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Hip replacement

A hip replacement involves replacing your hip joint with an artificial version. The hip jointis a ball and socket joint. A hip replacement provides a long-term solution for worn or damaged hip joints, which can cause severe pain and loss of mobility.
Brought to you by NHS Choices

Introduction

At least 50,000 total hip replacements a year are carried out in Britain.

The operation replaces both the natural socket (the acetabulum) and the rounded ball at the head of the thigh-bone (the femoral head) with artificial parts. These parts replicate the natural motion of the hip joint.

Hip resurfacing

Total hip replacement surgery is usually very successful, but it can be invasive and require a lengthy recovery period. An alternative method, known as metal-on-metal hip resurfacing, involves replacing the diseased or damaged surfaces in the hip joint with metal plating, which requires less prosthetics and less bone removal.

Hip resurfacing can be considered for people with advanced hip disease. Resurfacing is likely to last longer than a conventional replacement joint. Because the technique is still relatively new, it is not known precisely how long the resurfacing will last.

All types of hip replacement surgery are beneficial, offering an end to joint pain, increased mobility and a better quality of life.

Do I need a hip replacement?

Only you can make this decision. Your overall health and activity level are more important than your age in predicting success. You may want to consider the following:

  • Is the pain so severe that it’s interfering with your quality of life, including sleep?
  • Have medications and other treatments not worked or do they cause severe side effects?
  • Are everyday tasks difficult or impossible?
  • Are you feeling depressed as a result of pain and lack of mobility?
  • Are you unable to work or have a normal social life?

Why it should be done

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

  • osteoarthritis - this is the most common form of arthritis and 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 is a form of arthritis that occurs when the joint becomes infected,
  • fracture of the neck of the thigh bone (femur) - this causes a loss of blood supply to the rounded head of the bone and may also lead to crumbling (avascular necrosis),
  • Paget’s disease of bone - this affects bone growth and can make bones weak and deformed,
  • bone tumours, and
  • other joint injuries.

Hip replacements are also sometimes required:

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

Alternatives to surgery

There are no surgical alternatives to hip replacement, but a variety of medications may help:

  • Painkillers - these include non-steroidal anti-inflammatory drugs (NSAIDs), if your hip joint is also inflamed.
  • Steroid injections - these can help in some cases, although their results are unpredictable in the hip so not really recommended.
  • Pain-relieving creams, gels and rubs, available over the counter or on prescription. It’s not known how these compare with more conventional ways of taking painkillers.
  • Disease-modifying medications - these drugs alter the working of the immune system to block the underlying processes involved in certain forms of inflammatory arthritis.

Preparing for the operation 

I’ve been asked to give consent for my details to be recorded on the National Joint Registry. What is this?

The National Joint Registry (NJR) collects details of hip replacements carried out in England and Wales. Although voluntary, this is worth doing as it enables the NJR to link you to the implant(s) you received during surgery so that if a problem with a specific implant comes up in future you can be identified. It also gives you the chance to participate in a patient feedback survey and to express your views on whether the hip replacement has improved your quality of life. All your details are kept confidential and you have a right under the Freedom of Information Act to see what details are kept about you.

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 a medical history, examine you and organise any tests needed, to make sure you are healthy enough for an anaesthetic and surgery. 

They 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 the packaging 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 on alternative medications.

Make use of this opportunity to ask any questions you have.   

How can I prepare for the operation?
Stay as active as you can. Strengthening the muscles around your hip will aid in your recovery. You may be referred to a physiotherapist, who can give you helpful exercises. If you’re able, keep up any gentle exercise, such as walking and swimming, in the weeks and months before your operation.

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

  • Put one foot on the second stair or a kitchen stool (hold on to the banister or other 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 your legs alternately up on to your chest, keeping the other leg flat down on the bed. (Note: this should only be done 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.

When will I go into hospital and what will happen?
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.

How can I prepare for my hospital 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. Line up a friend or relative to help you at home for a week or two after coming home from hospital.
  • Sort out transport. Arrange for someone to take you to and from the hospital – either a friend or relative or a taxi.
  • Prepare your home. Before you go for your operation put your TV remote control, radio, telephone, medications, tissues, address book and glass on a table next to where you will spend most of your time when you come out of hospital. 
  • Stock up. Get in a stock of 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 good long bath or shower, cut your nails – don’t forget to take 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.

How is it performed?

You will either receive a general anaesthetic, in which case you will be asleep, or a spinal (epidural) anaesthetic, which means you’ll be awake but will lose feeling from the waist down.

Once anaesthetised, the surgeon removes the existing hip joint completely. The upper part of the femur (thigh bone) is removed and the natural hollow for the head of the femur (the acetabulum) is hollowed out. A plastic 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 for hip replacements

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 material (which has many tiny holes) that 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 a ceramic head.

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


How can I decide what kind of hip replacement to have?

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

NICE recommends only those 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. For more information visit the NICE website.

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

What should I be looking for in a specialist?

The key is to choose a specialist who performs hip replacements on a regular basis and can discuss their results with you. This is even more important if you are  having 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 as an individual.

Risks of surgery

The most common problem that can arise as a result of a hip replacement is loosening of the joint, which usually occurs 10-15 years after surgery. This can be caused by the shaft of the prosthesis becoming loose or dislocated in the hollow of the thigh bone, or due to thinning of the bone around the implant. Another operation (revision surgery) is necessary in around 10% of all total hip replacement cases.

Another common complication of hip replacement surgery is caused by the wear and tear of plastic 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, but otherwise further surgery may be advised.

Less common complications resulting from a hip replacement are:

  • 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 around 10% of 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).

As it is a relatively new technique, little information is available about the long term safety and reliability of hip resurfacing. If hip resurfacing is recommended, your surgeon will explain any associated risks and benefits with you before the procedure is carried out.

Recovering from hip replacement

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 around an hour after your return to the ward and you’ll 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. One to two days after surgery you may be able to sit on the edge of the bed, stand, and even walk with help. 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 to 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 shouldn’t be done after the operation. They will teach you how to bend and sit so as to avoid damaging your new hip.

When can I go home?

You will usually be in hospital for around six to 10 days. 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?

Don’t 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 might be other aids that can help you. You may want to arrange to have someone to help you out for a week or so.

An occupational therapist should be available to you. They will assess how physically capable you are. When you are about to leave hospital they will assess your circumstances at home. They 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 might include things like a raised toilet seat and things to help you dress. 

How soon will the pain go away?

The pain that you may have previously been experiencing should go immediately, although you can expect to have a different form of pain from the operation, but this is temporary.

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

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

Will I have to go back to the hospital?

You will be given an outpatient appointment to check up on your progress – usually six to 12 weeks after your hip replacement. The surgeon will want to see you a year later to check everything is OK and five yearly 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 discard 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’s 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.

When can I drive again?

It depends, but usually after about six weeks. Your surgeon can advise. It can be tricky getting in and out of your car at first. It’s best to ease yourself in backwards and swing both legs round together.

When can I go back to work?

It depends on your job but usually between six 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 but as a rule of thumb, so long as you are careful, it should be fine after six to eight weeks. You should avoid vigorous sex and more extreme positions.

Will I need another new hip?

These days eight out of 10 hips last for 20 years or more, so if you are older, with a bit of luck your new hip may well last your lifetime. If you are younger you may need another new hip at some point.

Revision surgery, as it is known, is more complicated and time-consuming for the surgeon to perform than a first hip replacement and complication rates tend to be higher. The good news is that these days it is much more successful than it used to be and eight out of 10 people report success for 10 years or more.

The hip can be replaced as often as necessary, although results tend to be slightly less effective each time.

If you do have to have another new hip you may need a bone graft. This is where a piece of bone is taken from another part of your body such as your thigh bone. Recovery may take longer but once you have recovered, the results are usually good.

How can I look after my new hip?

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

  • Avoid bending your hip more than 90° (i.e. a right angle), during any activity.
  • Avoid twisting your hip.
  • Do not swivel on the ball of your foot.
  • When turning around, take small steps.
  • Avoid pressure on the wound in the early stages, e.g. 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 chairs and toilet seats.

Future prospects

There are several ways in which hip replacement surgery is being improved for the future. New stronger plastics for prosthetics are in development that will allow longer wear and better joint mobility, and enhancements are being made to resurfacing and new ‘cementless’ implants. Younger patients can be recommended newer types of joints such as ceramic on ceramic and ceramic on plastic.

In addition to this, a new kind of minimally invasive surgery (MIS) is sometimes used in order to reduce the size of the surgical incision. This can be enhanced still further by computer-assisted surgery (CAS), which generates an image of the hip joint to allow greater visibility and precision.