In this Article
What Is A Hip Replacement?
A hip replacement is a surgical procedure that replaces the painful hip joint with an artificial hip joint.
In a hip replacement, the head of the femur (the bone that extends from the hip to the knee) is removed along with the surface layer of the socket in which it rests (called the acetabulum).
- The head of the femur, which is situated within the pelvis socket, is replaced with a metal ball and stem. This stem fits into the shaft of the femur.
- The socket is replaced with a plastic or a metal and plastic cup.
For nearly a century, doctors have been putting various materials into diseased and painful hip joints to relieve pain. Up until the 1960s, outcomes had been unreliable. At that time, the metal ball and plastic socket for the replacement of the hip joint was introduced. Today, the artificial components used in a hip replacement are stronger and more designs are available.
There are many different shapes, sizes, and designs of artificial components of the hip joint. For the most part these are composed of chrome, cobalt, titanium, or ceramic materials. Some surgeons are also using custom-made components to improve the fit in the femur.
The “Normal” Hip
The hip is a ball-and-socket joint comprised of the following structures:
- Head of the femur
Acetabulumof the pelvis
- Ligaments of the hip joint
The head of the femur or “ball” of the hip joint articulates or moves within the cup-like “socket” called the acetabulum of the pelvic bone. Together, these structures are referred to as a “ball and socket” joint. The femoral head and acetabulum are covered by a specialized surface called
When Is A Hip Replacement Needed?
Hip replacement can benefit individuals suffering from a variety of hip problems resulting from either wear and tear from a lifetime of activity or from disease and injury. Some of the common hip problems leading to a hip replacement are:
- Rheumatoid arthritis
- Traumatic arthritis
- Avascular necrosis
- Other reasons
Osteoarthritis refers to wear and tear of a joint from oversuse or from aging or from previous injury to the joint. The cartilage surface that normally covers and cushions the ends of the femur and the lining of the acetabulum, begins to wear thin causing the hip bone to rub against the socket. This results the erosion and misshaping of bone tissue. When the hip joint deteriorates, as a result either of arthritis or injury, the resulting pain, stiffness, and limitation of motion can be oppressive.
Early symptoms of osteoarthritis may be controlled through medication and exercise. However, when pain becomes so severe that the individual can no longer be helped with medication and when activities of daily living are significantly reduced, hip replacement surgery may be the next step.
Rheumatoid arthritis is a chronic,
When a severe fracture of the hip occurs that cannot be reconstructed then a hip replacement will be offered
Avascular necrosis is the result of a loss of blood supply to the ball or head of the femur bone. As a result, articular cartilage wears away leaving a “bone on bone” interaction for hip joint movement.
Other abnormalities of the hip joint that could result in a need for a hip replacement include:
- Paget’s disease occurs mainly in the elderly. Bones become enlarged and weakened, with the potential of a fracture or deformity of the hip bones
Malignant bonetumors of the femur, and sometimes benign tumors, may necessitate removal of the part of the femur resulting in the need for a hip replacecment. can alter the shape and congruency of the joint and also disrupt blood supply of the joint, affecting articular cartilage
How Is The Diagnosis Made For The Need For A Hip Replacement?
A complete history and physical examination allows the physician to determine any correlation between symptoms of pain with past history and demands that have been placed upon the hip. The physician will inquire about experiencing episodes of trauma or instability, and examine the ligaments and hip alignment.
X-rays are used to determine the extent of degeneration to the cartilage or bone and may suggest a cause for the degeneration of the hip joint.
Blood tests and
How Do I Prepare For A Hip Replacement?
Preparing for a total hip replacement often begins several weeks prior to the actual surgery. Emphasis is placed upon the individual maintaining good physical health before the operation. Upper body strength becomes important for the ability to use a walker or crutches after the operation.
Before surgery the person will be scheduled for an appointment for preadmission testing usually consisting of:
- Blood work/Urine test– A blood transfusion is often necessary after hip surgery. One option is autotransfusion after surgery. In this case, the person may wish to donate several pints of blood prior to surgery. In the event that blood transfusion is needed, the individual will receive his or her own blood. This is called autologous blood donation. The first donation must be given within 42 days of the surgery and the last no less than seven days before surgery.
When donating blood, the individual must be healthy, without a cold, flu or infection. This is to reduce the chances of the person becoming ill with the same illness when the blood is transfused at the time of surgery.
Various other tests such as a complete blood count may be used with the blood work to finalize the “all clear” for surgery. The physician may order blood tests and urinalysis two weeks before surgery to make sure that a urinary tract infection is not present. Urinary tract infections are common, especially in older women, and often go undetected.
- EKG– Provides information regarding the condition of the heart for surgery.
- Chest x-ray – Provides information about the respiratory status of the individual.
- Anesthesia consult– An anesthesiologist (a medical doctor specializing in anesthesia) explains what types and options of anesthesia are available for hip surgery. The anesthesiologist will also advise about taking routine medications on the day of surgery.
- Assessment by a member of the nursing staff– The nurse meets with the individual to explain and describe nursing care prior to and after the surgery.
- Assessment by a social worker– The social worker assesses the needs of the patient regarding special equipment and /or services needed upon discharge and will provide a list of community resources available to meet these needs once the patient is discharged from the hospital. A social worker is also available to plan an extended period of recovery within the hospital if necessary.
- Assessment by a physical therapist and an occupational therapist– These two members of the rehabilitative team provide preoperative education to help prepare for the surgery. The physical and occupational therapists can assist with preoperative programs which may include exercises as well as arranging for special equipment such as walkers, canes, and reaching aides that may be needed after surgery.
- Other preparations– Some individuals may be asked to have a dental checkup if they have not had one recently. Addressing dental problems before hip replacement can prevent infections that might affect the new joint. The person undergoing surgery for total hip replacement will be given specific instructions regarding eating and drinking before surgery from the anesthesia department. The physician, anesthesiologist, and nursing staff will need a list of all prescription and non-prescription medications being taken. At the discretion of the surgeon, aspirin or aspirin-containing medications may be discontinued two weeks prior to surgery
How Is A Hip Replacement Procedure Done?
During surgery, once the hip joint is exposed, the head and neck of the femur are removed. The shaft of the femur is then reamed to accept the metal component consisting of the head, neck, and stem. The acetabulum is then reamed to accept a plastic cup. The ball and socket are then replaced into normal position. Both of these implants can be fastened into the bone with or without special cement.
- Cemented procedure. The cemented procedure utilizes a doughy substance mixed at the time of surgery that is introduced between the artificial component and the bone. This type of fixation in total hips remains the gold standard and is the method of choice for many surgeons. Depending upon their health and bone density, people over the age of 60 will receive this type of joint fixation.
- Noncemented procedure. Despite its common use, not all individuals are candidates for a cemented hip. Studies show that young active adults tend to loosen their artificial components prematurely. The current trend therefore, is to use an artificial joint covered with a material that allows bone tissue to grow into the metal. A tight bond of scar tissue if formed, which anchors the metal to the bone. This is called a cementless total hip replacement.
This type surgery is technically more sensitive, requiring a more exact fit of the metal component to the femur. In this procedure, the surface of the metal is prepared with a small porous roughened coat, which attracts bone in growth. This process is called porous ingrowth or oseointegration.
In general, the artificial joint implants used in the non-cemented procedure are larger than those used with cement but are still proportional to the size of the individual bone. Since their introduction, many different devices using cementless fixation have been used with the hope that these implants will maintain their attachment to bone for a longer period of time.
Other Types Of Hip Replacement Procedures
There are other types of hip replacement procedures:
- Hybrid fixation refers to a procedure in which one component (usually the socket) is inserted without cement, and one component (usually the stem for the ball of the femur) is inserted with cement.
- Hemi-surface replacement for
osteonecrosis. This is one option the surgeon will utilize to minimize tissue reaction. It involves replacing only the diseased part of the joint. A hemi-surface replacement is often recommended for people who have avascular necrosisand have some remaining articular cartilageon the acetabulum. The hemi-surface replacement preserves and maintains bone by providing stress transfer to the femoral neck and upper femur. It can also help avoid inflammatory reaction and joint loosening.
- Surface replacement of the hip. If the surgeon chooses to do a surface replacement procedure, the neck of the femur is preserved rather than amputated as in conventional stem-type total hip replacement. The femoral head is then reshaped and resurfaced with an artificial or prosthetic shell. When this procedure is used, the femur accepts more of the load (as a normal hip does) and thereby preserves bone. Since the resurfaced head is very similar in size to the normal hip, it proves to be more stable and risk of dislocation is greatly minimized.
What Are The Risks And Complications of a Hip Replacement?
As with all major surgical procedures, complications can occur. Some of the most common complications following hip replacement are:
- Deep venous thrombosis (DVT)
DVT can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. Thrombosis occurs when the blood in a large blood vessel of the leg or pelvis forms blood clots; in DVT it is within the veins.
DVT may cause the leg to:
- Become warm to the touch
- Become painful
Surgeons take DVT prevention very seriously. Some of the commonly used preventative measures include:
- Encouraging activity as soon as possible
- Pressure stockings to keep the blood in the legs moving
- Medications that thin the blood and prevent blood clots from forming
For further information about deep vein thrombosis, go to Deep Vein Thrombosis.
The chance of getting an infection following hip replacement is less than 1%. Superficial infections involving the surgical incision are easily treated with antibiotics. More serious infections can result from bacteria invading the bone in the presence of metal and cement.
Infection can be serious enough to cause the artificial implant to loosen. Some infections may show up very early, even before the discharge from the hospital. Others may not become apparent for months, or even years, after the operation.
Infection can spread into the artificial joint from other infected areas.
Your surgeon may want to make sure that you take antibiotics when you have surgical procedures on your bladder and colon to reduce the risk of spreading germs to the joint. This precaution includes any dental work as mentioned earlier.
Dislocation has a low incidence of approximately 3%. This can be the result of the individual not being compliant with postoperative restrictions. Dislocation can also result from muscle imbalance and tightness around the hip joint.
In the cemented hip, a major reason why artificial joints eventually fail is the result of loosening where the metal or cement meets the bone. In the case of the non-cemented joint, the bone itself fails to attach itself properly to the surface of the implant. In either case, loosening of the joint implants will often lead to a total hip revision.
Since there are no ligaments to hold the components of the new hip together, a person must be careful in the first few weeks following surgery to avoid positions that could dislocate the hip. However, with time, the body will make enough scar tissue to stabilize the new hip replacement
Hip Replacement: What Can I Expect During Recovery?
Postoperative care begins with a team of heath professionals within the hospital. Those closely involved with the postoperative total hip patient are:
- Respiratory Therapists
- Physical Therapists
- Occupational Therapists
After surgery, vital signs and sensation in the lower extremities are observed and checked by the nursing staff and documented for the physician. Antibiotics are frequently administered every eight hours, for two to three days, to reduce the risk of infection.
The surgical incision is observed closely for:
- Excessive drainage
- Proper initial healing
- The need for changing of sterile dressings
The respiratory therapist is vital at this stage for:
- Instruction in coughing and deep breathing exercises to help prevent complications, such as congestion or pneumonia.
- Instruction in the use of a bedside device called an incentive spirometer to assist in deep breathing exercises. Use of this device and deep breathing exercises are important in minimizing the risk of lung complications by removing excess secretions that may settle in the lungs during surgery.
Shortly after surgery the physical therapist addresses:
- Circulation – The acute care physical therapist in the hospital instructs the patient in early stage exercises such as moving the ankles up and down to promote circulation and prevent clots.
- Range of motion – The physical therapist will instruct the patient to perform exercises to improve upon hip range of motion.
- Mild strengthening – Following surgery, the total hip patient will work with the hospital physical therapist to improve range of motion to the hip as well as initiate muscle strengthening. This will progress the patient into becoming independent in walking, going up and down stairs, getting in and out of bed, and doing exercises to improve the range of motion and strength of the hip. This initial rehabilitation generally takes 5-7 days. During this time, patients may experience discomfort may be experienced while walking and exercising. To address this problem, pain medication will be ordered by the doctor as needed.
- Gait training – The physical therapist assists the patient in walking short distances using crutches or a walker. This not only promotes range of motion and strength but is also important for endurance and stamina. Weight bearing will depend on the nature of the implant fixation. If cement was used on both the socket and the
femurside, weight bearing as tolerated using a walker will be instituted. If the joint is cementless, weight restrictions will be recommended for 4 to 6 weeks. It is critical for patients to adhere to the weight bearing status given to them following surgery.
The occupational therapist is involved in evaluating and addressing how independently and safely the patient functions in activities of daily living such as dressing, bathing, and caring for his or herself following hip surgery. Issues such as how safely and independently the patient is able care for himself is evaluated. The occupational therapist teaches patients how to use equipment that prevents excessive bending of the new hip.
Precautions After Hip Replacement Surgery
General rules of total hip replacement that the patient needs to follow are:
- In the first six to eight weeks after the operation, the individual receiving a total hip needs to avoid bending the hip beyond 90 degrees. This can be achieved by keeping knees below the hips when sitting. Sitting on a small pillow can help with this positioning. Avoiding sitting in sofas or couches which may cause excessive bend at the hip.
- Avoid bending over from the hip to reach the floor.
- Avoid crossing the surgical leg over the non-surgical leg. When sitting, it is good advice to keep the legs three to six inches apart.
- Avoid turning the operated leg inward, i.e. pigeon-toed.
Going Home After A Hip Replacement
In general, most individuals after hip surgery are discharged after 4 to 10 days providing there are no complications and particularly if there are family members to assist with daily activities. In some cases, the social service department at the hospital will find a temporary nursing home or intermediate stay facility until returning home is a viable option.
Once discharged from the hospital, a nurse, physical therapist, and an occupational therapist will likely see the person for in home treatment. This is to ensure that the newly discharged individual is safe in and about his or her home. The number of home health care visits ranges from one to several. These are carried out for safety checks and reviews of the exercise program. In some cases, up to three visits home care visits before individuals can begin outpatient physical therapy. In other cases, the individual may be functioning adequately and may not require outpatient therapy.
The home exercise program for hip replacement is often similar to the regimen used in the hospital. It will progress with resistance and repetitions of strengthening exercises and increased distance and independence of ambulating. The individual continues to adhere closely to the weight bearing status assigned following surgery.
The occupational therapist involved in the home health care of the postoperative hip patient closely examines how safely and independently the patient is able to dress, bathe, and care for his or herself within the home environment. The occupational therapist can also determine the need for home medical devices such as elevated commodes and long arm instruments that help reach to the floor or apply socks.
Outpatient Physical Therapy
Once the postoperative hip patient is no longer homebound, most medical insurance plans will not cover home health care. If additional rehabilitation is needed, a new evaluation is generally conducted at an outpatient physical therapy facility.
In an outpatient physical therapy clinic the physical therapist may use the following methods of treatment to help reduce persistent swelling or pain and promote mobility:
- Thermotherapy or cryotherapy (use of heat or ice)
Electrical stimulation Ultrasound
- Soft tissue mobilization
- Joint mobilization
Progression Of Ambulating And Exercise
Continued use of a walker or crutches is commonplace for the individual progressing to the outpatient setting. However, the goal is generally to progress each person with hip replacement to ambulating without an assistive device when possible.
Once initial hip precautions are no longer a concern, increasing the postoperative individual’s endurance can be addressed through walking, swimming, bicycling, and upper body exercises. The physical therapist will select a group of exercises that can be used to simulate day-to-day activities, like going up and down steps and raising up on the toes. Once the goals have been met in an outpatient setting regarding range of motion, strength, endurance, and ambulating, the person is ready for discharge with an independent program or possible exercising at a fitness center.
What Can I Expect After A Hip Replacement?
New technology involving the implants for artificial hip replacement and advances in surgical techniques has improved the immediate and long-term outcome of the surgery. Generally today’s artificial hips can last a lifetime. However, if the person is very young, the plastic can wear out. Fortunately, with the new socket implants for the pelvis, the socket can be changed without removing the other portions of the hip joint.
The person with a hip replacement may be able to take part in physical activities that were impossible before surgery.
Some additional tips and precautions for recreational activities include the following:
- Stress from rotation on the lead leg and hip in golf may be minimized by use of a smooth spikeless shoe.
- Because bicycling introduces risk factors related to the resistance (such as from uphill inclines), avoid heavy pedaling when riding.
- Although skiing on smooth groomed slopes in proper light is relatively safe, falls can have serious effects.
- The surgeon will review x-rays and scans and can advise about current risk factors that may affect the life of the implant.
Your Future Activities
Most individuals following hip replacement surgery are able to return to work within a month or two of surgery. Yet, some individuals that are exposed to work requiring a great deal of repetitive climbing or crawling, may find it necessary to change jobs. Overall, many find that the activities that were once painful such as climbing up and down stairs, sitting for extended periods of time, and getting in and out of cars can now be performed with less pain.
What If The Hip Replacement Fails?
Loosening of the implant is the most frequent cause of failure of a total hip replacement. If that happens, revision surgery may be needed.
The extent of a revision surgery depends on the complexity of artificial implant removal along with restoration of bone. Revision of a surface replacement is likely to be less involved because the intact
Are There Alternatives To Hip Replacement?
Each individual contemplating hip replacement should review alternativdes with his or her physician to determine possible options. Some alternatives to hip replacement include:
Often pain can be controlled with medication adequately enough to provide comfort with the person’s present activity level i.e. the person can still comfortably manage their day to day activities or manage at work. If this is the situation, then the decision to delay is the best option.
Appropriate exercises to strengthen the hip and knee joint muscles may be helpful enough to reduce the pain and allow surgery to be delayed. But eventually, the person will likely come to surgery
Supplements have become common these days in an attempt to reduce the joint pain. Some people say there pain is greatly helped; others say they find no benefit. Popular supplements include glucoseamine, chondroitin and omega 3 fatty acids. Science does not really support their use as a formal treatment for hip pain.
These are experimental. Some find these helpful others not at all. They include hyaluronic acid, platelet-rich plasma, or stem cells. These particular injections are however mostly offered for osteoarthritis of the knee not the hip. Steroid injections into joints with painful arthritis are common amongst some doctors but one cautions against these injections as, while they do reduce inflammation and so may reduce the pain, the do weaken the cartilage and therefore actually make the condition worse. Therefore, they should not be offered in early to mid stages of arthritis, and infrequently in later stages.
These are operations that were performend before hip replacement was popularized and are essentially no longer offered unless special circumstances require these procedures. A femoral osteotomy realigns the femur which affects the fit of the head into the socket and so may alleviate the pain. It is not anything as successful as a hip replacement in terms of eliminating the pain. An arthrodesis relieves the pain by fusing the hip joint. Therefore the hip joint can no longer move. Most patients prefer to avoid this situation but it is very successful in resolving the hip pain.
Hip Replacement: Frequently Asked Questions
Here are some frequently asked questions related to hip replacement:
Q: If I decide to have a total hip replacement, how many years will it last?
A: New materials used in total hip replacement are very durable and are expected to last greater than ten years in 90% of individuals receiving total hips. The chance of hip replacement lasting 20 years is 80%.
Q: How soon following total hip replacement should I be able to progress to walking independently?
A: The speed with which a person is able to abandon the use of crutches, a walker or cane varies from individual to individual and with the type of artificial implant used. The majority of people require only a cane after six weeks, although others may need more time to progress.
Q: How soon can one drive again after total hip replacement?
A: Following total hip replacement, individuals are generally advised not to drive for six weeks. However, some may be able to return earlier. The surgeon will determine the appropriate time upon re-evaluation of the new hip joint.
Q: Will my medical insurance policy cover all or most of a total hip replacement?
A: Because of the nature and potential need for this particular surgery, Medicare and most other medical insurance policies cover some or the majority of the surgery. However, it is often necessary to contact the medical insurance company before the surgery and inquire if prior authorization for coverage is needed. At that time, the insurance company will advise what percentage of the charges will be paid for by the patient.
Q: How often do I need to do my instructed exercises and for how long after surgery?
A: The exercise program should be performed 2 times per day for the initial 6 to 8 weeks. After this time, if the individual has progressed to a cane or to walking without an assistive device, frequency can be reduced to 3 times a week to maintain strength and endurance. Because recovery times vary, the final decision should be made only by the physician and/or physical therapist.
Hip Replacement: Putting It All Together
Here is a summary of the important facts and information related to hip replacement:
- Individuals suffering from a variety of hip problems can benefit from total hip replacement especially when pain results from wear and tear, disease, and injury.
- Following total hip replacement, most people are up and around walking to some degree the day after surgery. They also can expect to return to normal or near normal activities very soon and without much pain.
- Some of the common hip problems leading to total hip replacement are: osteoarthritis, rheumatoid arthritis, traumatic arthritis, and
- Depending on the condition, people in their late teens and in their 90s can possibly be candidates for a hip replacement. However, the majority of individuals in need of hip replacement are in their 60s and 70s.
- During hip joint replacement surgery, the head and neck of the
femurare removed and replaced with a ball and stem. The acetabulumis reamed to accept a plastic cup. The ball and socket are then replaced into normal position and fastened into the bone with or without special cement.
- To ensure the newly discharged individual is safe in and about his or her home, a nurse, physical therapist, and an occupational therapist will likely see the patient for in home treatment.
- Home health visits are important for a safety check and review of an exercise program.
- The person with a hip replacement may be able to take part in physical activities which were impossible before surgery
- Loosening of the implant is the most frequent cause of failure of a total hip replacement, and may require revision surgery.
- Alternatives to total hip replacement include medication, femoral
Hip Replacement: Glossary
Here are definitions of medical terms related to hip replacement:
acetabulum: The cup-shaped cavity or socket at the base of the hipbone where the ball-shaped head of the femur fits.
ambulating: To walk from place to place; move about.
arthrodesis: The surgical immobilization of a joint so that the bones grow solidly together.
arthroplasty: An artificial joint or implant.
articular cartilage: Cartilage covering and protecting surfaces of bones or of a joint or joints
autoimmune disease: Relating to or caused by antiboides or T cells that attack molecules, cells, or tissues of the organism producing them.
avascular necrosis: Tissue death resulting from a lack of blood supply to the area.
benign bone: Bone tissue being of no danger to health; not recurrent or progressive; not malignant.
deep venous thrombosis (DVT): An abnormal vascular condition where a formation, presence, or development of a blood clot occurs within a vein.
electrical stimulation: A modality or form of treatment used in physical therapy utilizing various frequencies and wave forms of electrical current having therapeutic effects on the nervous and musculolskeletal system.
electrocardiogram: (ECG or EKG), a measurement of the electrical activity of the heart which is obtained by attaching electrodes to the body. The ECG can detect an abnormal heart rhythm or other abnormality.
femur: The longest and largest bone in the human body, extends from the hip to the knee.
joint aspiration: The process of removing fluids from within a joint with a suction device such as a sterile needle and syringes.
malignant bone: Bone tissue that is threatening to life; such as in a malignant disease and has the potential and tendency to metastasize.
osseointegration: Process in which a surface of a material is prepared and attracts bone growth. Also referred to as called porous ingrowth.
osteotomy: Surgical procedure where there is a separation or sectioning of bone.
osteonecrosis: Death of bone tissue.
Piaget’s Disease: A chronic disease of bones characterized by their great enlargement and becoming thin, porous, or less dense.
pelvis: A basin-shaped structure composed of two large bones on the sides which rests on the lower limbs and supports the spinal column.
prosthesis: An artificial device used to replace a missing body part, such as a limb, a tooth, an eye, or a heart valve.
synovial membrane: Part of a sac surrounding the cavity of a freely movable joint; the dense connective tissue membrane secretes synovia, a joint lubricating fluid.
ultrasound: Sound waves at a very high frequency of over 20,000 vibrations per second. Ultrasound has many medical applications, including increasing soft tissue temperature with associated increased circulation.
Hip Replacement: Additional Sources Of Information
Here are some reliable sources that can provide more information on hip replacement:
Associations And Web Sites
American Academy of Orthopaedic Surgeons
American Physical Therapy Association
Phone: 800/999-APTA (2782)
American College of Rheumatology/Association of Rheumatology Health Professionals
National Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse (NAMSIC) National Institutes of Health
Phone: 301/ 565-2966 TTY
Phone: 301/881-2731 Automated faxback system