Hip replacement Q&A

The Consultants

• Professor Lee Jeys is a consultant orthopaedic surgeon at The Priory Hospital
• Mr David Houlihan-Burne is a consultant orthopaedic surgeon at The Chiltern Hospital and Bishops Wood Hospital
• Mr Andrew Manktelow is a consultant orthopaedic surgeon at The Park Hospital

What is a hip replacement?

Professor Lee Jeys: Hip replacement is a surgical procedure in which the diseased parts of the ball and socket hip joint are removed and replaced with new, artificial parts. These artificial parts are called as prosthesis. It is a highly effective treatment that offers a long-term solution for hip joint damage.

Mr David Gerard Houlihan-Burne: A hip replacement is an operation primarily for arthritis of the hip. It involves removing the ball and socket joint of the hip and replacing it, most commonly, with a combination of a metal and plastic joint. The surgery takes about an hour and the patient is in hospital for 2-3 days. It must be remembered this is an artificial joint and not the same as native joint but an excellent 'second best'.

Mr Andrew Manktelow: Hip replacement is a procedure that is designed to treat arthritis of the hip. Hip arthritis can occur for a number of reasons and causes pain and restricted mobility.

Typically, the procedure itself involves removing the worn part of the hip, the top of the thigh bone, and replacing that with a metal stem that is introduced and secured into the thigh bone (femur). The component can either be secured using bone 'cement' or by using a component with a special surface coating, into which the bone would be expected to grow and secure the implant.

On the other side of the joint, in the pelvis, a socket is positioned inside the bone of the pelvis. Again, this can either be secured with bone 'cement' or indeed with 'uncemented' technology.

Subsequently, a 'liner' is inserted into the acetabular component. Similarly, a' ball' is put onto the femoral component. This gives a 'ball and socket' joint which allows a very much better range of movement and a very significant, if not total, reduction in the patient's pain.

Who might need a hip replacement?

Professor Lee Jeys: You might need a hip replacement if your damaged hip joint causes persistent pain, affects your mobility such as walking, driving and interferes with every day activities such as getting dressed.

Osteoarthritis (wear and tear of the cartilage inside the hip joint causing bones rubbing against each other) is the most common cause of this type of damage. However, other conditions, such as rheumatoid arthritis (body's immune system mistakenly attaching cartilage of the hip joint), hip fracture and avascular necrosis (death of bone caused by insufficient blood supply) may need hip replacement surgery.

Mr David Gerard Houlihan-Burne: Hip replacements are indicated for patients with painful arthritis of the hip. The aim of the surgery is to eliminate the pain of arthritis. It is not an operation for increased flexibility nor to allow a patient to return to sports. The prime aim is to remove pain which should be severe and unremitting.

Mr Andrew Manktelow: While the average age for hip replacement surgery in the United Kingdom is in the late 60s, hip replacement surgery can be required at any age. The youngest patient in whom I have had to replace a hip is 13, the oldest is at 97.

While arthritis is perhaps the most common cause for patients to require hip surgery, there are other conditions that can occur in a patient's childhood that can pre-dispose to developing arthritis and require surgery. Similarly, other factors such as infection or trauma can cause damage to the hip and can accelerate wear and result in the patient requiring surgery.

Are there any lifestyle or dietary changes I can make to reduce the risk of needing a hip replacement?

Professor Lee Jeys: Exercise, weight loss and walking aids may alleviate some of the stress from damaged painful hips. However, damage and wear in the hip joint will not improve with lifestyle or dietary changes but usually deteriorates over time.

Mr David Gerard Houlihan-Burne: Arthritis of the hip responds well to weight loss and exercise. Building the muscles around the hip joint and increasing its flexibility will reduce pain and prevent the need for premature surgery. This is often best done under the guidance of an experienced physiotherapist. Food supplements such as omega oils, chondroitin and glucosamine can, in some patients be of benefit.

Mr Andrew Manktelow: It is important to keep oneself fit, active and healthy for many reasons. Keeping your hip healthy and strong is no different. There is no strong evidence that diet affects arthritis of the hip. However, keeping your weight at an optimal level is important. Some patients do find dietary supplements such as glucosamine helpful in early arthritis.

What are the benefits of a hip replacement?

Professor Lee Jeys: For the majority of people who have hip replacement surgery, the procedure results in:

• A decrease in pain
• Increased mobility
• Improvements in activities of daily living
• Improved quality of life

People who benefit from hip replacement surgery often have:

• Hip pain that limits everyday activities, such as walking or bending
• Hip pain that continues while resting, either day or night
• Stiffness in a hip that limits the ability to move or lift the leg
• Inadequate pain relief from medications, exercises or walking aids

Mr David Gerard Houlihan-Burne: Relief of pain from arthritis is the aim of a hip replacement. This is often dramatic and instant. Secondary gains include improved mobilisation, increase flexibility and for some patients with advanced arthritis causing a shortening of the leg, restoration of equal leg lengths.

Mr Andrew Manktelow: The results of hip surgery are very reliable with many patients reaching a stage where they have almost forgotten which of their hips they have had replaced over time and as function improves.

As such, the benefits of a total hip replacement really are a very definite and reliable improvement to the patient's activity with reduction in pain and an improved range of movement that should allow the patient to get back to a very good level of activity.

There are numerous different types of hip replacement, different bearings and different ways that the components can be fixed to bone. Hip replacements should have very good medium and long terms outcomes.

Patients should expect a hip replacement to have a 95 per cent chance that it will last to ten years and beyond. Indeed, many hip replacements would be expected to last a great deal longer than this.

All the various options in hip surgery should be discussed, prior to the surgery.

What are the possible complications of a hip replacement?

Professor Lee Jeys: Hip replacement carries risk of complications like any other major surgery, although serious complications are uncommon, occurring in one in 100 cases.

• Infection: You will be given antibiotics during and after surgery to reduce the risk of infection. Minor infections of the wound are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis
• Blood clots: Small risk of blood clots developing either inside one of your leg veins, known as deep vein thrombosis or inside your lungs, known as pulmonary embolism within first few weeks of surgery. You will be given blood thinning medication and leg stockings to reduce this risk
• Loosening: Loosening of the artificial hip is the most common cause of failure of hip replacement. It can happen at any time but is most common after 10-15 years. If loosening is painful, a second surgery called revision may be necessary
• Dislocation: Dislocation occurs if the ball of hip comes out of the socket. It is most likely to happen in the first few months after surgery when the tissues are healing. It needs to be put back in place under anaesthetic. For recurrent dislocations, brace or further surgery may be required
• Leg length discrepancy: A small risk of your leg slightly shorter or longer after hip replacement and you may need to wear a raised shoe to correct your balance
• Nerve damage: Nerve damage can cause numbness around the scar or rarely loss of sensation or weakness in the foot. It usually is temporary

Mr David Gerard Houlihan-Burne: Patients must be fully informed and aware of all the potential complications of having a hip replacement. These include general complications of any surgery, as well as those specific to having a hip replacement. General complications include infection, both superficial wound infections and deep infections, and blood clots in the legs, more rarely in the lungs. Preventative measures are given for both of these.

More specific complications include dislocation of the artificial hip, damage to nerves and blood vessels, fracture of the bones of the hip and thigh and unequal leg lengths following surgery. Patients should also be aware of the life span of a hip replacement, with current replacements and surgical techniques providing a lifespan in excess of 10-15 years.

Mr Andrew Manktelow: Like any surgery, there are potential concerns. Clearly an infection in a hip replacement is a major issue and this can sometimes require the hip replacement to be removed and necessitate further surgery.

Similarly, there are complications such as the hip jumping out of joint (dislocating), nerve injury and bleeding. Broken bones can occur as a consequence of the surgery. Similarly, clots can develop in the legs or indeed in the chest after surgery. For this reason various chemical and physical treatments are used to reduce the risks around the time of the procedure.

While there are very definite risks, patients who require hip surgery should be reassured by the fact that these risks are extremely uncommon. However, clearly all the potential concerns should all be discussed in detail with the surgeon.

If there is any specific or increased chance of there being complications, these should be identified. It is essential that everything that can be done should be done, to reduce those risks.

What happens during hip replacement surgery?

Professor Lee Jeys: A hip replacement operation usually lasts for 1-2 hours. Prior to operation, your anaesthetist will discuss with you the type of anaesthesia. Surgical cut on your hip and thigh will be around 6-8 inches long. The socket of the hip will be hollowed out and a new artificial socket will be fixed in it.

The ball at the top end of your thigh bone (femur) will be removed and a smaller artificial ball on a metal stem will be inserted into your thigh bone to articulate with the new socket. Both cemented and uncemented hip replacements are undertaken at our hospitals. Your surgical wound will be closed with sutures or staples.

Mr David Gerard Houlihan-Burne: Patients are anaesthetised, most commonly using a spinal or epidural technique to numb them from the waist down. This means they do not have to be asleep, but many prefer sedation as well, or rarely they are given a general anaesthetic. After being positioned on the operating table, usually on their side, the leg is sterilised and an incision is made around the hip.

The existing hip joint is dislocated and removed. The socket is prepared and a new socket inserted, either with cement (a medical glue) or press fit (uncemented). Similarly, the thigh bone is then prepared to accept a stem on which the new ball of the ball and socket joint sits. This is also either cemented or uncemented. Finally, a new ball is fitted to the stem, the hip relocated and the wound sutured closed.

Mr Andrew Manktelow: Typically, these operations are performed using spinal/epidural-type anaesthetics with an injection into the back, to 'numb' the hip and the legs. Subsequently medication is used to relax and gently sedate the patient so that if they wish, they do not need to be aware of exactly what is going on at the time of surgery.

This technique can have benefits in allowing good pain relief following the surgery but also reducing the amount of blood loss and reducing the risk of clots happening after the operation. In some circumstances, however, the anaesthetist may decide that it would be better to use a general anaesthetic technique.

Again, all of these options should be discussed with the patient and with the surgeon prior to the procedure.

What is involved in the recovery from surgery and how long is the recovery period?

Professor Lee Jeys: Once the operation is over, our nursing team will monitor your progress to ensure your recovery. Physiotherapist will usually visit you at regular intervals. They will guide you to do the exercises to improve your mobility and hip muscles strength.

They will also teach you the proper techniques for simple activities of daily living, such as bending and sitting as the new artificial hip has limited range of movement compared to a natural healthy hip.

You will be discharged from hospital once you are able to walk safely and on stairs with the help of crutches. Your hospital stay is generally between 3 to 5 days. Your stitches or skin staples will be removed at 12-14 days. You will need to use crutches or sticks for 4-6 weeks.

You should continue to do daily exercises as advised by physiotherapists and gradually improve your physical activity each day. You can usually return to light work at around 6 weeks. It may take longer if your work involves prolonged standing or lifting.

Full recovery from the surgery takes about 3 to 6 months. Swimming except breaststroke can be started at 6 weeks, cycling and sports involving bending or twisting of the hip at 12 weeks.

Mr David Gerard Houlihan-Burne: Patients should all now follow a rapid recovery protocol and be mobilised the same day as the surgery. Over the course of 2-3 days, they will progress to walking with crutches and managing stairs. They are discharged when safe and able to be self-caring.

Pain killers and crutches are needs for about 3-4 weeks whilst the wounds heal and the patient becomes more mobile. It is recommended not to drive or go back to work until a minimum of 6 weeks after surgery. Pain and mobility can then continue to improve for up to 6 months after surgery, with physiotherapy guidance for the first few months.

Mr Andrew Manktelow: While the operation does involve some discomfort following surgery, pain is not a major concern and we would expect the patient to mobilise soundly on either the day of or indeed the day after the procedure. Typically, patients are kept in hospital between two and five days and then are mobilised at home.

During the hospital stay, physiotherapy colleagues see the patient to aid with rehabilitation. There may be one or two living aids that are delivered to the patient's home to allow them to mobilise safely.

Over the first few weeks, the patient should mobilise on the hip, working hard with the exercises given to, aimed at improving mobility in the hip, increasing the amount of weight that is put through the leg.

Typically, patients will feel very definite improvement both in their range of movements and their pain within the first few weeks. This would be expected to progress steadily.

One would expect the patient to be walking essentially free of crutches within six weeks and for their movement to continue to improve, the swelling and discomfort to settle steadily and really for the patient to have made a very sound reliable recovery by around three months.

• Everything you need to know about recovering from hip replacement surgery

Are there any alternative options to surgery? What else can I do to manage hip pain?

Professor Lee Jeys: Exercises, walking aids, pain medication, weight loss and modification of lifestyle may help as alternatives to surgery although the non-surgical options will not cure your symptoms. You can be referred to pain clinic for appropriate pain medication as long-term consumption of some medicines can have serious side effects, such as stomach upset, drowsiness.

Mr David Gerard Houlihan-Burne: There are alternatives to hip replacement surgery and these should all have been discussed and explored before making a decision to proceed with surgery. In some patients the arthritis may be so advanced and the pain so severe, the surgeon will recommend going straight to surgery without other options being appropriate. Weight loss is mandatory and reducing your BMI to a normal level can dramatically improve your pain.

Painkillers and physiotherapy are also important and can keep the symptoms under control for many years. Injection of steroids into the hip, done under X-ray or ultrasound guidance, are also a useful way of reducing symptoms and allowing physiotherapy and muscle strengthening to progress.

Mr Andrew Manktelow: There are many other options that can be used to treat early degenerative arthritis and indeed there are now operations that we are considering, to try and prevent arthritis from occurring in the first place, in certain circumstances.

While the early stages can be treated with simple painkillers, gentle physiotherapy and a change in the patient's activities, as the condition worsens the cartilage damage progresses. Pain can worsen such that it interferes with a patient's function at work, home and indeed with their desired level of recreational activities.

Unfortunately, as the pain and restricted mobility starts to worsen the use of simple painkillers, physiotherapy, walking aids and reduced activity starts to become less successful. Patients can experience anterior groin pain that can radiate down into the thigh and towards the knee or indeed buttock pain and will experience worsened mobility in the hip.

Patients might limp and many find it a struggle to put on their shoes and socks, to climb stairs and to get in and out of the car. Once the situation progresses so that they are unable to enjoy their desired level of activity, hip surgery may well need to be considered.