What is Hip Replacement?
When the arthritis is severe and the pain management is not adequate with non-operative treatments, eventually a total hip replacement may need to be carried out. In this procedure, the entire joint is replaced. The operation generally takes about 1-1.5 hrs, and it involves a 2-3-day hospital stay. Patients can put full weight on the limb after surgery, but they have to use crutches or a walker for several weeks after the operation.
Full recovery after this procedure generally takes 3-4 months, but patients may notice ongoing improvement for over one year after surgery.
A hip replacement involves surgically removing the damaged acetabulum and femoral head, and replacing them with new metal, plastic or ceramic joint surfaces to restore the function of the hip joint.
The hip is a “ball-and-socket” joint. The socket is also known as the acetabulum which is part of the pelvis. The top of the femur bone is the “ball” part of the hip joint and is known as the ‘femoral head’. There is cartilage coating the femoral head and also coating the acetabulum which allows the femoral head and the acetabulum to glide against each other and allows the hip joint to move freely.
In osteoarthritis, the cartilage in the hip joint gradually wears away over time. This can result in bone rubbing on bone which is painful. Bone spurs can form which lead to stiffness and decreased function. Osteoarthritis develops slowly and it typically worsens with time.
This man has a normal left hip (right side of page) but end stage arthritis in the right hip.
Are there different types of hip replacement?
A ‘standard’ hip replacement is made of metal and very hard plastic. The femoral head is made of cobalt chrome which is a very hard metal alloy. It is attached to a stem that is placed into the femoral shaft and secured by allowing your bone to in-grow into the stem or some are cemented into place. The socket is made of titanium with a very hard plastic liner. The results of this standard hip replacement are excellent overall.
The longevity of a hip replacement depends on a variety of factors and one of these is the wear rate of the prosthetic hip joint. A ‘standard’ hip replacement has a life-span of 20-25 years. Any technology that can reduce the wear rates in hip replacements can decrease the likelihood of future surgeries on the hip joint due to the hip joint wearing out.
Standard hip replacement
Ceramic hip replacement offer the advantage of low wear rates and the superior wear characteristics of ceramic materials have been verified in many clinical and experimental studies. There are other risks associated with ceramic hip replacements that you should discuss with your surgeon if you feel you may be a candidate for this option.
Metal-on-metal bearings also reduce wear dramatically, but metal wear particles can lead to delayed hypersensitivity reactions, and the long-term effects of systemically dispersed fine metal wear particles remain a matter of speculative concern.
The operation is primarily done to help relieve pain from arthritis. The success rate is generally excellent, with the majority of patients noticing excellent relief of pain and return to function. Unlike knee replacements, many patients, after a hip replacement, feel their hip feels like a normal hip.
There may be some mild numbness around the incision on the side of the hip which is normal. You may set off airport security and may be required to discuss your hip replacement with security.
The vast majority of patients are happy after a hip replacement. However, sometimes the patient does not achieve as much pain relief as they were expecting or they do not achieve the function they were hoping for. Rarely, the patient may be left with a limp or some discomfort on the side of the hip after a lot of activity. Overall, hip replacements are one of the most successful operations in orthopaedic surgery.
Ceramic hip replacement
Post Operative
A total hip replacement can lead to quite a bit of pain after surgery. This is normal. Narcotic type medications are prescribed while in hospital and these are continued post-operatively. It is useful to combine the narcotic medications with acetaminophen.
Swelling and bruising are quite common after surgery. This needs to be watched closely, but it is generally normal. Icing can help with pain management and it can help control the bruising.
A cryocuff is a device that helps circulate ice water through a wrap around the hip. Many patients use this device to help manage pain and swelling after surgery. You can pre-purchase a cryocuff if you call your surgeon’s office. This way, it can be applied immediately after surgery to help control the swelling and pain. There is good research documenting the positive effect on pain relief of cryocuff treatment after surgery. There are different types of units available ranging from $200-$400. Most extended health care plans will cover the majority of the cost.
After surgery, the physiotherapist will work with you to get you up and walking as soon as possible. If your surgery is done earlier in the day, you may start mobilizing that same afternoon. Otherwise, work on mobility will generally start the following morning. You will use crutches or a walker to help you mobilize after surgery. The physiotherapist will also explain the mobility restrictions you must follow for the first 6-12 weeks while the hip heals to avoid any instability of the hip joint.
Patients generally stay in hospital for 2-3 days after surgery. Discharge will occur when the patient has met their mobility criteria. The decision to discharge a patient involves input from the physiotherapists, nurses and doctors.
Upon discharge, you will be given a booklet with exercises you can carry out yourself at home. The staples are removed 10-14 days after surgery. Physiotherapy will continue as an outpatient after the wound has healed and the staples are taken out. Outpatient physiotherapy can be carried out at a hospital closer to home. It does not necessarily need to be done at Lions Gate Hospital. The physiotherapist in the hospital will discuss outpatient physiotherapy with you while you are still in hospital.
Wound Care - It is important you keep your wound dry until it is healed and the staples have been removed. The nurses will apply a waterproof dressing on your wound, and they will give you instructions on changing the bandage if necessary. You can make an appointment to see your family physician or surgeon in order to have the staples removed. Many patients who live further away from Lions Gate Hospital choose to see their family physician for staple removal. It is very important that the incision is dry when it is time to remove the staples. If there is ANY drainage after 10-14 days, it is important you notify your surgeon’s office immediately. This drainage can be a sign of an early infection, and it needs to be treated aggressively. Antibiotics are generally not useful when treating these post-operative infections.
Follow-up - After discharge, you will see your surgeon or family physician at 10-14 days after surgery to remove the staples. The next follow-up with your surgeon is generally 6-8 weeks after the surgery date. Subsequent follow-ups vary depending on your surgeon’s pattern of practice.
Long-term Results - A total hip replacement will generally last 20 to greater than 25 years. However, there is no guarantee how long the prosthesis will last. Some fail earlier for various reasons so it is important to investigate any change in symptoms to ensure there are no signs of early failure. Your surgeon may recommend routine x-rays at various periods to assess the prosthesis and watch for early signs of loosening.
Activity Level - Patients are encouraged to remain active after a total hip replacement. However, the prosthesis is not designed to allow participation in impact type sports. Prolonged running is generally discouraged after a hip replacement as it will cause early wear of the components.
After surgery, patients can walk, hike, bike, and swim. Lighter impact sports such as golf, doubles tennis and light skiing can be done as well. It is important to maintain a good fitness level after total hip replacement. Talk to your surgeon about activities that you may want to try.
Risks & Complications
Although most patients do well after total hip replacement, there are risks after this surgery.
Infection - This is a devastating complication after joint replacement. It occurs in about 1% of cases. However, there are higher rates of infection associated with diabetes, obesity and any condition or medication that weakens your immune system (rheumatoid arthritis, prednisone, etc).Prior to surgery, it is important to do everything you can to lower the risk of infection. It is important to maintain good nutrition. A malnourished patient has a higher chance of infection. If you have diabetes, the blood sugars need to be controlled properly for several months prior to the surgery. The skin and soft tissues need to be healthy, particularly around the area where the incision is going to be made. If there are bad cuts or scrapes in the surgical area, your procedure will be cancelled.During the operation, everything possible is done to minimize infection risk. Patients are given antibiotics prior to the surgery. All equipment is sterilized and the operating room personnel wear sterile gowns. Special surgical preps are used to sterilize the skin on the limb as well.
Bleeding - There will be blood loss due to the surgery. This is watched closely while you are in hospital. If the hemoglobin levels (blood counts) become too low, a blood transfusion may be necessary. Your doctor will decide if you need a transfusion after surgery. In general, less than 10% of patients require a blood transfusion.
Nerve injury - A nerve injury after surgery could affect the movement of the foot. Luckily, this significant complication is extremely rare. If it does occur, it will generally be observed. Nerve function generally returns, but it can take several months. A permanent nerve injury is quite rare.It is quite common to notice numbness around the incision after surgery. It does get better with time but can there can sometimes be a small area of sensation change permanently.
Dislocation - A total hip replacement is not as stable as a native hip and there is a risk of dislocation albeit small. The risk of dislocating the hip after surgery decreases with time for the first several months. During this time there will be certain movements and positions you will not be allowed to make. For example, a deep hip bend or crossing your legs. You will also be encouraged to not sit in a low chair because this position can risk a dislocation until the tissues are healed. The overall risk of dislocating your hip replacement is approximately 1-2%. Most often it can be popped back in without further issues. Occasionally if the hip dislocates more than once, another surgery is required to stabilize it.
Limp - With modern hip replacements it is unusual to have a permanent limp after surgery. It is common to limp for the first 2-4 months after surgery as the tissues heal. Rarely, the limp persists and can be permanent.
Leg length discrepancy - Your surgeon uses preoperative templating and intraoperative measurements to make sure your leg length is reproduced as accurately as possible. Sometimes, after surgery patients feel their legs are of different lengths. Usually this feeling gets better over time. A length different of up to 1 cm is normal but the difference is usually less than that. Sometimes during surgery the surgeon has to increase or decrease your leg length a bit to ensure adequate stability of your new hip. Less than 5% of patients have a leg length difference that bothers them enough that they require a shoe lift.
Loosening - The total hip replacement prosthesis has a limited lifespan. The surgeon generally expects the prosthesis to last 20 to greater than 25 years. However, there is no guarantee how long the prosthesis will last. Sometimes, the prosthesis will fail or loosen early so it is important to obtain periodic radiographs.
Blood clots - Blood clots can occur after a total hip arthroplasty. They can be very serious, particularly if they travel to the lung (pulmonary embolism). The best way to prevent them is to move around as much as possible after surgery. You will also receive medications to help prevent blood clots. These medications can be injected daily and there are others that can be taken orally. After a hip replacement, you will likely receive medications to prevent blood clots for approximately two weeks after surgery.It is normal to experience swelling in the leg after surgery. This should gradually improve as time goes on. If the swelling seems excessive or continues to worsen after surgery, you should be investigated for the presence of a blood clot. An ultrasound of the limb is done to look for a blood clot.If you develop any chest pain or shortness of breath after surgery, this could be related to a blood clot that has gone to your lung. This constitutes an emergency and should be investigated right away. You should go to your local emergency department immediately if this occurs.
Chronic pain - The vast majority of patients improve drastically after surgery and are very happy with the results. Occasionally, the hip continues to hurt after surgery. This is very rare and can be caused by things like failure of the implants to heal to the body, a low grade infection, a metal allergy or other rare conditions. Sometimes, the pain cannot be explained even after investigation.