Hip Replacement

Hip replacement surgery, also known as hip arthroplasty, is a surgical procedure that involves removing damaged or worn-out parts of the hip joint and replacing them with parts made of metal, ceramic, and very hard plastic.

This surgery aims to relieve pain, improve mobility, restore function, and help people carry out daily activities and do the things they enjoy.

Hip replacement is generally recommended for people experiencing significant pain and loss of mobility because of hip arthritis, hip fractures, or other severe joint disorders that do not respond to more conservative treatments.

In the United States, there are an estimated 450,000 total hip replacement surgeries performed each year, a number that is expected to grow as the population ages.

The hip is one of the body’s largest joints, and it’s a ball-and-socket joint. The socket is formed by the acetabulum, a part of the pelvis. The ball is the femoral head, which is the upper end of the femur, or thigh bone.

The most common reasons people undergo hip replacement surgery include:

• Osteoarthritis This age-related “wear and tear” type of arthritis usually occurs in people age 50 and older. The cartilage that cushions the bones of the hip wears away, causing the bones to rub against each other.
• Rheumatoid Arthritis This autoimmune condition causes inflammation in the joints that can damage cartilage.
• Posttraumatic Arthritis A serious hip injury or fracture can cause damage to the cartilage.
• Osteonecrosis (Also Called Avascular Necrosis) An injury to the hip may disrupt the blood supply to the femoral head, leading to bone death and joint collapse.
• Childhood Hip Disease Some people are born with hip problems or have them as children. Even if the issue is successfully treated at the time, it may still cause arthritis later in life, because the hip may not grow normally, affecting the joint.

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There are several factors that go into the medical decision on whether a person needs a hip replacement, says Nathan Mesko, MD, the section head of orthopedic oncology and trauma at Cleveland Clinic in Ohio.

• Symptoms The most common symptoms leading to hip replacement include groin pain or pain in the front of the thigh that can radiate to the knee.
• Imaging Changes X-rays, CT scans, or MRIs that show clear arthritic changes factor into the decision to do the surgery.
• Lifestyle and Quality of Life A person’s lifestyle, including what they are giving up because of their symptoms and what they would like to get back to, influence the decision about whether to have a hip replacement, says Dr. Mesko.
• Previous Treatments Nonsurgical treatments such as anti-inflammatory drugs, physical therapy, activity modifications, and injections are usually tried before surgery is considered.

“Every case is unique, and sometimes it may make sense to move into a more surgically based discussion immediately based on severity and intensity of symptoms, advanced imaging changes, and minimal hope that nonsurgical measures will provide meaningful relief,” Mesko says.

During hip replacement surgery, the damaged bone and cartilage is removed and replaced with a prosthetic implant.

There are two main types of hip replacement surgery:

• Total Hip Replacement In total hip replacement, the whole hip — both the femoral head (the ball) and the acetabulum (the socket) — are replaced. Almost all hip replacements are total hip replacements.
• Partial Hip Replacement Very rarely, only part of the hip needs to be replaced. This is usually recommended for specific types of hip fractures or to remove certain types of tumors.

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To access the joint, the surgeon will begin by making an incision, either in the front, the back, or the side of the hip. These approaches are called anterior, posterior, and lateral, respectively.

“The outcome of the surgery is generally the same regardless of the approach used. What matters most is the surgeon’s experience and expertise. You want a surgeon who performs hip replacements regularly and has mastered their technique,” says Mesko.

In simultaneous bilateral total hip replacement, both hip joints are replaced during a single surgery. This is used for people with pain or loss of function in both hips because of arthritis, childhood hip disorders, or other hip-related bone diseases.

There are benefits to the surgery if a person needs both hips replaced, including having one surgery rather than two, less expense (compared with two surgeries), and one round of rehab instead of two.

But having both hips replaced at once is associated with a longer exposure to anesthesia, more blood loss, and a higher risk of complications such as blood clots.

Take steps to prepare yourself and your environment before surgery to ensure a smooth procedure and recovery. Mesko recommends "doing your homework," and if you have any concerns or questions, make sure to have a discussion with your provider.

He also offers the following tips to set yourself up for a successful hip replacement:

• Stop smoking. Smoking can hinder wound healing and increase the risk of complications.
• Work on your core strength. Ask your provider for recommendations on how to safely improve your core strength through exercises such as modified planks or bridges.
• Control any chronic conditions. If you have diabetes or other chronic conditions, make sure they are well managed before undergoing surgery. A target A1C of less than 8.0 is typically recommended for people with diabetes before surgery. Working to achieve a healthy weight before surgery can also make recovery easier.
• Visit the dentist. Take care of all outstanding dental work before surgery.
• Make sure any existing wounds are healed. If you have any open wounds, cuts, or sores, these should all be healed prior to an elective total joint replacement.
• Prepare your home for the recovery period. Preparing your home for recovery is essential. Ensure that there are no tripping hazards. If possible, rearrange your home so you can stay on a single level (no climbing or descending stairs) for one to two weeks after surgery to give yourself a chance to recover and adapt.

Hip replacement procedures are typically performed in a hospital or specialized surgery center. To make sure you don’t feel any pain, you’ll get a spinal block, which numbs you from the waist down, or general anesthetic, which induces a sleeplike state.

The surgery is usually completed within two hours.

The steps of a hip replacement are as follows:

• An incision is made over the hip.
• Diseased and damaged bone and cartilage are removed, and any healthy bone is left intact.
• The replacement socket is implanted into the pelvic bone.
• A metal stem is inserted into the top of the thigh bone, which is then topped with a replacement ball.
• The new ball is inserted into the new socket.
• The surgeon closes the incisions with stitches or clips and covers them with a bandage.

As with any surgery, there are risks associated with hip replacement. Although complications are rare, these are some of them.

Infection Infection can occur at the surgical site or deeper within the joint. It is typically treated with antibiotics, but in some cases, additional surgery may be needed.

Blood Clots Deep vein thrombosis (DVT) can develop in the legs after surgery, posing a risk if the clot moves to the lungs (pulmonary embolism).

Fracture Healthy parts of the hip joint can fracture during surgery. Sometimes the fractures are small and can heal on their own, but larger fractures might need to be stabilized with wires, screws, a metal plate, or bone grafts.

Dislocation The new hip joint can occasionally become dislocated, especially in the first few months after surgery.

Implant Problems Over time, the implant may wear down or loosen, requiring revision surgery.

“With advancements in surgical techniques and materials, the risk of complications is generally low. However, it’s important to follow all postoperative care instructions and attend regular follow-up appointments to monitor for any issues,” says Mesko.

There is pain after surgery, but most people start to feel better quickly. A walker, cane, or crutches may be needed for one or two weeks after the surgery, but recovery is typically fast.

Care during your initial recovery period generally includes:

Postoperative Monitoring You will be monitored for signs of infection, blood clots, and proper healing. Moving with the help of crutches or a walker is encouraged. Applying pressure to the legs by wearing compression stockings or inflatable air sleeves and taking blood-thinning medications may be recommended to help prevent blood clots.

Wound Care The stitches or staples used to close the incision will be removed after about two weeks. The incision takes about six weeks to heal. It’s okay to shower during this time, but swimming and bathing should be avoided until it’s completely healed.

Pain Management Your doctor will prescribe pain medications to help you manage discomfort. Nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen (Tylenol), or opioids may be used, depending on your needs.

A combination of medications may be used for pain relief as well as to minimize the need for opioids — they are narcotics and can be addictive. In some cases, a series of regional blocks using local anesthetics may be used.

Icing the leg and the incision site, and keeping the leg elevated above the heart when you lie down can help with pain and swelling.

Follow-Up Appointments You will need to see your provider in the days or weeks following surgery to check for proper healing and assess the function of the new hip joint.

You may need to use a cane, crutches, or a walker for a week or two after surgery, but recovery is relatively fast. In about three to six weeks, most people can resume the light activities of daily living such as sitting, standing, and climbing stairs.

In recent years, technological advancements such as robotic-assisted surgery and the use of artificial intelligence during the procedure have enhanced the precision of the surgery, improving both the accuracy of the procedure and the recovery process.

While complications like infection, dislocation, or nerve injury can occur, these are typically rare, especially when performed by an experienced surgeon, he says.

To ensure the best possible outcome after hip replacement surgery, Mesko recommends the following.

Pre-Surgery Strengthening Focus on improving core strength and hip muscle strength through exercises like bridges and planks.

Post-Surgery Physical Therapy Adhere to your prescribed physical therapy regimen to help regain mobility and strength in the hip.

Weight Management If you are overweight, losing weight can reduce the stress on the new hip joint and improve your recovery.

Support System Arrange for help at home during the recovery period, as you will need assistance with daily tasks in the early weeks.

The Takeaway

• Hip replacement surgery is highly effective for people with severe hip pain and mobility loss due to conditions like arthritis or fractures, with a success rate of over 90 percent.
• Preparation for surgery is key to a smooth recovery, and includes preoperative testing, physical therapy, managing chronic conditions, and preparing your home for post-surgery care.
• Most people who engage in physical therapy can expect to regain mobility and return to low-impact activities like walking within a few weeks.
• Follow postoperative care instructions and attend follow-up appointments to improve outcomes and help prevent complications.