If you’re experiencing a lot of pain in your hip, your healthcare provider may recommend a procedure called a hip replacement. This common surgery replaces your hip bone(s) with an artificial one, enabling you to move easier and without pain. Recovering from a hip replacement takes time, and there are many rules to follow to keep you safe and healing.
What is a hip replacement (hip arthroplasty)?
This surgery is where your hip (or parts of it) is replaced with a manmade implant (prosthesis). It’s usually performed on adults after other treatments like using a cane or walker, weight loss, medicines and physical therapy have failed to help. You may need a hip replacement because of:
- Inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis).
- Femoroacetabular impingement syndrome.
- Injuries, like a hip fracture or dislocation from a fall.
- Developmental hip dysplasia.
- An injury that didn’t heal right.
- Osteonecrosis (avascular necrosis).
- Childhood hip disorders, like Legg-Calvé-Perthes disease and slipped capital femoral epiphysis.
- Because all surgery has risks, and prostheses can fail as time goes by, your healthcare provider may recommend delaying a hip replacement until severe symptoms are present.
What is the hip?
Your hip is a joint — a ball-and-socket joint — that connects the thigh bone (femur) of your leg to your pelvis. Your femur has a “head” at its top that’s shaped like a ball, and it fits into the acetabulum (the socket). It’s kept in place by ligaments, tendons and muscles around the joint. Your hip is the most flexible and free-moving joint in your body and can move backwards and forwards, to the side and can perform twisting motions.
What are the types of hip replacements?
There are two major types of hip replacements:
Total hip replacement (the most common type): A total hip replacement switches both the femoral head and the acetabulum with a prosthesis.
Partial hip replacement: A partial replacement substitutes the femoral head only. This is typically done for patients with certain types of hip fractures.
What kind of healthcare provider performs hip replacements?
If a hip replacement is the best treatment for you, your healthcare provider may send you to an orthopaedic surgeon for evaluation. Your orthopaedic surgeon will evaluate your hip joint with a full physical exam and X-rays and develop a treatment plan for how surgery can best benefit you.
What symptoms may indicate that I need a hip replacement?
Some of the following symptoms may be related to conditions that hip replacements address. They include:
- Pain in the anterior hip or groin.
- Pain in the buttock and trochanteric region.
- Pain with activity and at rest.
- Pain that gets worse when you put weight on the leg.
- Stiffness/tightness of the hip.
- Loss of motion.
- Difficulty sleeping.
- Difficulty walking.
- Difficulty putting on shoes and socks.
Who shouldn’t go through a hip replacement?
Hip replacement surgery isn’t for everyone. Even if someone is in pain and can’t move their hip as well as expected, they aren’t automatically considered for a hip replacement. You might be ineligible if you have:
- Severe medical problems such as heart failure, anemia, recent myocardial infarction (heart attack), unstable angina and more. Talk to your healthcare provider about issues that may disqualify you.
- An active infection.
- An immature skeleton.
- Irreversible or permanent muscle weakness.
- Paraplegia, quadriplegia.
- A neuropathic (Charcot) joint.
- Severe morbid obesity.
Is a hip replacement surgery outpatient or inpatient?
Most people need to stay in the hospital for about one to two days.
How do I prepare for surgery? What happens before a hip replacement?
In order to prepare for surgery, you’ll schedule a series of appointments to receive testing and clearance. During these appointments, studies including lab testing, urine analysis, an EKG and X-rays may be performed. Based on the results of these tests and your health history, clearance is or is not initiated for the surgery.
Before surgery, your medical risk will be assessed. Your healthcare providers need to make sure that the risks of a hip replacement don’t outweigh the benefits. They will check for:
- How anxious/stressed you are about your surgery.
- How well you’ll handle blood loss.
- How well you might tolerate anesthesia.
- How you might manage the rehabilitation process.
- How your other medical problems may affect your healing.
- How active you are.
- How appropriate your weight is.
Your lower extremities will be evaluated before surgery. Your healthcare providers will do the following:
- Muscle testing: Strength of the hip flexors, extensors, abductors and adductors. Also the strength of the limb below the hip.
- Nerve and vascular status testing: Sciatic and perineal nerve function testing, sensory examination and an assessment of the arterial pulses. Checking if there’s any severe vascular disease.
- Palpation testing: Palpation helps rule out other causes of hip pain which are not from the joint
- General inspection: Examining your gait (walk), any previous incisions, abnormal swelling, cuts, discolorations and infections.
- Range of motion testing: Hip flexion/extension, abduction/adduction and internal/external rotation.
- Trendelenburg sign: Tests the strength and function of the hip abductor muscles.
- Measure your leg length.
- Straight leg rise: Testing groin pain, radiating pain (pain that starts in one place and travels to another), back pain, posterior hip pain and lower leg pain.
You will have radiographs (X-rays) of the hip and pelvis to assess the status and structure of the hip joint. Occasionally advanced imaging (MRI or CT scan) may be needed to assist in the diagnosis or treatment planning.
Your healthcare provider will likely require some tests before surgery. Tests may include:
- Complete blood count (CBC).
- Prothrombin time (PT).
- International normalized ratio (INR).
- Activated partial thromboplastin time (aPTT).
- Blood type/screen.
- Basic chemistries.
- Other tests, as needed.
- Electrocardiogram (ECG).
You can also take some steps to help ensure an easier and safer recovery after surgery. Make a few simple changes around the house, and arrange for someone to help you following surgery. If you smoke, quit or cut down to improve your surgery risk and recovery rate. It’s also helpful to lose weight if needed, have an obstructive sleep apnea screening, and try to resolve other conditions you have. Don’t eat or drink anything after midnight the night before surgery.
You can try these tips at home prior to surgery:
- Remove any loose rugs, as they can be hazardous when you’re walking in the house. Make sure you tape down all electrical cords.
- Store additional canned and frozen foods, and make sure all supplies are between waist and shoulder level.
- Prepare a sleeping room on the main floor, or make sure that you only have to climb the stairs once a day.
- Special equipment can help ensure an easier recovery following surgery. Your physical and occupational therapists will recommend equipment for you and will help you and your family get this equipment following surgery. Some of this equipment may include:
- Elevated toilet seats.
- Shower seats.
- Handrails and grab bars.
- Grasping device for putting on socks and shoes.
Do I still take my normal medications before surgery?
Inform your surgeon about all of your medications, both over-the-counter and prescription. Some medications don’t react well with anesthesia, and others such as aspirin, ibuprofen and blood thinners increase bleeding. For these reasons, you may need to stop taking certain medications before your hip replacement. If you’re taking aspirin or aspirin-based medication for arthritis, you must stop taking these two weeks before your surgery. If you’re taking medications for other medical problems, don’t discontinue taking these without checking with your primary healthcare provider. Make sure to bring a list of all medications, the dosages and how often you take them. This includes all herbal supplements and vitamins. This is important information that will be documented in your hospital records.
What medications will I receive right before, during, and right after the hip replacement?
Antibiotics: Medication to help prevent infection.
Anesthesia: An anesthesiologist will meet with you before your surgery. They will explain the various types of anesthesia available to you and the risks and benefits of each with your health history. The spinal, or regional anesthetic block, is the most common method used for orthopaedic joint replacement procedures. You’ll also be asked to complete a health questionnaire from the anesthesia department for surgery clearance to ensure your safety.
Thromboprophylaxis: Medication to help prevent blood clots (thrombosis).
Pain control: Various medications can help control pain, including NSAIDs, narcotic pain medications and peripheral nerve block.
When do I see a physical therapist?
You may be evaluated by a physical therapist before surgery. After surgery, you’ll have daily physical therapy.
What is the prosthesis made of?
The prosthesis is constructed of metal and plastic. Titanium, stainless steel, cobalt-chromium, ceramic and polyethylene are the most common materials. A prosthesis for a total hip replacement consists of four components:
- Femoral stem.
- Femoral head.
- Acetabular liner.
- Acetabular shell.
They are linked, but flexible, so that the surgeon can adjust for anything unexpected. The prosthetic is then fixed to the remaining bone using either:
- Fixation to the host bone by relying on a bony ingrowth onto or into the porous surface of the bone that has either been “interference-fit” or “press-fit” into the surrounding bone.
- Medical cement (methylmethacrylate cement), if the original bone’s quality is low.
How long does the surgery last?
One to two hours is typically how long the surgery takes.
RISKS / BENEFITS
What are the benefits of a hip replacement?
Relief from pain is the greatest benefit and the major reason for hip replacement surgery. The procedure offers other benefits, including:
- Improved movement.
- Improved strength.
- Improved coordination of the torso and leg.
- The ability to walk, climb stairs and maintain an active lifestyle in greater comfort.
What are the risks of surgery? What are the possible complications?
There are some risks and complications that may happen through a hip replacement surgery associated with anesthesia, including respiratory or cardiac malfunction. Other complications that can happen right after surgery or even years later include:
- Blood clots. About 1% of people who go through a hip replacement will have a blood clot in their leg (deep vein thrombosis) or lungs (pulmonary embolism).
- Infection. This is uncommon — it happens to 0.4% to 1.5% of people who undergo a hip replacement.
- Loosening. The loosening of the implant caused by wear and tear is a common long-term problem that happens far less than it used to. This happens less and less as prosthetic materials and surfaces get better.
- Breakage. Sometimes old implants can break down. Less than 0.5% of people end up with a broken implant.
- Change in leg length. The lengths of your legs will be measured before, during and after your surgery. Rarely, individuals end up with one leg longer than another, and need a shoe lift to even them out.
- Injury to nerves and blood vessels.
- Stiffness or instability of the joint. Your joint may stiffen because of heterotopic ossification, which is where soft tissues harden into bone.
- Need for additional surgeries.
- Dislocation. Sometimes the ball can separate from the socket. This happens to less than 2% of people.
- People at an increased risk for complications are those with severe rheumatoid arthritis or systemic lupus. In addition, individual with obesity, diabetes, malnourishment, hemophilia or those who have had previous prosthetic joint infections are at higher risk. Make sure to contact your orthopaedic surgeon immediately if you experience any of these problems after surgery.
RECOVERY AND OUTLOOK
What happens after surgery?
After surgery, you’ll be given pain medication and an antibiotic. Medicines or physical therapy may be prescribed by your surgeon to prevent blood clots. To decrease your chances of having a Deep Vein Thrombosis (DVT) after surgery, you may be given medication, wear special stockings and do ankle pumps for two to three days following surgery. You may have an appointment depending on the wound closure method preferred by your surgeon to have the staples or external sutures removed (if present). You should call your surgeon if you experience any of the following symptoms:
- Increased redness.
- Pain or swelling.
- Drainage at the incision.
- Bumps or pimples.
- Any other changes you question.
- Physical therapy will start within 24 hours.
How long will I be in the hospital?
You may be in the hospital up to two days after surgery. If it is unsafe for you to return directly home from the hospital, you might have to go to a rehabilitation center prior to discharge home. Talk to your healthcare provider about the best recovery plan.
How long that ends up being in the hospital depends on three things:
- If your pain is under control: You won’t go home if your pain is unbearable.
- How well you safely move around: You won’t go home if it looks like you might be unsafe there.
- How stable you are, medically: You won’t go home if, for example, your blood pressure is too high.
What does recovery look like? What’s the rehabilitation after hip replacement surgery?
Rehabilitation and physical therapy are started immediately following surgery and continue throughout hospitalization and at home for one year after surgery. Your physical therapist will monitor the strength and flexibility in your leg and hip, as well as your ability to stand and sit. In addition, a physical therapist will provide goals and instructions for you to complete while in the hospital and at home.
Although discharge home is the goal for the majority of patients, your healthcare provider may determine that it’s best for your recovery if you go to a rehabilitation center or nursing home after discharge from the hospital. At the rehabilitation center, you will have concentrated time with a physical therapist and occupational therapist and will regain your strength, learn about all your exercises and the precautions that you’ll need to follow. Your length of stay at this facility is approximately five to 14 days, depending on your recovery progress. Your healthcare provider’s assistant or nurse will discuss facilities available for your needs, and a case manager specializing in discharge planning will meet with you during your admission. The case manager handles all of the planning for your rehabilitation.
How long is the recovery period after surgery? How long will I have to perform physical therapy exercises?
Several variables affect the ultimate success of a hip replacement surgery and the length of the recovery time. These include the strength of your bones and muscles and your general health and lifestyle. Commitment to a rehabilitation program is also an important part of the recovery process, since improvement to the hip joint is determined by your rehabilitation efforts.
You’ll perform daily exercises that strengthen and stretch the muscles around your hip joint — likely 20 to 30 minutes two to three times per day. You’ll also slowly return to climbing stairs, bending and walking, gradually regaining motion and strength. It will be several weeks to several months before you’re completely back to normal.
Will I need surgery again?
Joint replacements don’t last forever — although experts have noticed that modern prostheses can last longer than the ones that were used years ago. Hip revision surgery may become necessary if an artificial hip becomes painful.
How long before I can drive?
Do not drive for several weeks after surgery. You may resume driving once you have good strength and control of the legs, are comfortable sitting in a car, and are off of pain medication. Discuss this with your surgeon based on your recovery.
How will I have to limit my movement following surgery?
After surgery, your physical therapist will instruct you regarding hip movement precautions and any limitations you may have for range of motion. Keep in mind that your physical therapy and strengthening exercises will help you gain greater mobility and ensure an easier recovery following surgery. It’s highly recommended that you continue therapy treatment for the recommended timeframe prescribed by your physical therapist.
Your physical therapist will tell you that there are several basic rules about positioning that you should be aware of following surgery. The specific precautions will vary based on the surgical approach (window into the hip joint) used during surgery. Precautions may include that you don’t bend forward more than 90 degrees, and do not lift your knee on the surgery side higher than your hip. Also, don’t cross your legs or rotate your leg outward, or twist or pivot your operated hip.
How can I manage at home during recovery from hip replacement surgery? What are hip replacement precautions and restrictions?
There are some general safety tips to keep in mind. For example, simplify your surroundings:
- Remove clutter.
- Keep stairs free of objects.
- Keep supplies in the same place.
- Remove small rugs throughout the house.
- Keep walking areas safe:
- Watch out for your pets when walking.
- Keep hallways/stairways well lit.
- Purchase night lights for bedrooms and bathrooms.
- Stairs should have securely fastened handrails. Non-skid threads on stairs add to safety. If you have problems with your vision, add a contrasting color to mark stair edges.
WHEN TO CALL THE DOCTOR
What side effects of hip surgery mean that I should contact my orthopedic surgeon?
You should contact your surgeon right away if you experience any of the following:
- Drainage at the incision.
- Bumps or pimples.
- Increased redness.
- Pain or swelling.
- Any other changes you question.
How frequently should I schedule follow-up appointments with my healthcare provider?
Post-operative visits help your surgeon know that your hip is healing well. Make sure to schedule your first evaluation within the timeframe your surgeon recommends. It’s important to comply with this schedule and to see your healthcare provider regularly for routine office visits to ensure safe and effective recovery from total hip replacement.