Arthroplasty – Total hip replacement

Total hip replacement (arthroplasty)

Authors
Greg A Erens, MD
Peter H Schur, MD
Section Editor
Daniel E Furst, MD
Deputy Editor
Paul L Romain, MD

Disclosures

HIP REPLACEMENT OVERVIEW — Normally, the hip functions as a “ball and socket” joint. The top of the femur bone (ball) fits into a part of the pelvis called the acetabulum (socket), allowing the joint to move smoothly in multiple directions (figure 1). Total hip replacement is a surgical procedure that replaces the hip joint with artificial parts (called prostheses). (See “Total hip arthroplasty”.)

The most common cause of joint deterioration is osteoarthritis; other possible causes include inflammatory arthritis (eg, rheumatoid or psoriatic arthritis), hip disorders of infancy and childhood, and trauma.

This article will discuss total hip replacement surgery. A review of other treatment options for arthritis is available separately. (See “Patient information: Osteoarthritis treatment” and “Patient information: Rheumatoid arthritis treatment” and “Patient information: Psoriatic arthritis”.)

REASONS FOR HIP REPLACEMENT — Total hip replacement is only considered when you have tried more conservative treatments but continue to have pain, stiffness, or problems with the function of your hip.

Total hip replacement may be performed on adults with a deteriorated hip. However, the replacement parts can deteriorate over time, and healthcare providers generally recommend delaying hip replacement until it is absolutely necessary.

ALTERNATIVES TO HIP REPLACEMENT — While total hip replacement can be helpful under the right circumstances, you should only consider it after a discussion of the risks, benefits, and alternatives with a healthcare provider.

Nonsurgical treatment — Nonsurgical treatment methods are initially recommended for people with hip problems due to osteoarthritis or other conditions. Nonsurgical treatments for people with osteoarthritis include:

Weight loss or maintaining a healthy weight
Physical therapy
Using an assistive device (such as a cane or walker)
Taking pain-relieving medications
Having a glucocorticoid (steroid) injection into the painful joint (see “Patient information: Hip pain”).
People with inflammatory arthritis (such as rheumatoid arthritis) may benefit from a treatment regimen of antirheumatic or other medications. (See “Patient information: Rheumatoid arthritis treatment”.)

Surgical alternatives — There are a few surgical alternatives to total hip replacement. Surgical alternatives to hip replacement, such as hip fusion or osteotomy, may be considered in people who are young, in whom a hip replacement may not be durable enough to last for many years and/or withstand an active lifestyle. Total hip resurfacing is another option for younger patients. The best surgical procedure depends upon the reasons that the joint deteriorated. More information about surgical alternatives to hip replacement is available separately. (See “Total hip arthroplasty”.)

TOTAL HIP REPLACEMENT PROCEDURE — Total hip replacement is performed in an operating room after you are given general or regional (epidural or spinal) anesthesia. In traditional hip replacement surgery, a single incision is made along the outer hip and thigh. Less invasive hip replacement surgery techniques, which use small incisions and specialized instruments, may also be used.

The type of prosthesis used depends upon the needs of the particular patient and the surgeon performing the procedure. There are a variety of types of prosthetic surfaces, including metal on plastic, metal on metal, and ceramic on ceramic. An example of one type of prosthesis is shown here . Each surface has unique advantages and disadvantages, and your surgeon can discuss which surface is appropriate for you. (See “Total hip arthroplasty”.)

AFTER SURGERY

Management — After surgery, you will be given pain medication through your IV or by mouth. You will also be given an antibiotic to prevent infection. (See “Prevention of prosthetic joint infections”.)

Most people are also given a medication to help prevent blood clots in the legs. Compression boots (devices that are worn around the legs and inflate periodically) are often worn to prevent blood clots. Compression stockings may also be recommended. (See “Prevention of venous thromboembolic disease in surgical patients”.)

Rehabilitation — Physical therapy is an important part of the recovery process. Most people are able to try standing and even walking, with the help of a physical therapist, within the first 24 hours.

Your length of stay in the hospital will depend upon a number of factors, although most people stay two to four days, during which time you will work with a physical therapist to develop an exercise and rehabilitation program. You may continue your therapy at home under the supervision of a physical therapist, or stay in a rehabilitation facility and continue PT until you are able to independently perform daily activities.

The rehabilitation program generally includes exercises to stretch and strengthen the muscles surrounding the hip joint, as well as training in activities of daily life (eg, stair climbing, bending, walking). The goal of the rehabilitation is to regain strength and motion.

After several months of rehabilitation, you will be encouraged to maintain an active lifestyle. Most people can resume their normal activities within three to six months. While high-impact sports such as running or contact sports are not usually recommended after hip replacement, you can typically participate in activities like walking, cycling, and swimming.

Most hip replacements last 10 to 15 years or longer, and most people are very satisfied with the outcome. Newer prosthetic types may extend the life of the hip replacement.

TOTAL HIP REPLACEMENT COMPLICATIONS — Serious complications after hip replacement surgery are not common and can be minimized by choosing a physician who is experienced and performs the procedure frequently, and by choosing a hospital that is experienced in caring for patients before, during, and after surgery.

Complications can occur during surgery, in the immediate postoperative period, or many years after surgery. It is important to understand these potential risks before deciding to undergo hip replacement. For most patients, the benefits of reduced pain and improved function outweigh the small risk of complications. (See “Complications of total hip arthroplasty”.)

Complications during surgery — Very rarely, complications can occur during the actual hip replacement procedure. These include fractures (typically of the femur), and injury to the surrounding nerves or blood vessels. Most of these complications can be treated during the course of the surgery.

Blood clots — People who undergo hip replacement are at increased risk for developing blood clots after surgery. With appropriate preventive treatments, only about 1 percent of people will develop a blood clot. (See “Patient information: Deep vein thrombosis (DVT)” and “Patient information: Pulmonary embolism”.)

Infection — Infection following hip replacement is uncommon (between 0.4 and 1.5 percent of patients). Antibiotics are routinely given to help prevent infection. (See “Patient information: Joint infection” and “Treatment of prosthetic joint infections”.)

Dislocation — Dislocation of the artificial hip joint can occur if the ball becomes dislodged from the socket. Dislocation occurs in less than 2 percent of patients. In most cases, an orthopedic surgeon can move the joint back into place while the patient is sedated.

To minimize the risk of dislocation, most patients are given specific precautions related to the motion of the hip. The particular precautions depend upon how your surgery is performed, and should be discussed with your surgeon.

Loosening — Loosening of the joint implant is most often caused by wear of the prosthetic components. It is the most common long-term problem associated with total hip replacement, although the number of people who develop loosening is decreasing as prosthetic materials and surfaces are improved.

Breakage — Breakage of the implant itself can occur as a result of wear and tear of the prosthesis, often over the course of years. Older implants are more likely to break, while newer prostheses are stronger and more durable. This is a rare occurrence, with less than 0.5 percent of people experiencing breakage.

Change in leg length — Before, during, and after hip replacement surgery, a surgeon carefully measures the length of your legs in an attempt to make them equal length. However, in rare cases, the procedure results in one leg being slightly longer than the other. Some people with a significant difference in leg length find that wearing a lift in one shoe is helpful.

Joint stiffening — Joint stiffening caused by extra bone formation, also called heterotopic ossification, is a process in which some soft tissues around the hip harden into bone. People with this problem may experience hip stiffness, or may feel no discomfort at all. If you are at risk for joint stiffening, your healthcare provider may recommend a preventive treatment.

SUMMARY

Total hip replacement (THR) is a very effective surgical procedure that involves replacing the damaged “ball and socket” parts of the hip with replacement (prosthetic) parts, with the goal of relieving pain and improving function.
Most patients require THR due to pain caused by arthritis. (See ‘Reasons for hip replacement’ above.)
Following surgery, you will be given medications to prevent infection and control pain. Measures are also taken to prevent blood clots. (See ‘Management’ above.)
You will work with a physical therapist after surgery to strengthen and stretch the muscles around the hip. (See ‘Rehabilitation’ above.)
After surgery, you can usually resume your normal activities within three to six months. Newer surgical techniques may allow some patients to return to normal activities even faster. Low-impact activities such as walking, cycling, and swimming are recommended. High impact activities, such as running, are not usually recommended after hip replacement surgery.
Complications following hip replacement surgery are uncommon, and can usually be prevented with careful post-operative management. (See ‘Total hip replacement complications’ above.)
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: Osteoarthritis treatment
Patient information: Rheumatoid arthritis treatment
Patient information: Psoriatic arthritis
Patient information: Hip pain
Patient information: Deep vein thrombosis (DVT)
Patient information: Pulmonary embolism
Patient information: Joint infection

Professional Level Information:

Complications of total hip arthroplasty
Low molecular weight heparin for venous thromboembolic disease
Clinical manifestations and diagnosis of prosthetic joint infections
Prevention of prosthetic joint infections
Prevention of venous thromboembolic disease in medical patients
Prevention of venous thromboembolic disease in surgical patients
Surgical therapy of osteoarthritis
Total hip arthroplasty
Total joint replacement for severe rheumatoid arthritis
Treatment of prosthetic joint infections

The following organizations also provide reliable health information.

National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)

The Arthritis Foundation
(800) 283-7800
(www.arthritis.org)

American Academy of Orthopaedic Surgeons
(orthoinfo.aaos.org)

The National Institute of Arthritis and Musculoskeletal and Skin Diseases
(www.niams.nih.gov/Health_Info/Hip_Replacement)

REFERENCES
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McLaughlin JR, Lee KR. Total hip arthroplasty in young patients. 8- to 13-year results using an uncemented stem. Clin Orthop Relat Res 2000; :153.
Keisu KS, Orozco F, Sharkey PF, et al. Primary cementless total hip arthroplasty in octogenarians. Two to eleven-year follow-up. J Bone Joint Surg Am 2001; 83-A:359.
Ibrahim SA, Stone RA, Han X, et al. Racial/ethnic differences in surgical outcomes in veterans following knee or hip arthroplasty. Arthritis Rheum 2005; 52:3143.
Saleh KJ, Kassim R, Yoon P, Vorlicky LN. Complications of total hip arthroplasty. Am J Orthop (Belle Mead NJ) 2002; 31:485.