Do I need a hip replacement?
The hip is a ball-and-socket joint, which allows a wide range of movement. Arthritis damages the cartilage-covered surfaces of the joint so the ball moves less smoothly and less freely within the socket. In a hip replacement or resurfacing operation, the surgeon replaces the damaged surfaces with artificial parts, which may be made of metal, plastic or ceramic materials.
Hip replacement is most commonly recommended for severe osteoarthritis, but it’s sometimes used for inflammatory conditions such as rheumatoid arthritis or ankylosing spondylitis or for problems with development of the hip during childhood. Hip surgery may also be needed for fractures of the hip, including those resulting from osteoporosis.
You won’t necessarily need a hip replacement if you have arthritis of the hip, but it may be worth considering if your hip is severely damaged and the pain, disability or stiffness are having serious effects on your daily activities. Your doctors will always try other measures before suggesting a hip replacement – for example, painkillers, physiotherapy and/or walking aids, or occasionally a steroid injection into your hip joint.
There are no age limits for having hip replacement surgery, although the younger you are when you have surgery, the greater the chances that your new joint will eventually wear out. However, it’s usually possible to have another hip replacement later on if you need to.
Freedom from pain is the main possible advantage of hip replacement surgery, along with improved mobility. Both of these should improve your quality of life. You'll have some pain from the surgery to begin with but you should soon start to notice improvements soon after the operation.
It's important to remember that an artificial hip isn't as good as a natural hip. It has some limitations; for example, extreme positions such as squatting aren't recommended because of the risk of dislocation.
About 1 in 10 people have some pain around the hip that won't go away after the operation. It's not always possible to explain the cause of this. However, most people who have hip replacements don't have continuing pain.
After the operation you may find that one leg is slightly longer than the other, but this can be corrected with a shoe insert (insole).
There are some risks associated in having major surgery, and you should discuss these with your surgeon before you decide to have a hip replacement.
Types of surgery
There are two main types of hip replacement operation, but a number of different components and surgical techniques may be used.
Total hip replacement
In a total hip replacement, part of the thigh bone (femur) including the ball (head of femur) is removed and a new, smaller artificial ball is fixed into the rest of the thigh bone. The surface of the existing socket in the pelvis (the acetabulum) is roughened to accept a new socket component that will join up (articulate) with the new ball component.
Many artificial joint components are fixed into the bone with acrylic cement. However, it's becoming more common, especially in younger, more active patients, for one part (usually the socket) or both parts to be inserted without cement. If cement isn’t used, the surfaces of the implants are roughened or specially treated to encourage bone to grow onto them. Bone is a living substance and, as long as it’s strong and healthy, it’ll continue to renew itself over time and provide a long-lasting bond. Where only one part is fixed with cement, it’s known as a hybrid hip replacement.
The replacement parts can be plastic (polyethylene), metal or ceramic and are used in different combinations:
- Metal-on-plastic (a metal ball with a plastic socket) is the most widely used combination.
- Ceramic-on-plastic (a ceramic ball with a plastic socket) or ceramic-on-ceramic (where both parts are ceramic) are often used in younger, more active patients.
- Metal-on-metal (a metal ball with a metal socket) is very occasionally used in younger, more active patients
Metal-on-metal hip replacements
Resurfacing the original socket and the ball of the thigh bone is a different form of hip replacement. Instead of removing the head of the thigh bone and replacing it with an artificial ball, a hollow metal cap is fitted over the head of the thigh bone. The socket part of the joint is also resurfaced with a metal component.
People who have this type of operation have a lower risk of dislocation and may be able to return to a higher level of physical activity compared with those having a conventional hip replacement.
This type of hip surgery is linked with a release of metal particles from the joint replacement materials, which may cause local inflammatory reactions and have unknown effects on your general health. The complication rates and early repeat surgery rates for hip resurfacing procedures in the National Joint Registry for England and Wales are much greater than for conventional hip replacements. Complication rates are particularly high in older patients and in women. Metal-on-metal resurfacing isn’t suitable for people with low bone density or osteoporosis, where the bones are weakened.
Little is known about the long-term performance of these joints as the technique hasn’t been in use for as long as total hip replacements. However, the poorer mid-term performance for these types of hip replacement means they're being used less frequently in the UK and in other countries.
Preparing for surgery
Once you’ve decided to go ahead with the operation, your name will be put on a waiting list and the hospital will contact you, usually in the next 6–8 weeks.
Most hospitals invite you to a pre-admission clinic, usually about 2–3 weeks before the surgery. You’ll be examined to make sure you’re generally well enough for the anaesthetic and the operation. This may involve the following tests:
- blood tests to check for anaemia and to make sure your kidneys are working properly
- x-rays of your hip
- a urine sample to rule out infection
- an electrocardiogram (ECG) tracing to make sure your heart is healthy.
The hospital team will probably tell you at this stage whether the operation will go ahead as planned.
It’s also advisable to have a dental check-up and get any problems dealt with well before your operation. There’s a risk of infection if bacteria from dental problems get into your bloodstream.
You should discuss with your surgeon, anaesthetist or nurse at this pre-admission clinic whether you should stop taking any of your medications or alter the doses before you have surgery. Different units and different surgeons may have differing opinions on this.
Read more about types of anaesthetic.
At this visit you may also see an occupational therapist to discuss how you’ll manage at home in the weeks after your operation. They’ll also advise you on aids and appliances that might help. You can also ask about these when you go for your pre-op assessment.
Going into hospital
You’ll probably be admitted to hospital early on the day of surgery, but it may be earlier if you haven’t attended a pre-admission clinic or if you have another medical condition that needs to be treated before you have the operation.
You’ll be asked to sign a consent form giving your surgeon permission to carry out the treatment. You may also be asked if you’re willing for details of your operation to be entered into the National Joint Registry (NJR) database. The NJR collects data on hip and knee replacements in order to monitor the performance of joint implants.
Just before your operation you’ll be taken (usually in your bed, but you may be walked) from the admission ward to the operating theatre. If you're feeling worried, you may be given a sedative medication (a pre-med) while waiting in the admission ward, which will make you feel a little drowsy. You’ll then be given an anaesthetic. This may be either an epidural or a spinal anaesthetic, or alternatively a general anaesthetic.
An epidural will only affect the lower half of your body, and a spinal anaesthetic will only stop you feeling pain in the affected area. This means you'll be awake during the operation, but you may also be sedated, if necessary, to keep you relaxed during the course of the operation. A general anaesthetic will affect your whole body and will probably make you lose consciousness.
After the operation
When you leave the operating theatre you’ll probably have an intravenous drip in your arm – this is a tube that allows any fluids and drugs you may need to flow straight into your bloodstream through a needle into your vein. You may also have either one or two suction drains in your hip – plastic tubes that drain away fluid produced as the body heals.
You’ll be taken to a recovery room or high-care unit until you’re fully awake and the doctors feel that your general condition is stable. Then you’ll be taken back to the ward, often with a pad or pillow strapped between your legs to keep them apart.
You’ll be given painkillers to help reduce pain as the effect of the anaesthetic wears off. These may include:
- local anaesthetic patient-controlled analgesia (PCA) – a system where you can control your own supply of painkiller going into a vein by pressing a button
- painkilling injections or tablets.
The drip and any drains are usually removed within 24 hours. You’ll then be able to start walking, first with a frame and soon with elbow crutches or sticks.
How quickly you get back to normal depends on many factors, including:
- your age
- your general health
- the strength of your muscles
- the condition of your other joints.
Accelerated rehabilitation programmes
If your surgeon feels that everything is going well, you may be included in an accelerated rehabilitation programme, also called the enhanced recovery programme (ERP). This programme is becoming more common and aims to get you walking and moving within 12–18 hours and home within a few days. If you’re suitable, the ERP will start when you go for your pre-admission clinic to make sure you’re fully prepared for the surgery and understand the programme. After the operation the programme aims to get you moving and eating normally as soon as possible, and when you’re discharged from hospital you’ll be given supporting therapy and follow-up checks. The programme focuses on making sure that you take an active role in your own recovery process.
Physiotherapy and occupational therapy
A physiotherapist will see you in hospital after the operation to help get you moving and advise you on exercises to strengthen your muscles. A physiotherapist or an occupational therapist will tell you the dos and don’ts after hip surgery – how to get in and out of a bed, a chair, the shower etc. It’s very important to follow this advice.
You shouldn’t bend the hips to more than 90º (e.g. squatting, or sitting in a low chair or couch) and never cross your legs because these positions could dislocate your new hip. An occupational therapist will advise you on the correct height of seating.
Before you leave hospital, an occupational therapist will assess your physical ability and your situation at home, and may give you equipment such as a raised toilet seat and gadgets to help you dress.
Most people are able to climb stairs and are ready to leave hospital within 4–8 days.
You’ll need to attend the outpatients’ department, usually 6–12 weeks after the operation, for a routine check-up to make sure your recovery is going well. You may also be offered outpatient physiotherapy if your doctors feel that this will help your recovery.
Once you’re at home the district nurse will change your bandages and take out any stitches (sometimes called sutures). If you have any problems with your wound healing then you should tell the hospital staff straight away.
Looking after your new hip joint
You may not be able to bend your leg towards your stomach as far as you’d like to – it’s important not to test your new joint to see how far it’ll go. You need to take great care during the first 8–12 weeks after the operation to avoid dislocating the hip. But it’s also important to continue with the programme of muscle-strengthening exercises recommended by your physiotherapist.
There are some general rules to remember as you start to become more active:
- Don't twist your body as you sit or stand.
- Don't bend your hips past 90o (a right angle).
- Don't cross your legs or feet.
- Don't roll your knees or toes inwards.
Getting back to normal
You’ll be expected to sleep on your back with a hip abduction wedge (a support to keep your legs stable) between your legs for the first 6 weeks.
You’ll probably need walking sticks for the first 4–6 weeks, but this varies between individuals. Your surgeon or physiotherapist will be able to advise how well you’re progressing.
You’ll probably be able to have sex after about 6–8 weeks, although you should avoid extreme positions of the hip. Don’t be afraid to ask for advice about suitable positions – you won’t be the first to have asked. Read more about sex and arthritis.
Can I work and drive afterwards?
You can expect to drive again after about 6 weeks, as long as you can safely control the vehicle and do an emergency stop. It’s important to check with your insurance company whether you’re covered during your recovery, and you need to be confident that you can adequately control the vehicle in all situations.
Getting in and out of a car can be difficult – you’ll need to sit sideways on the seat first and then swing both your legs around together. Some people put a plastic bag on the car seat to make it easier to swivel round. Your occupational therapist will advise you about other movements that you need to take special care with.
You could also return to work at this stage if you have a job that doesn’t mean too much moving around. If you have a job that involves a lot of walking, you may need up to 3 months to fully recover before returning to work. If you have a very heavy manual labour job, you may wish to consider changing to a lighter form of work.
Exercise following a hip replacement
Regular exercise is very important. Walking and swimming are fine, although some surgeons advise against breaststroke when swimming. Cycling may be difficult until about 12 weeks after the operation, as it’ll be hard to get on and off the bike. Sports that involve bending or twisting at the hip will be difficult for the first 12 weeks.
We don’t recommend running on hard surfaces or sports that involve sudden turns or impacts – for example, squash or tennis. If in doubt, ask your surgeon or physiotherapist for advice. You should always try to avoid extreme movements at the hip and activities with a high risk of falling, such as skiing.
You can also download a selection of exercises that are designed to stretch, strengthen and stabilise the structures that support your hip. These are general hip exercises, so it’s a good idea to get advice from your doctor or physiotherapist about specific exercises before you begin.
All surgery carries some risk of complications. In the case of hip replacement, these include blood clots or bleeding from the wound, dislocation, wear or loosening of the new joint, infection and nerve damage.
Hip replacement is a big operation and all major surgery carries risks. Possible complications include:
- blood clots
- wound haematoma (bleeding)
- infection of the joint
- one leg longer than the other
- nerve damage
- ongoing discomfort
It’s very important to seek medical advice straight away if, following surgery, you have pain or swelling in the leg, chest pain or sudden breathlessness.
Some people can develop blood clots in the deep veins of the leg (deep vein thrombosis, or DVT) causing pain and/or swelling in the leg. This is because of changes in the way the blood flows and its ability to clot after surgery. There are various ways to reduce the risk of this happening, including special stockings, pumps to exercise the feet and drugs that are given by injection into the skin such as heparin or fondaparinux.
Rivaroxaban, dabigatran and apixaban tablets have recently become available to help prevent DVT. If your surgeon prescribes these, you’ll need to take them for five weeks after you go home from surgery. The tablets are more convenient than injections, and don’t need monitoring, which make them easier to take at home.
A small minority of blood clots, particularly those in the thigh veins, can detach and travel through the blood vessels to the lungs, where they may become stuck. This can cause sudden breathlessness, chest pain or even collapse. However, it’s usually possible to treat pulmonary embolism with blood-thinning medicines and oxygen therapy.
Sometimes an artificial hip may dislocate. This occurs in less than 1 in 20 cases, and the hip needs to be put back in place under anaesthetic. If the hip keeps dislocating, you may need further surgery or a brace to stabilise it. Even after you’ve started walking without support it’s important to continue with a programme of muscle-strengthening exercise to help stabilise your hip and improve function.
To reduce the risk of infection, special operating theatres that have clean air pumped through them are often used, and you’ll probably be given a short course of antibiotics at the time of the operation. Despite this, a deep infection can occur in about 1 in 100 cases. The infection can be treated but the new hip joint usually has to be removed until the infection clears up. New hip components are then implanted 6–12 weeks later.
Plastic hip sockets may wear over a period of time. The worn particles of plastic may cause inflammation and this can eat away the bone around the new hip. Ceramic-on-ceramic or metal-on-metal joints tend to wear less and are therefore less likely to cause this problem. New, harder-wearing plastics are also being developed.
The most common cause of failure of hip replacements is when the artificial hip loosens. This can happen at any time but is most common after 10–15 years. It usually causes pain, and your hip may become unstable. Loosening is usually linked with thinning of the bone around the implant, which makes the bone more prone to fracture. A fracture around the implant usually needs to be fixed through surgery and/or revision of the implant.
Bleeding and wound haematoma
A wound haematoma is when blood collects in a wound. It’s normal to have a small amount of blood leak from the wound after any surgery. Usually this stops within a couple of days. But occasionally blood may collect under the skin, causing a swelling. This can discharge by itself, causing a larger but temporary leakage from the wound usually a week or so after surgery, or it may require a smaller second operation to remove the blood collection. Drugs like aspirin and antibiotics can increase the risk of haematoma after surgery.
How long will the new hip joint last?
Your new hip should allow you virtually normal, pain-free activity for many years. Around 80% of cemented hips should last for 20 years. Younger, more active patients often get cementless hip replacements and these may last longer, although this isn't confirmed in long-term studies.
Repeat hip replacements are possible and great advances have been made in this type of surgery in recent years. Revision surgery is more complex than the original operation, the time in hospital is longer and the results are slightly less good with each revision. Even so, over 80% of patients report success for 10 years and more.
Some revisions may need a bone graft, where a piece of bone is taken from another part of the body or from a donor patient to help replace bone loss. Bone grafts may need protection from movement, and this might mean that you’ll be on crutches for longer. However, the eventual result is usually good.
Research and new developments
Newer techniques include minimally invasive surgery, which causes less tissue damage. Research into which implants work best for which patients is ongoing, based on data from the National Joint Registry.
Versus Arthritis is currently funding a review of the status of hip replacements in the UK. This study, based at University of East Anglia, will explore the hip implant market in terms of the number of effective competitors, the range of products, manufacturer size and how easy it is for new manufacturers to enter the market. They’ll use data from the National Joint Registry and Hospital Episode Statistics databases to find out if patients receive the best ‘value-for-money’ implants.
We have also set up a metal-on-metal task force. This is a panel of experts who will investigate the evidence that metal-on-metal joint replacements are possibly bad for patients’ health. This will also help to show what areas of research within this topic we should look into in the future.
Minimally invasive surgery
Minimally invasive surgery is a technique that involves a much smaller cut (incision) and so it causes less damage to the soft tissues (muscles, tendons and ligaments). This should mean a shorter recovery period after the operation, although this hasn’t been conclusively shown in clinical trials. There’s no real benefit of minimally invasive surgery in the longer term compared with traditional hip replacement techniques, and the results may not be as good as with conventional surgery because it’s more difficult to position the implants.
At present, minimally invasive surgery is used in only a small proportion of hip replacements because of the problems outlined above. However, it may be more widely used in the future, possibly alongside computer-assisted surgery (also known as image-guided surgery). This uses infrared beacons attached to the patient’s body and to the operating tools to generate images of the inside of the joint. This may allow the components to be placed more precisely.
It is very uncommon for someone my age to have a hip replacement, and many people fail to understand the difficulties a younger person has to face when living with a chronic condition, especially one that is worsening.
Few people actually understood what I was going through, and it was very hard – emotionally and physically. Due to lack of knowledge of how my arthritis was affecting me, people still expected me to do things that I really couldn’t. I hope that by highlighting my experiences of having arthritis and hip replacements whilst at university, it will give a better insight into how younger people are affected by illness.
I developed arthritis after a viral infection at the age of five. I started steroids which seemed to work well, and in 2003 I was put on etanercept injections. From then on my life seemed to go very well. After A levels I wanted to go to university and become an occupational therapist and I felt well enough to be able to go.
My first year of university in 2004 went really well; I made lots of friends and had fun! But when I started my second year my left hip began hurting when I walked. I thought it was nothing I couldn’t handle. Over Christmas 2005 it got worse. I saw my orthopaedic consultant who said my hip was showing signs of severe degeneration; I needed a replacement. At this point I was still active, and convinced myself that I’d be OK to wait to have the operation in summer 2006. The thought of having a hip replacement really scared me. I didn’t want to have it unless I absolutely had to.
January 2006 came, and I could not walk for more than five minutes: my hip locked on sitting, making it hard to walk or get up from a chair without being hunched over and limping.
In February we all passed an exam and arranged to go out to celebrate. I told myself I would be careful; sit down and not dance. The night started out well, I saved my energy, despite wanting to dance with everyone else. By midnight, I felt shattered and was stuck watching everyone having a great time, so I ended up leaving. The next day I couldn’t walk. I dosed myself up on painkillers and had to use my mobility scooter to get from my room to the toilet, only seconds away. I felt angry, because I now knew that every part of the life I used to love I now hated because everything seemed to be dominated by the pain. I couldn’t do anything anymore.
I now wasn’t able to go out with my friends, go shopping, or walk around campus. I had no choice but to use the scooter to get around, but I hated it. Normally I hid my arthritis well; few people had ever noticed that there was anything ‘different’ about me and I liked it that way. I had always hated anything that drew attention to my illness or showed people how I wasn’t like them.
My academic life was suffering as I was constantly tired and always drowsy from the painkillers. Doing coursework was difficult, as I just stayed in my room and slept. I missed days and had to catch up. I think I was in denial, believing that as I had coped with pain before, I could cope now, convinced I didn’t need the surgery. At the time I felt waiting was the right thing to do. The thought of being set back a year at university for something that wasn’t my fault was in some ways my motivation to continue and a way of me controlling something for a change.
But by March 2006 I really couldn’t kid myself any longer. I couldn’t cope any more and university was becoming a nightmare. I still feel sad that I lost out on a lot of my university life in that second year; I’ll never get that year back. I kept in contact with my friends but I couldn’t feel a part of things like I did.
I had my operation in June 2006 and the pain immediately disappeared, which was a really strange feeling. The pain had become a part of my life – I had been experiencing it everyday. Afterwards, I was completing four hours a day of physiotherapy alongside hydrotherapy. I still felt as though I had no life, as my life had become filled with the exercises I had to do to get my hip muscles strong. I found myself in a really low state, and one night, the realisation of the operation I’d had suddenly hit me, and I felt nobody understood what it was like. As I didn’t get to see many friends or family following the surgery, I was convinced that nobody cared. At this point I was feeling physically well and I was dying to get back out with friends, but due to the precautions I was following for 12 weeks I couldn’t. Now the pain had gone I just wanted to be free...be normal...and get on with my life.
As I had missed my clinical placement in April, it now seemed possible to still complete it over summer, after my operation. A local placement was arranged, which I began eight weeks after my surgery. Needless to say, at eight weeks the placement was a struggle. I was battling fatigue due to my lack of energy combined with my rehabilitation and I was faced with issues regarding self image as I was using walking sticks. Again, this was something that drew attention to the fact I wasn’t like everyone else...somehow, the sticks made me feel more vulnerable and less capable than I normally felt when on placements. I felt shadowed by them and by the association of being ‘disabled’. Also, no sooner had my hip been replaced, the other hip began giving me problems. This made the placement even more difficult as I was now facing another problem on top of my recovery.
The surgeon said this might happen, as once the restrictions on the left side had gone the right side was now ‘weaker’. However, it wasn’t a huge problem, so I began my third year in September 2006.
The right hip lasted much longer than the left. Because of my previous experience, I took things much easier avoiding anything that would aggravate my hip, and I knew how to pace myself and deal with difficulties around university. I really saved my energy for the things I needed it for the most. I managed to complete my degree without having the surgery...just! I had my second hip a week after I graduated.
Now, both hips are feeling great and I am doing so much more than I have done for a long time. I have been on day trips, long walks and long shopping trips – something I had greatly missed!
The past two years have been the hardest of my life but I never wanted to let my arthritis get the better of me. I am glad that I managed to finish my degree on time and with a good result. One thing I will say to others with chronic conditions is, just because you have an illness, do not let this affect something you want to do. There is always support and ways to get around a problem.
I pursued my career path, and although I had hurdles along the way I still did it. I proved to myself and others that I WAS capable of getting a degree, I just had to alter my course a little on the way…
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