hip replacement can relieve pain and restore range of motion and function of your hip joint.

When is Hip Replacement Surgery recommended?

Symptoms that might lead you to consider hip replacement include:

  • Persistent pain, despite pain medication

  • Pain exacerbated by walking, even with a cane or walker

  • Poor sleep due to pain

  • Difficulty going up or down stairs

  • Trouble rising from a seated position

  • Inability to participate in formerly enjoyable activities because of pain

The goal of hip replacement surgery is to relieve pain and increase the mobility and function of a damaged hip joint. If a stiff, painful hip joint has forced you to cut back on everyday activities, successful surgery may allow you to resume them.

Before thinking about surgery, though, your doctor may recommend other treatments, such as pain medications, physical therapy, exercise, and use of a cane or walker. If these treatments are not enough, hip replacement may be the right option for you.

Conditions that can damage the hip joint, sometimes necessitating hip replacement surgery, include:

  • Osteoarthritis

  • Rheumatoid arthritis

  • Broken hip

  • Bone tumor

  • Osteonecrosis, which occurs when there is inadequate blood supply to the ball portion of the hip joint 

What are the causes?

The most common reason that people have hip replacement surgery is the wearing down of the hip joint that results from osteoarthritis. Other conditions, such as rheumatoid arthritis (a chronic inflammatory disease that causes joint pain, stiffness, and swelling), avascular necrosis (loss of bone caused by insufficient blood supply), injury, and bone tumors also may lead to breakdown of the hip joint and the need for hip replacement surgery.

Before suggesting hip replacement surgery, the doctor is likely to try walking aids such as a cane, or non-surgical therapies such as medication and physical therapy. These therapies are not always effective in relieving pain and improving the function of the hip joint. Hip replacement may be an option if persistent pain and disability interfere with daily activities. Before a doctor recommends hip replacement, joint damage should be detectable on x rays.

In the past, hip replacement surgery was an option primarily for people over 60 years of age. Typically, older people are less active and put less strain on the artificial hip than do younger, more active people. In recent years, however, doctors have found that hip replacement surgery can be very successful in younger people as well. New technology has improved the artificial parts, allowing them to withstand more stress and strain. A more important factor than age in determining the success of hip replacement is the overall health and activity level of the patient.

For some people who would otherwise qualify, hip replacement may be problematic. For example, people with chronic diseases such as those that result in severe muscle weakness or Parkinson's disease are more likely than people without chronic diseases to damage or dislocate an artificial hip. Because people who are at high risk for infections or in poor health are less likely to recover successfully, doctors may not recommend hip replacement surgery for these patients.

How is Hip Replacement Surgery diagnosed?

Before surgery you'll meet with your orthopedic surgeon for an examination. The surgeon will:

  • Ask about your medical history and current medications

  • Do a brief general physical examination to make sure you're healthy enough to undergo surgery

  • Examine your hip, paying attention to the range of motion in your joint and the strength of the surrounding muscles

  • Order blood tests, an X-ray and possibly an MRI

This preoperative evaluation is a good opportunity for you to ask questions about the procedure. If you have any concerns about the surgery, be sure to ask.

Your doctor or surgeon may also recommend that you begin an exercise program in preparation for your surgery. Some doctors believe that people who have an established muscle-building and flexibility program before surgery have better outcomes and faster recovery time following surgery. Preoperative exercise programs may have less effect in those with advanced osteoarthritis, however. Talk to your doctor before starting any exercise program.

What are the treatment options for Hip Replacement Surgery?

When you check in for your surgery, you'll be asked to remove your clothes and put on a hospital gown. The first member of the medical team to visit may be the anesthesiologist. You'll be given either a general anesthetic or a spinal block, which numbs the lower half of your body.

Because infection and blood clots are possible complications of hip replacement surgery, your surgeon may order preventive medications — antibiotics and blood thinners — to be given before the surgery begins.

During the procedure

To perform a hip replacement, your surgeon:

  • Makes an incision over the front or side of your hip, through the layers of tissue

  • Removes diseased and damaged bone and cartilage, leaving healthy bone intact

  • Implants the prosthetic socket into your pelvic bone, to replace the damaged socket

  • Replaces the round top of your femur with the prosthetic ball, which is attached to a stem that fits into your thighbone

Your new, artificial joint is designed to mimic the natural, gliding motion of a healthy hip joint.

Techniques for hip replacement are evolving. As surgeons continue to develop less invasive surgical techniques, the hope is that these techniques might reduce recovery time and pain compared with standard hip replacements. However, studies comparing the outcomes of standard hip replacement with those of minimally invasive hip replacement have had mixed results.

After the procedure

After surgery, you'll be moved to a recovery area for a few hours while your anesthesia wears off. Nurses or other anesthesia aides will watch your blood pressure, pulse, alertness, pain or comfort level, and your need for medications.

Blood clot prevention

After your surgery, you'll be at increased risk of blood clots in your legs. Possible measures to prevent this complication include:

  • Early mobilization. You'll be encouraged to sit up and even try walking with crutches or a walker soon after surgery. This will likely happen the same day as your surgery or on the following day.

  • Pressure application. Both during and after surgery, you may wear elastic compression stockings or inflatable air sleeves similar to a blood pressure cuff on your lower legs. The pressure exerted by the inflated sleeves helps keep blood from pooling in the leg veins, reducing the chance that clots will form.

  • Blood-thinning medication. Your surgeon may prescribe an injected or oral blood thinner after surgery. Depending on how soon you walk, how active you are and your overall risk of blood clots, you may need blood thinners for several more weeks after surgery.

What are the risk factors for Hip Replacement Surgery?

Hip replacement surgery is generally safe, but as with any surgery, complications can occur. Although some complications are serious, most can be treated successfully. Complications of hip replacement include:

  • Blood clots. Clots can form in your leg veins as a result of decreased leg movement after surgery, as well as from pressure on the veins during surgery. Your doctor usually gives you blood-thinning medications after your surgery to try to prevent clots from forming. Compression devices, such as elastic stockings, and exercise to increase blood flow through the veins in your legs also can reduce your risk.

  • Infection. Infections can occur at the site of your incision and in the deeper tissue near your new hip. Most infections are treated with antibiotics, but a major infection near your prosthesis may require surgery to remove and replace the prosthesis.

  • Fracture. During surgery, healthy portions of your hip joint may fracture. Sometimes the fractures are so small that they heal on their own, but larger fractures may be corrected during surgery with wires, cables or bone grafts.

  • Dislocation. Certain positions can cause the ball of your new joint to become dislodged. To avoid this, it is often recommended that after surgery you don't bend more than 90 degrees at the hip and don't let your leg cross the midline of your body. If the hip dislocates, your doctor may fit you with a brace to keep the hip in the correct position. If your hip keeps dislocating, surgery is often required to stabilize it.

  • Loosening. Although this complication is rare with newer implants, your new joint may not become solidly fixed to your bone or may loosen over time, causing pain in your hip. Surgery might be needed to fix the problem.

  • Breakage of the prosthesis. Another rare possibility is that your artificial hip could break several years after surgery. Another surgery would be required to replace the broken joint.

  • Change in leg length. Your surgeon takes steps to avoid the problem, but occasionally a new hip may make one leg longer or shorter than the other. Sometimes this is caused by weakness in the muscles surrounding the hip. In this case, progressively strengthening and stretching those muscles can make the hip more stable.

  • Joint stiffening. Sometimes the soft tissues around your joint harden (called ossification), making it difficult to move your hip. This usually isn't painful. If you're at risk of ossification, your doctor may recommend medications or radiation therapy to prevent it.

  • Wear and tear over time. Your prosthetic hip joint may wear out eventually, so if you have hip replacement surgery when you're relatively young and active, you may need a second hip replacement within your lifetime. However, new materials are making implants last longer, so a second replacement may not be needed for many years.

Can Hip Replacement Surgery be prevented?

Gentle Range of Movement Exercise

Use range of motion exercises to help keep the hip joints "oiled." Lying on your back, bend both knees, and lift the feet off the floor. Place your hands on each knee cap, and moving from the hip joint, rotate the knees away from each other. The action of the legs will resemble the movement of an old-fashioned egg beater. Do a few rotations in one direction, and then repeat to the other. If you have stiffness, alternate by moving one knee and then the other.

Hip Adductor Exercise

Use exercise machines in the gym to strengthen the muscles around the hip joints. Begin with the hip adductor machine. Select a very low weight, and set the machine to form into a V-shape. Sitting tall and drawing the lower abdominal muscles toward the spine, bring the legs together, pausing briefly when your inner thighs are together. Do eight to 12 repetitions to start, and work up to three sets over time.

Hip Abductor Exercise

Proceed to the hip abductor machine. Set a low weight, and begin with the legs together. Press the legs apart, against the resistance of the weights. Do eight to 12 repetitions, and work up to three sets.

Leg Press Machine

Integrate your muscular strength with leg presses to help keep the hip joints stable and free of injury. Stand on the platform with feet apart hips-width distance and big toes facing straight forward, and select a very low weight. Begin with your knees bent at about a 90-degree angle, and press through your feet to extend the legs so they are straight. Do eight to 12 reps to start, and build up to three sets.

Walk Stairs and Bike

Walk stairs slowly, or ride a bike at a mellow pace. Both activities move the legs in a way that keeps the hip joints in neutral rotation and also exercises all the muscles of the hips and legs that support and help stabilize the hip joints. Do not sprint or run stairs or blast up hills on your bike; the idea is to do low-impact, low-tempo movement that does not strain the hip joints. Take the stairs whenever it is practical, and bike for 15 to 20 minutes to begin, two to three times a week. This is not for weight loss but to prevent hip joint degeneration. To help you lose weight, the American Academy of Sports Medicine recommends 30 minutes of cardiovascular exercise five days a week.

How fast can you recover?

A physical therapist may help you with some exercises that you can do in the hospital and at home to speed recovery.

Activity and exercise must be a regular part of your day to regain the use of your joint and muscles. Your physical therapist will recommend strengthening and mobility exercises and will help you learn how to use a walking aid, such as a walker, a cane or crutches. As therapy progresses, you'll gradually increase the weight you put on your leg until you're able to walk without assistance.

After Discharge?

You had a hip joint replacement surgery to replace all or part of your hip joint with an artificial joint. This artificial joint is called a prosthesis.

What to Expect at Home

By the time you go home, you should be able to walk with a walker or crutches without needing much help. Most people do not need them after 2 to 4 weeks. Check with your doctor about when to stop using crutches.

You should also be able to dress yourself with only a little help and be able to get into and out of your bed or a chair by yourself. You should also be able to use the toilet without much help.

You will need to be careful that you do not dislocate your artificial hip, especially in the first few months after surgery. You will need to learn exercises that make your new hip stronger and take special precautions.

You will need to have someone with you at home 24 hours a day for 1 to 2 weeks after you leave the hospital or rehab center. You will need help preparing meals, bathing, moving around the house, and doing other daily activities.

Over time, you should be able to return to your former level of activity. You will need to avoid some sports, such as downhill skiing or contact sports like football and soccer. But you should be able to do low impact activities, such as hiking, gardening, swimming, playing tennis, and golfing.

Home Setup

Your bed should be low enough for your feet to touch the floor when you sit on the edge of the bed. Your bed should also be high enough so that your hips are higher than your knees when you sit on the edge. You will not need a hospital bed, but your mattress should be firm.

Keep tripping hazards out of your home.

  • Learn to prevent falls. Remove loose wires or cords from areas you walk through to get from one room to another. Remove loose throw rugs. Do not keep small pets in your home. Fix any uneven flooring in doorways. Use good lighting.

  • Make your bathroom safe. Put hand rails in the bathtub or shower and next to the toilet. Place a slip-proof mat in the bathtub or shower.

  • Do not carry anything when you are walking around. You may need your hands to help you balance.

Put things where they are easy to reach.

Place a chair with a firm back in the kitchen, bedroom, bathroom, and other rooms you will use. This way, you can sit when you do your daily tasks.

Set up your home so that you do not have to climb steps. Some tips are:

  • Set up a bed or use a bedroom on the first floor.

  • Have a bathroom or a portable commode on the same floor where you spend most of your day.

Activity

You will need to be careful to not dislocate your new hip when you are walking, sitting, lying down, dressing, taking a bath or shower, and doing other activities.

Keep moving and walking once you get home. Do not put your full weight on your side with the new hip until your doctor tells you it is okay. Start out with short periods of activity, and then gradually increase them. Your doctor or physical therapist will give you exercises to do at home.

Use your crutches or walker for as long as you need them. Check with your doctor before you stop using them.

After a few days you may be able to do simple household chores. But, do not try to do heavier chores, such as vacuuming or laundry. Remember, you will get tired quickly at first.

Wear a small fanny pack or backpack, or attach a basket or strong bag to your walker, so that you can keep small household items, like a phone and notepad, with you.

Wound Care

Keep your dressing (bandage) on your wound clean and dry. You may change the dressing according to when your doctor told you to change it. Be sure to change it if it gets dirty or wet. Follow these steps when you change your dressing:

  • Wash your hands well with soap and water.

  • Remove the dressing carefully. Do not pull hard. If you need to, soak some of the dressing with sterile water or saline to help loosen it.

  • Soak some clean gauze with saline and wipe from one end of the incision to the other. Do NOT wipe back and forth over the same area.

  • Dry the incision the same way with clean, dry gauze. Wipe or pat in just 1 direction.

  • Check your wound for signs of infection. These include severe swelling and redness and drainage that has a bad odor.

  • Apply a new dressing the way you were shown.

Sutures (stitches) or staples will be removed about 10 to 14 days after surgery. Do not shower until 3 - 4 days after your surgery, or when your doctor told you to shower. When you can shower, let water run over your incision but do not scrub it or let the water beat down on it. Do not soak in a bathtub, hot tub, or swimming pool.

You may have bruising around your wound. This is normal, and it will go away on its own. The skin around your incision may be a little red. This is normal too.

Self-care

Your doctor will give you a prescription for pain medicines. Get it filled when you go home so you have it when you need it. Take your pain medicine when you start having pain. Waiting too long to take it will allow your pain to get more severe than it should.

In the early part of your recovery, taking pain medicine about 30 minutes before you increase your activity can help control pain.

You may be asked to wear special “compression” stockings on your legs for about 6 weeks. These will help prevent blood clots from forming. You may also need to take blood thinners for 2 to 4 weeks to lower your risk of blood clots. Take all your medicines the way your doctor or nurse told you to.

Your doctor will tell you when it is okay to start sexual activity again.

People who have a prosthesis, such as an artificial joint, need to carefully protect themselves against infection. You should carry a medical identification card in your wallet that says you have a prosthesis. You will need to take antibiotics before any dental work or invasive medical procedures. Check with your doctor and make sure you tell your dentist that you had a hip replacement and need antibiotics before any dental work.

When to Call Your Doctor

Call your doctor if you have:

  • A sudden increase in pain

  • Chest pain or shortness of breath

  • Frequent urination or burning when you urinate

  • Redness or increasing pain around your incision

  • Drainage from your incision

  • Blood in your stools, or your stools turn dark

  • Swelling in one of your legs (it will be red and warmer than the other leg)

  • Pain in your calf

  • Fever greater than 101°F

  • Pain that is not controlled by your pain medicines

  • Nosebleeds or blood in your urine or stools if you are taking blood thinners

Also call your doctor if you:

  • Cannot move your hip as much as you could before

  • Fall or hurt your leg on the side that had surgery

What are the results of the surgery?

Hip replacement surgery is successful more than 90 percent of the time.

Expect your new hip joint to reduce the pain you felt before your surgery and increase the range of motion in your joint. But don't expect to do anything you couldn't do before surgery. High-impact activities — such as running or playing basketball — may never get your doctor's approval. But in time, you may be able to swim, play golf, walk or ride a bike comfortably.

What are the complications?

The most common problem that may happen soon after hip replacement surgery is hip dislocation. Because the artificial ball and socket are smaller than the normal ones, the ball can become dislodged from the socket if the hip is placed in certain positions. The most dangerous position usually is pulling the knees up to the chest.

The most common later complication of hip replacement surgery is an inflammatory reaction to tiny particles that gradually wear off of the artificial joint surfaces and are absorbed by the surrounding tissues. The inflammation may trigger the action of special cells that eat away some of the bone, causing the implant to loosen. To treat this complication, the doctor may use anti-inflammatory medications or recommend revision surgery (replacement of an artificial joint).

Less common complications of hip replacement surgery include infection, blood clots, and heterotopic bone formation (bone growth beyond the normal edges of bone).

Cost of Surgery?

The cost of surgery for Hip Replacement depends on many factors. They include the cost of being in the hospital for several days. Unexpected events that result in an extended hospital stay will also increase the overall cost.

Costs also vary depending on the type of insurance coverage you have. Many insurance companies cover the cost of the surgery, the hospital stay, and the instruments to straighten the spine. You may owe a co-payment or you may be billed the balance of what your insurance does not cover.

Be sure to contact your insurance provider prior to surgery to discuss the extent of your coverage. Discuss with your surgeon, as well as the hospital billing department to make sure you understand all the costs involved.

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