Total Hip Replacement (Arthroplasty)

What is it?

A total hip arthroplasty is a proven treatment option for arthritis involving the ball and socket joint of the the hip. It involves removing the arthritic surfaces of the top of the femur and the pelvis, and providing a new articular surface between a ceramic head and a plastic liner. An uncemented titanium metal stem is placed into the femoral canal to hold the ball in place and a uncemented titanium metal cup is placed in the pelvic bone to hold the new plastic "cartilage" in place.

The earliest recorded attempt at hip replacement was done in 1891 but became popularized in the states in the 1940's. The hip is now the 2nd most commonly replaced joint behind total knee replacements. It has an excellent track record for providing long term pain relief and improvement in function. Many well done hip replacements last 20-30 years.

How is it performed?

The actual surgery takes around an hour. You will be in the surgical suite a bit longer while the anesthesiologist cares for you before and after the procedure. After surgery, you will spend an hour or so in the recovery room. When you are ready, the nurse will invite a family member or friend back to see you.

In the surgery, the arthritic femoral head is removed and the arthritic bone in the pelvis (acetabulum) is removed and a fresh smooth articulation is placed. A short stem is placed down into your femur to hold the new ball in place. These implants are sized to match your bone. A ceramic head on polyethylene joint surface is used to eliminate risk of metal corrosion which has been an issue with some other designs.

A hip replacement can be performed through an anterior, lateral or posterior approach. Although I have significant experience and training performing all approaches I prefer the anterior approachfor the following reasons:

• Muscles are split instead of cut or detached. This makes potential blood loss less and the early recovery more rapid. It also makes the potential for post-operative limping much less.
• There is decreased risk for hip instability and dislocations post-operatively. Therefore, there are no restrictions on hip positioning in the post-operative period.

What are the risks?

Major medical complications are rare during the peri-operative period of a total hip replacement.  We screen patients carefully to ensure that they are at a minimal risk for any of these complications.  Aside from routine surgical and anesthetic risks (bleeding, infection, anesthesia side effects...), below are some of the most common risks associated with a hip replacement:

• Healthy patients have less than a 1% risk of major complications.  The risk can be increased if the patient is not in good health – in such cases I work with my medicine colleagues to develop a plan for minimizing the risk.
• The two most common surgical complications include infection (this may require further surgery) and blood clots (usually treated with strong blood thinners such as Coumadin).
• The risk of leg length inequality, dislocation, implant loosening and wear are very low with the anterior approach.

How do I know if I have hip arthritis?

Patients with hip arthritis often have pain in the groin, buttock, lateral hip or even upper thigh.  Loss of motion can occur so that it's difficult to put on their socks and shoes.  Some patients may notice painful grinding, popping, catching, and cracking.  Patients may experience a constant dull ache within the hip which is worsened with activity.

X-rays and examination are typically all that is needed to diagnose hip arthritis.  These will demonstrate loss of the joint space in the hip and bone spur formation around the periphery of the joint as shown in these x-rays.

Hip replacement is also used as a treatment for Avascular Necrosis (or Osteonecrosis) of the femoral head.  In this case, the blood supply to the femoral head has been lost and the bone collapses.  This may be due to a history of cancer, steroid use, alcoholism, but often we cannot find a reason.

How long is the recovery?

• Our goal is to help you get up and around as quickly as we can after surgery and to minimize the need for pain medications that could slow your progress. I find that the sooner patients are on their feet, the better they feel.
• While in the hospital, a physical therapist will help you get up a few hours after surgery.  You will be allowed to put full weight on your leg.  You will be taught to climb and descend stairs prior to leaving the hospital.
• My patients often use a cane or walker as needed for the first 2 weeks and are back to gentle exercising by 2 weeks (walking and gentle spinning on a stationary cycle).  You will progress your activity as your comfort allows. At a month after surgery, my patients generally start activities such as elliptical, easy golf, gentle yoga, longer walks and swimming.  Please hold off on running and jumping sports for 3 months.
• The majority of our patients do not require formal physical therapy after the procedure.

Who is not a good candidate for a total hip?

While a hip arthroplasty generally provides predictably good results following surgery, there are some patients in which the results of a total hip replacement are less predictable.  These include the following types of patients:

• Patients with severe spinal problems
• Patients on chronic pain medications
• Patients who actively smoke
• Patients in poor general health and physical conditioning

While having any of these conditions does not mean that a total hip arthroplasty cannot be performed, it could mean that alternative methods of treatment may be safer and more predictable.

When is the Right Time for Hip Replacement?

Do I need a hip replacement?

Hip replacement surgery is a proven treatment option for management of end-stage arthritis of the hip joint.  The pain and stiffness experienced by a patient with arthritis results from a degenerative process in which your joint has lost its normal smooth cartilage.   Loss of the smooth cartilage results in irregular surfaces rubbing against each other when you move your hip or place weight on it.  Unless you had an injury, your hip arthritis may be related to your heredity or to heavy use.  X-rays of patients with hip arthritis will demonstrate narrowing of the space between the bones of the hip joint.

Hip replacement surgery should be considered when your hip arthritis keeps you from performing the activities you enjoy due to hip pain (such as golfing, hiking, walking, working out, dancing, climbing stairs).  You may notice loss of motion, deep pain, grinding in your hip, groin or buttock, and difficulty putting on your socks and shoes.  It is important that you are in your best state of health before proceeding – good preparation makes for a good recovery.

Evaluation by a trained specialist which includes obtaining your medical history, examining your hip, and reviewing your x-rays can ultimately determine if you would be a good candidate for hip replacement surgery.