- Inform yourself about outcomes and risks of surgery.
- Get recommended medical, dental, and other checks to ensure safety.
- Exercise muscles before surgery, whether upper or lower body.
- Understand and follow discharge instructions when you leave the hospital.
- Communicate with your surgeon and primary doctor often, especially if you have questions.
- Avoid smoking and excess alcohol use during recovery.
- Maintain good hygiene and reasonable body weight.
- Participate in scheduling, planning, discharge, and related processes.
- Select a surgeon in whom you have confidence and trust.The decision to have elective surgery should be made after careful thought and deliberation.
How do the implants work in a hip replacement?
You have a natural socket (called the acetabulum) in the pelvis. The hip ball normally sits in this socket. By reaming away the damaged bone and cartilage, fresh bone is exposed, and a slightly oversized hemispherical socket made of a sturdy, inert titanium alloy is impacted into your bony socket. Usually this impaction does not require fixation with screws since the mechanical press-fit is snug enough. Into this titanium shell, a bearing surface of polyethylene, ceramic, or metal is then locked mechanically.
Next, the femur (thigh bone) is prepared by cutting off the arthritic femoral head (the ball of your hip joint). The cavity inside the femur bone is enlarged, and a slightly oversized femoral implant is securely impacted into the femur. The stem has a metal junction at its top end, designed to fit an artificial ball. This ball is made of a cobalt-chrome alloy, or ceramic, and matches the diameter of the bearing earlier fitted inside the artificial socket.
Once the ball is placed in the socket during surgery, the surgeon must adjust leg lengths, implant stability, muscle tension, and range of movement of the hip joint. This is where surgeon judgment and expertise are critical. The new artificial ball will rotate inside the synthetic shell just like a natural hip ball and socket would, except the artificial parts will not produce any pain.
What materials are used in a hip replacement or resurfacing?
The structural parts are made of titanium alloy. Structural means that the skeleton grows and bonds permanently to these parts. Alloy means that the metal is not pure titanium. It is a mixture of other metals to enhance the safety, performance, and avoid possible allergic reaction to any one metal.
Titanium alloys are used for this purpose because of durability, biocompatibility, several decades of experience, and the fact that titanium is less stiff than other metals and therefore better suited for skeletal reconstruction.
The bearings are mounted on the structural parts, using specially engineered tapers. Bearing surfaces in the hip are made of plastic, metal, or ceramic. The choice of bearing depends on the individual patient.
In engineering hip replacement components, the structural parts are optimized for their ability to bind to living bone and for long-term biocompatibility and durability, while the bearings are optimized for the lowest wear rates.
What do you do on the socket side of a hip replacement?
On the socket (pelvic) side of a hip replacement or resurfacing, a metal half-shell is fitted inside the patient’s own bony socket. Inside this shell, a locking mechanism fastens the bearing, which can be polyethylene, metal, or ceramic. Screws were once used to fix the socket to the pelvis bone, but with modern designs, screws are rarely necessary.
The bearing part can be changed even years down the road, without disturbing the metal cup that has grown into the pelvis.
What do you do on the femur side of a hip replacement?
On the femur (thigh bone) side, the inside cavity of the thighbone is enlarged, and a metal femoral stem is implanted in this cavity, where it will bind to the bone. On this stem, an artificial ball is attached using an engineering taper. The ball is made of either cobalt-chrome metal, or ceramic. The ball can be changed at any time in the future, if need be, without removing the stem from the femur.
What brand of hip implants do you use?
Brands such as Zimmer, OMNI, and Wright Medical Products have been popular in the past, but new ones are always being tested. Look for designs that have withstood the test of time, with excellent long-term results. Implant companies make several models and designs of implants, and the precise application depends on individual patient needs and anatomy.
The most common bearing surface used in hip replacements is a cobalt-chrome ball with a cross-linked polyethylene socket liner. This bearing is built upon decades of experience with standard (non cross-linked) polyethylene; the material offers more flexibility and options to make hip replacement safe and predictable.
If you have a strong preference for a certain type of joint prosthesis, or a certain type of material, discuss that with your surgeon.
There is very little difference between the implants offered by the major manufacturers. Be wary when companies pay doctors to promote or use any product.
What if I want a particular brand of hip replacement?
Simply let your surgeon know. You want to work with someone who embraces the latest technology, biomaterials, and surgical methods.
Be cautious about the unregulated marketing and promotion of hip and knee implants though. Orthopaedic companies and hospitals want business, and their advertisements rarely give the complete picture. Your surgeon should offer you unbiased opinion about different implants, while respecting whatever decision you make in this regard.
How much do the parts used in hip replacement weigh?
The parts weigh about 3 to 5 pounds. The bone removed during hip replacement weighs a little less. So, you may gain a few pounds of body weight as a result of hip replacement surgery. This is more than balanced by the fact that people tend to lose weight after surgery due to diminished appetite and the stress of an operation.
Why does an artificial hip wear?
Everything wears out over time. Artificial hip bearings are no exception. During everyday activity, our hips endure several million cycles a year. People who are athletic or walk more than usual will load their joints even more. Cyclic loading leads to wear, even though modern hip bearings are extremely wear-resistant. But, no bearing surface is completely wear-proof.
Realistically, for most patients, bearing wear in an artificial hip is not a practical concern. Assuming the surgery is done properly, most modern hip bearings will last longer than the patient’s lifespan.
Where do wear particles from the artificial hip go?
All hip bearings produce microscopic wear particles that collect in the soft tissue envelope around the artificial hip. This layer of tissue, called the hip capsule, forms around the prosthetic joint after surgery. Cells in this layer act like a “biological sink” by absorbing and storing the wear particles.
Some wear particles migrate into the body, and are spread by the circulating blood to remote organs such as the heart, liver, spleen, and lymph nodes. No study has shown any adverse impact of such wear particles from artificial hips that spread throughout the body, although this remains an area of investigation and research.
What is the advantage of ceramic bearings in hip replacement?
Ceramics are synthetic materials, used in industrial applications. When used in orthopaedic bearings, their wear rates are extremely low.
A disadvantage of ceramic bearings is that there are fewer options for the surgeon. This is related to engineering limitations. With future developments, ceramic bearing use may become more widespread. Today, for most patients, a cobalt-chrome ball and cross-linked polyethylene offers the best trade-offs between safety, longevity, flexibility, long-term wear, and sizing options.
Can ceramic parts be used in my hip replacement?
Yes, such as a ceramic ball and a plastic socket. Or we can use ceramics in both the ball and the socket. Either combination offers extreme wear resistance and durability.
Old-design ceramics were brittle, and the extreme hardness of ceramic materials limited their use in hip replacement. The newer ceramics are super tough alloys, especially engineered for the orthopaedic market. They are safer, and have excellent long-term outcomes, with almost zero wear.
Even newer ceramic materials made of silicon nitride are in development; silicon nitride offers even less wear, with extreme durability and strength.
When do you use cement to fix the hip components?
Cementing implants is reserved for the elderly and for cases in which the bone anatomy requires a cemented implant. The majority of hip replacements are done without bone cement.
In decades past, cement was used extensively to attach metal parts to bone. Cement is now rarely use cement in hip replacements thanks to developments in biomaterials and implant design.
How durable are cemented parts in hip replacement or resurfacing?
Data from hip replacements done many decades ago show that cemented total hip sockets usually loosened up after 10 to 15 years and that cemented femoral stems usually loosened up after 15 to 20 years. Today, cement is rarely used in hip replacements; in fact, if a previously cemented hip replacement has come loose, the parts used in repeat surgery are of a cementless design. Such components are designed to heal to native bone; this type of skeletal fixation has almost indefinite durability.
How do cementless hip implants attach to bone?
They attach by healing directly to bone. Metal surfaces are designed with a porous honeycomb metal structure, into which bone can grow. This biologic fixation is very strong and will not loosen over time.
While bone is growing into such parts, initial stability relies on a mechanical fit between metal and bone. This is achieved by physically impacting or hammering the parts into bone during surgery.
Once bone grows into the socket and femoral stem, the bond is permanent.
Can I get the same hip implant that a famous celebrity has?
Implant companies use celebrities to promote hip replacement, typically showing the youthful lifestyle and active involvement in skiing, golf, and other outdoor activities. Please view all marketing and promotional information with skepticism; such information is not always complete.
In reality, participation in sports such as golf and other activities is just as possible with one brand of hip components as the other. No brand in the market today is superior in terms of returning patients to activities faster or in giving patients an advantage in a specific sport, no matter which celebrity a company pays to tout its products.
Do I need a custom implant or instruments made from CT/MRI studies?
Hip components come in many sizes, configurations, models, and geometries. Off-shelf components give a precise fit in nearly all the patients. In some cases involving congenital abnormality, special-sized components can be ordered if necessary.
Technology keeps advancing, and in the future, custom-built hips that are designed precisely for one person to ensure perfect leg lengths, tissue tension, fit, and sizing will probably become a reality. Surgery advancements will probably mean that some patients may even be able to go home the day of surgery. These innovations reflect research and product development that professionals around the country are actively engaged in at the present time, to further improve on the already very successful operation of hip replacement.
Do you use human tissue or parts for hip replacement?
In routine total hip replacement, no such tissue is needed. Many years ago, we used allograft bone in some complicated cases to restore deficient bone. But with newer metal composites that can be shaped like bone, human tissue is no longer necessary for hip surgery.
In fact, metal augmentation techniques have advanced such that we can help patients who in the past were probably beyond help. The ability to rebuild hips that have had multiple operations previously, and to restore people to function, is a practical advantage of innovation and improvement in our health-care system.
Can patients develop an allergy to the artificial hip?
Such occurrences are exceedingly rare. Most commonly, what is often called an allergy is a missed, subtle infection. True metal allergies are usually well known to the patient ahead of time. In such unusual cases, it is possible to use components made of alternative metals, based on allergy testing, to which the patient is not sensitive.
Some patients did develop allergies and reactions to the metal-on-metal bearings; those designs have been recalled from the market.
Here are answers to frequently asked questions about what happens during hip surgery and immediately afterward. Procedures vary somewhat at different hospitals and with different surgeons. Be sure to discuss this with your specific surgeon and medical team!
Who will be doing my hip surgery?
Hip surgery is complex, and requires judgment and experience. Although team members will assist, and resident physician or students may observe, you can expect that an experienced orthopaedic surgeon will perform the entire operation.
Where will the surgery be done?
There are many state-of-the-art, technologically advanced specialty orthopaedic hospital in the U.S. Such centers are specifically equipped for joint replacement surgery and national data show a lower risk of complications, such as infections, and better outcomes from hip and knee replacement surgery.
What type of anesthesia will I have?
Typically, a spinal anesthetic with sedation will be used. This type of anesthesia is safer than general anesthesia for hip replacement surgery. In addition, we used a combination of injections and pain relief modalities. If you have any preference for a certain kind of anesthetic, please let your medical team know. Modern anesthetic drugs ensure that you will probably remember very little, if anything, about the surgery.
What should I do the day of my surgery?
Do not eat or drink anything, including gum and candy. Unless advised differently, take your blood pressure and heart medications with a sip of water. Avoid make-up, nail polish on fingers or toes, perfume, or cologne. Remove all jewelry in anticipation of surgery.
Can I wear my contact lenses to surgery?
You will have to remove your contact lenses prior to going into the operating room. Bring glasses, if you have them, or bring solution and a holder for your contacts.
Where does family wait and who updates them?
Your family will be in a waiting room while you are in surgery. They will be informed when surgery is over and you are in the recovery room. You will remain in the recovery room for approximately 1 or 2 hours before going to your room. Your family can see you once you have arrived in your room.
How much will I hurt after surgery?
There is very little pain early on, since modern pain medications and anesthetic techniques are very effective. Recovery from surgery is far more comfortable today than it was just a few years ago.
The hip joint itself and the tissues around it are injected with local pain-killing drugs.
If you were taking narcotic drugs before surgery, pain control is more difficult since the body gets desensitized to the pain-killers. In such cases, doctors typically prescribe a higher dose of pain-killers, and sometimes use a combination of drugs.
Pain medicines can be given by mouth, intravenously, or by intramuscular injection. If you hurt, please let someone know; they want to minimize discomfort and customize the treatment for you.
By the time you leave the hospital, your pain will be properly controlled by an oral pain medication. Depending on the patient, such medications may be taken for several weeks.
What can I expect right after surgery?
You will notice a bulky dressing and an ice pack on your hip. The ice pack helps to control pain and swelling. You may also have a drain in the incision that looks like a plastic tube; this is removed within 24 to 48 hours. Expect a catheter in your bladder to keep urine drained; this is usually removed within 24 hours.
After an hour or so the nursing staff will take you to a private room. If your family plans to stay in the hospital room with you, please talk to your nurse so that arrangements can be made.
The nursing staff will coach you to take frequent deep breaths after surgery. You will have a breathing device to help with this. This is a plastic breathing exercise machine designed to prevent pneumonia and keep the lungs healthy.
You will have an overhead lift on your bed to assist you in moving independently. This allows you to use your arms to move your body. Feel free to position your body in any way you want after hip surgery. For the first night, we prefer the leg slightly bent, on a pillow, since this reduces bleeding in the hip. The head of the bed can be in any position that you like.
You will have elastic stockings on and some sort of pump device squeezing your feet or legs to reduce the chance of a blood clot. You should exercise your calf and ankles regularly after surgery while you are awake. This will cut down the risk of a blood clot.
Why are there pumps on my feet after surgery?
Mechanical foot pumps are used to squeeze the feet and ankles intermittently after surgery in order to decrease the risk of blood clots. These are useful while you will be in bed and resting; you will not need them at home.
When can I eat after surgery?
Right after surgery, avoid eating solid foods. It is better to start with liquids and make sure that you can handle these before you progress to a full diet. Nausea is a very common side effect of modern pain medications. So, go slowly right after surgery to make sure you can keep liquids down, without nausea, before you progress your diet.
How are hip surgeries performed?
Common approaches are covered here.
What is a surgical approach?
The anatomic pathway used to reach the bones of the hip joint is also referred to as the surgical approach. Each surgical approach is a different technique to gain access to the joint itself, and exposes the anatomy for a hip replacement or hip resurfacing.
The most common hip joint surgical approach used by U.S. surgeons is called the posterior (from the rear) approach. Patients who have had a posterior approach typically have a curved scar on the outside of the thigh with a top part of the scar curving into the buttock. This approach is very popular, easy to learn, predictable, and cuts through a limited amount of muscle and tendon, resulting in good recovery.
Even in the hands of very good surgeons, the posterior approach is associated with a small risk of the hip popping out after surgery. Newer techniques and implants have reduced this risk somewhat, but a small possibility of hip dislocation remains associated with the posterior approach.
Another common surgical approach to hip replacement is the lateral (from the side) approach. The lateral approach also involves a scar on the side of the thigh, but instead of being curved, the scar is usually a straight line. The advantage of this approach over the posterior approach described above is a lower risk of dislocation.
The lateral approach nearly eliminates the risk of dislocation, but the approach involves cutting through more muscle tissue on the way to the hip joint. As a result, patients will usually have a slight limp after surgery, which generally disappears 6 to 12 months following surgery.
Another popular approach is called the anterior (from the front) approach. This method is still new in the U.S., with more surgeons using it every year. Very few surgeons in the United States use this approach routinely for all hip replacements. This is a true muscle-sparing approach with a very quick recovery.
What are the advantages of the anterior approach?
One advantage of the anterior approach relates to easier and safer patient positioning for surgery. The patient is on the back, which is a more natural position than placing the patient on the side, which is required in the posterior and lateral approaches.
Another advantage is that leg length checks are easier when the patient is on his or her back. Both legs can be easily assessed relative to each other.
Finally, the anterior approach does not cut through any muscle. The muscles are separated along their natural planes, and the entire joint can be replaced through a much shorter incision, with true sparing of muscle.
Muscle-sparing is beneficial in another way. The risk of dislocation (the hip ball popping out of the socket unexpectedly) is nearly zero with the anterior approach. With other methods of hip replacement, patients must follow certain precautions for a lifetime.
For example, patients are usually advised to not bend too far, tie shoes, or cross the legs for fear of the hip popping out of socket. These precautions and worries do not apply to hips replaced using our anterior approach.
Around 2003, a “two-incision” hip surgical approach was developed by surgeons in Chicago as the first truly minimally invasive hip replacement. We adopted that technique, published our results in peer-reviewed literature, and refined the method to make it safe and predictable in our patients.
The present-day anterior approach is an evolution of that work; instead of two incisions, the anterior approach allows us to perform the entire hip replacement through one short skin incision placed toward the front of the thigh.
Patient recovery and function are better with the anterior approach, when compared to conventional techniques.
What are the disadvantages to the anterior approach?
This technique is still relatively new and not widely used in the United States, since it involves new learning and is difficult to master. Very few surgeons use it routinely in all patients, given the technical challenges in learning it and getting comfortable with the technique.
Another reason is that with the scar in the front there is the risk of skin numbness over the side and front of the thigh as the result of microscopic skin nerves that are cut in during surgery. These nerves will heal over time, and thigh sensation is restored a few months after surgery. The nerves do not affect any muscles; subjective numbness is the only symptom.
Thigh numbness is usually not a significant issue other than a transient symptom that resolves. It is generally agreed that the temporary numbness is more than balanced out by the substantially improved recovery, reduced pain, absence of a limp, faster return to function, and virtual elimination of the risk of hip dislocation.
What surgical approach is typical for a complex total hip replacement?
In very difficult hip reconstructions, such as those in which the hip has been replaced many times previously, or the pelvis has to be repaired with plates and screws before placing a metal socket, or where extensive repair of the femur needed, the surgical method that spares the muscles while permitting the best exposure is called a trochanteric osteotomy.
A trochanteric osteotomy involves cutting a piece of bone near the top of the femur. This bone is called the trochanter, and is the bump you can feel on the side of the thigh. The major hip muscles involved in walking all attach to the trochanter.
Cutting the trochanter with all the muscles still attached is the oldest of hip approaches. Once the trochanter is cut, it can be moved aside along with the attached muscles, thereby facilitating entry into the hip joint. The resulting view of the hip is excellent for any type of hip replacement, no matter how complicated or difficult.
Metal cables are used to reattach the trochanter to the femur. The trochanter can be attached farther down the femur if tightening of the muscles is desired. This method gives the surgeon the freedom and flexibility to adjust leg lengths and tissue tension, independent of each other.
For first-time hip replacements, and even many repeat hip replacements, a trochanteric osteotomy, despite its above advantages, is rarely needed. This method is dictated by complex, difficult, and unusual hip replacement cases.
Do surgeons use computer navigation during hip replacement surgery?
Precise alignment of the bones and components is essential to the long-term success of both hip replacement and hip resurfacing. Computer and robotic technology can help in alignment of bones and reduce the possibility of error.
However, so far there is no substitute for the skill, judgment, experience, hands, and eyes of a high-volume surgeon.
Future technology is aimed at building custom hip components for each patient, thereby ensuring a precise operation and optimal implant placement, with no need for robots or computers.
What is the role of computer guidance in hip replacement?
At present, computer-assisted technology is most effective for low-volume surgeons. It helps such surgeons reduce the likelihood of error in implantation of the hip components. For some surgeons and hospitals, the greatest advantage of this technology is in marketing.
In other words, computer and robotic technology, while sounding fancy, do not add much value to the hands of an experienced, high-volume surgeon.
What about that minimally invasive hip replacement that I read about?
Bear in mind that all surgery is invasive to the mind, body, and psyche. Surgery is a very different experience for the patient than it is the surgeon, hospital, or implant manufacturer. Hip surgery is much easier today when compared to the past, but complications, pain, discomfort, and recovery still apply. Each patient’s expectations and physical, emotional, personal, and spiritual attributes are different and affect recovery profoundly.
For example, some patients can leave the hospital the same day or the day after hip replacement. But this is not true of all patients. Unfortunately, some health-care professionals use words like minimally invasive surgery, computer-driven surgery, custom-built implants, and same-day operation as business-driving tools. This type of marketing can be misleading and can create unrealistic expectations.
How long will my scar be?
The scar is about 3 to 5 inches long, and placed in front of the thigh. The length of the scar can vary, and will depend upon patient body size, the severity of arthritis, the condition of the soft tissues, and the deformity of the joint.
While the length of the scar has little to do with how fast you heal, everyone prefers to have the shortest scar. Your surgeon will aim for the smallest possible incision that allows safe and efficient surgery, with accurate implant placement.
Independent of the scar length, hip replacement surgery with our anterior approach avoids muscle damage. By spreading muscles apart, the recovery is much faster and easier.
Are there newer surgical approaches being developed?
Yes, there are exciting innovations constantly being developed. One example is the “Super-PATH” technique with which we hope will improve recovery by minimizing surgery so much that same-day discharge may be possible for some patients. These efforts entail painstaking, detailed experimental work in the laboratory, extensive cadaver-surgery training, development of new instruments, and collaboration with experienced and gifted colleagues nationwide.
What is hip resurfacing?
In hip resurfacing, a metal cap is glued on the arthritic ball instead of replacing the ball itself. Some implant companies and surgeons have promoted hip resurfacing in recent years, but hip resurfacing has been around for many decades.
How are hip resurfacing and hip replacement different?
Hip resurfacing and hip replacement are similar. Both replace all arthritic surfaces in the arthritic hip. On the socket side, both operations entail removing a layer of arthritic bone and cartilage from the pelvis, and replacing it with a metal cup.
The main difference between hip replacement and hip resurfacing is what is done to the femoral bone (thighbone).
In hip resurfacing, the arthritic ball is prepared such that a metal cap is glued onto your bone. The diameter of the metal cap matches that of the artificial socket.
In hip replacement, the arthritic femoral ball is cut and replaced with a new ball. The inside of the femur bone is prepared to implant a metal stem 3 to 5 inches in length. On this stem, a mechanism allows attachment of a metal or ceramic ball that matches the size of the socket. Once the ball is placed into the socket, the hip replacement is complete.
Do hip replacement and hip resurfacing cost the same?
A hip resurfacing is more expensive because surgical time is longer and the implants are more costly. At present, the parts for hip resurfacing cost about twice as much as hip replacement parts.
What are the advantages of hip resurfacing?
The advantage of hip resurfacing is preservation of 1 to 2 inches of bone, on top of the thighbone. In theory, if you need repeat surgery in the future, this bone is available to the surgeon to work with.
This made sense in previous decades, when the lifespan of hip replacements was limited by material quality; the older synthetic ball-socket would wear out in 10 to 15 years. The wear particles would result in inflammation and bone loss around the implants. As a result, the implants would loosen, requiring repeat surgery.
Modern hip replacement bearings and implants are much improved though, and should outlast the lifespan of most patients. This assumes of course that the prosthetic parts are properly implanted and accurately aligned during surgery.
Also, today, if repeat surgery is needed on a prosthetic hip, modern metal technologies allow us to rebuild and reconstitute missing skeletal bone.
Therefore, the only advantage of hip resurfacing (preservation of an insignificant amount of femoral bone) when compared to hip replacement, has little practical value.
Hip resurfacing and replacement feel the same to patients, and are equally effective in relieving pain, restoring function, and restoring the ability to participate in any activity.
What are the disadvantages of hip resurfacing?
One, the metal cap must be glued to the arthritic femoral head. This glue can loosen up over time, causing the resurfacing to fail. There is no cement-less version of the metal cap in hip resurfacing.
Two, the bone directly underneath the metal cap, called the femoral neck, can break, especially if it is weakened during implantation of the metal cap. If this happens, urgent surgery is needed to convert the hip resurfacing to a hip replacement.
Three, hip resurfacing is more invasive than hip replacement. Since the femoral head is preserved in hip resurfacing, the surgeon has less room to work; therefore, the incision is longer and the surgical exposure is more extensive with hip resurfacing. Some surgical methods, such as the anterior surgical approach, allow hip resurfacing through a less invasive approach, but the operation is still more extensive than a hip replacement.
Four, the only kind of bearing in hip resurfacing is metal-on-metal. In hip resurfacing, the inside of the socket is a polished metal, and so is the metal cap that covers the femoral head. Actual hip movement in hip resurfacing is from metal-metal contact; this bearing is the only one possible in all modern hip resurfacings. Recent studies have raised a worry that metal-metal hip bearings can cause a reaction in some patients, requiring more surgery.
What are the advantages of hip replacement?
A key advantage is its longevity and track record. The technology used in modern hip replacements is safe and well-proven in millions of patients. The nuances, complications, surgical techniques, and outcomes of this operation have been thoroughly investigated. A properly performed hip replacement should outlast the patient; this is significant since no one wants repeat surgery.
Of note, different bearing surfaces can be used in hip replacement. This is because there is more latitude in the engineering design of hip replacement components. In hip replacement, once the metal shell and the femoral stem are implanted, the surgeon and patient have a choice of bearing, including metal-metal, metal-plastic, metal-ceramic, ceramic-plastic, and ceramic-ceramic.
Also, hip replacement bearings can be changed out several years after the surgery; the bearings are removable independent of the implants. In contrast, hip resurfacing bearings cannot be changed; the entire component must be removed, along with some bone, if a change of bearing is desired for any reason in the future.
What are the disadvantages of hip replacement?
The disadvantage, when compared to hip resurfacing, is that an additional 1 to 2 inches of bone at the top of the femur must be sacrificed. However, removal of this bone is of little, if any, practical consequence. If a hip replacement should ever fail, repeat surgery is relatively straightforward and predictable in the hands of an experienced surgeon. Also, we have many ways of making up for lost bone today; saving an inch or two of bone is of no clinical consequence over the long-term.
What if I choose to have hip resurfacing based on what I have read?
If a hip resurfacing is your choice, then that is the operation your surgeon should perform for you. In our practice, there is no preference or bias, nor any financial inducement toward one procedure or the other. The above comments are presented to share information known to professionals in our field, and may differ from claims made by hospitals and surgeons promoting hip resurfacing.
Can hip replacement surgery change your height?
You’d be surprised how often this question is asked, and the answer may surprise you!
If both hips are replaced, can you add height to my body?
Yes. If both hips are replaced, it is possible to increase the leg length on one side and increase it by the same amount on the other side. But, any gain in height is about an inch or less. The limiting factor includes the muscles, tendons, and nerves, which only have so much stretch before there is injury or damage.
It is possible to replace both hips at the same time, if the patient is healthy enough for such surgery. Recovery from two hip replacements does not differ much from having one hip replaced, at least with newer, less-invasive surgical methods.
Will my leg be longer or shorter after hip replacement surgery?
This is an important topic, and should be understood before you embark on any hip replacement, no matter where you have the hip replacement done.
Hip resurfacing is an operation that is similar to replacement. During resurfacing, the arthritic ball is capped with metal, and an artificial socket is placed in the pelvis. Any bone removed is replaced with an equivalent thickness of metal in hip resurfacing, so there is no noticeable gain or loss in leg length during hip resurfacing.
In contrast to hip resurfacing, during hip replacement the arthritic ball is removed and replaced with a new ball. Since the artificial ball comes in different neck lengths, the surgeon is able to adjust muscle tension, leg length, and ball-socket stability during the hip replacement. These adjustments reflect complex decision-making and trade-offs during surgery. Rarely, because of anatomic constraints or other patient-specific reasons, slight leg lengthening may occur. If this is totally unacceptable, you should not consider hip replacement surgery.
In the overwhelming majority of cases, there is no change in leg length after hip replacement. In most cases where the patient feels a change in leg lengths, that perception will disappear over several months as the muscle and tissues stretch.
Can leg length be changed during hip replacement surgery?
Yes. An example would be a patient with a leg that was shortened from injuries after a motor vehicle accident, who now needs a new hip. In such cases, it is possible to restore the original leg length during surgery. The decision-making is complex, requires professional judgment, and is specific to each situation.
Likewise, if the patient has too long a leg before surgery, it is possible to shorten it during hip replacement, using specific surgical techniques that keep muscle tension within safe limits. Again, the exact steps taken and the decision-making are specific to each patient.
My leg ended up too long after a hip replacement. Can anything be done?
In most cases, with exercise, stretching, and healing over 6 to 12 months, the perception of a leg length difference will disappear on its own. During this time, to avoid a limp and facilitate walking, a shoe-lift built into the shoe can help.
The reason for waiting is that the majority of leg-length discrepancy after hip replacement is not a true difference in skeletal lengths. Rather, the discrepancy is from pelvic tilt, tight muscles, altered biomechanics, and even spinal arthritis that can lead to a curvature in the back. With muscles stretching, exercises, and time, such discrepancy will likely resolve in a few months.
If leg length discrepancy is permanent, additional surgery may be an option. During such surgery, the femoral stem component is removed, and the bone at the top of the femur is removed to equalize the leg lengths. Then, a new femoral stem is implanted.
While this sounds easy, additional steps must be taken to avoid improper muscle tensioning and to reduce the risk of creating hip instability and a limp. Recovery from this type of surgery is about 6 to 12 weeks.
How can we know if my leg is truly longer after a hip replacement?
Special X-ray studies can help determine if the perceived difference in leg lengths is really in the bone or arising from some other source, such as a tilted pelvis, a curvature in the back, or tight muscles. These X-rays, called scanograms, involve imaging the entire length of both legs with a measuring ruler that leaves no doubt about the actual length of each leg, from the top of the pelvis to the ankle.
We compiled a list of some frequently asked questions about treatment for hip arthritis and hope you find it useful!
Will exercise help an arthritic hip?
Yes. Exercises strengthen the muscles around the hip joint. Weak muscles mean higher forces across an arthritic hip joint, and more pain. That is why regular, light aerobic exercise helps to relieve pain from arthritic hips. Recommended exercises include walking, swimming, elliptical exercisers, and similar activities.
Reasonable levels of exercise will not accelerate the wear and tear of an arthritic hip joint. Stronger and more conditioned muscles reduce the loads placed on the hip, and relieve pain. Exercise may help postpone hip replacement surgery.
One caveat: If exercise hurts, then refrain from that activity and try another form of exercise.
Does a cane help with an arthritic hip?
Yes. A cane in either hand helps, but is most effective if used in the hand opposite the painful hip. A cane reduces the load across the arthritic hip, thereby relieving pain and improving walking ability.
Will injections into the hip joint ease arthritic pain?
Yes, cortisone injections placed into an arthritic hip will ease pain temporarily. For mild cases of arthritis the injections may help for many months. However, injections cannot build up cartilage or otherwise cure arthritis.
Cortisone injections can also help pinpoint the source of hip pain, if there is any doubt where hip pain is coming from. If hip pain is really from hip arthritis, and not referred from a bad back or another source, then cortisone injections should relieve pain, even if temporarily.
Hip joint injections require X-ray imaging to guide the needle into the hip joint. This is why such injections must be done in a special procedure room, equipped with X-ray imaging equipment. If done in the clinic, these injections can be guided by ultrasound technology.
Lubricant injections that are marketed as “visco-supplementation” can help arthritic hip joints temporarily. However, they are more commonly used for treating arthritic knees.
Research to alleviate the pain and inflammation of hip arthritis is ongoing and exciting, such as injections using gold nanoparticles with mild radioactivity.
Is there surgery for hip bursitis?
Yes, if injections in the hip bursa do not work reliably, there is an arthroscopic technique, done as outpatient, that works very well using only a couple of small holes made in the skin. Pain relief is predictable with this small operation. Again, this applies to hip bursitis, which is very different from hip arthritis.
What else, other than surgery, can help an arthritic hip?
If possible, avoid stairs and concrete floors; weight lifting; deep bending at the hip; and repetitive impact exercises such as jogging, golf, and racquetball. Reasonable exercises include walking on a treadmill, swimming, low-impact activities, and upper-body conditioning. There are no effective braces for hip arthritis.
Will arthroscopic surgery help hip arthritis?
In mild or early hip arthritis, yes. Mild hip arthritis can result in hip cartilage tearing; this condition, called a torn labrum, can be addressed with hip arthroscopy. Arthroscopy refers to an outpatient operation, involving small skin openings through which a small camera and surgical instruments are introduced to trim torn pieces and clean up the joint. At the same time, the surgeon can remove bone spurs that physically impinge against each other, causing pain and stiffness.
But, if the arthritis is too advanced, then arthroscopic surgery may not be too helpful.
One benefit of arthroscopic surgery is the ability to look directly inside the joint and understand the extent of arthritic damage. With this information, a surgeon can advise on further treatment.
What is osteotomy of the hip?
Osteotomy refers to cutting bone and realigning the leg, to relieve the pain of an arthritic hip. By altering biomechanics favorably, the loads across the ball and socket joint are lessened. Osteotomy was once a commonly used surgical option in young patients, back when hip replacements were not suitable for young and active people.
In cases where the socket or ball is mis-shapen since birth and the arthritis is diagnosed early, osteotomy can help, especially in young patients. The surgeon can cut the femur and the pelvis to create a more aligned hip joint, thereby slowing the progress of arthritis.
Osteotomy is a complex, major procedure, and requires special skills that we offer in our practice. The goal of osteotomy in such cases is to preserve the patient’s own hip joint. Few patients are candidates for such a procedure, because in most instances, hip arthritis has progressed enough that a hip replacement is more desirable.
What is a hip fusion?
This is another hip operation that was more common in the past. It involves eliminating the hip joint, by surgically welding, or fusing, the ball to the socket. By eliminating movement in the hip joint, pain is relieved without using implants.
Hip fusion is also called an arthrodesis. Increased movement in the back and knee usually compensates for the stiff hip after the fusion.
Hip fusion is nearly obsolete now, since hip replacement surgery is so durable and predictable. But back in the days when hip replacements were not quite as advanced, hip fusion was worth considering for young patients.
Does weight loss help relieve arthritic pain?
Yes. Biomechanical studies show that body weight is multiplied 2 to 3 fold across the hip joint. Losing excess body weight relieves arthritic pain by unloading the joint. Weight loss also decreases surgical risks should hip replacement be necessary.
Will chiropractic manipulations help hip arthritis?
For some patients, chiropractic manipulations seem to help arthritic pain. Alternative remedies, such as glucosamine, vitamins, oils, yoga, hypnotism, herbal supplements, heat packs, ice packs, massage, aromatherapy, aqua therapy, prolotherapy, and acupuncture might also help. Use these remedies if you feel that they are helpful, and if you are familiar with their proper use.
If you are scheduled for surgery, stop all alternative medications and vitamin supplements at least 10 days before surgery. This is to avoid excess bleeding and risky interactions with the anesthetic drugs.
What about injections for hip bursitis?
Injections to the outside of the thigh are commonly used to treat hip bursitis. These injections do not enter the hip joint, and do not need X-ray guidance for accurate placement.
Hip bursitis is not related to hip arthritis. Bursitis is a local inflammation in the tissues near the hip joint, caused by muscles and tendons rubbing against each other. The pain from hip bursitis is located on the outside of the thigh, making it hard to walk or lie on that side. Hip arthritis, in contrast, is deterioration and inflammation of the ball-and-socket joint itself.
A visit to the doctor can usually help determine if you have bursitis or arthritis.
Should I use pain medicine for hip arthritis?
Medicines such as aspirin, acetaminophen, ibuprofen, naprosyn, and other anti-inflammatory drugs can be taken for a long time, within proper dose range. These medicines are not addictive. Your primary physician should monitor any possible side effects, especially if you take such medicines regularly.
Alternative remedies, such as glucosamine chondroitin, are available over the counter. These can help arthritic hips and can be used without risk of addiction.
Narcotic drugs can also relieve pain, but can create dependence and related psychological problems. Long-term use of narcotic drugs before surgery will make pain relief after surgery more difficult. If you regularly require narcotic medicines to control hip pain, it may be time to consider hip replacement surgery.
Why not replace the hip instead of trying nonsurgical measures?
Patients who invest the time to understand all options will know what to expect, and usually have the most satisfying outcomes. Nonsurgical treatment can give you time to learn more about hip arthritis and assess all treatment options.
Also, nonsurgical means of pain relief can work for a long time, at least for some patients; hip replacement surgery should be the last step.
Will arthroscopic surgery buy some time with an arthritic hip?
It could, depending on the extent of arthritis. In mild cases, with cartilage tears in the hip joint causing catching and pain, arthroscopy can buy time before a hip replacement. But if X-rays show advanced hip arthritis, arthroscopic surgery will probably not have any lasting benefit.
What is a hip resection, or Girdlestone, procedure?
This refers to a removal, or resection, of the diseased hip ball, and replacing it with nothing. Historically, this operation was done for conditions like tuberculosis of the hip, long before the days of modern hip replacement. The infected bone would be removed, and the hip cavity would be left empty.
Over time, the empty hip cavity would fill with scar tissue and the leg would shorten by a couple of inches, making walking very difficult. But, removal of the infected ball would give the patient a chance at healing the tuberculosis infection, and relieve pain.
Today, a Girdlestone resection in the hip is done very rarely. Circumstances in which the procedure is considered include a serious infection that cannot be eliminated otherwise, severe bone loss from multiple failed operations, muscle paralysis, or advanced cancer.
Here are commonly asked questions about arthritis and your hip joint.
What is hip arthritis?
Arthritis is the roughening and destruction of the cartilage that lines the ball and socket. These rough surfaces generate friction and inflammation, causing pain and stiffness.
How do you diagnose arthritis or degeneration of the hip joint?
In many cases, a diagnosis can be made by X-ray studies and a physical examination. Damage to the hip creates a narrowing of the space between the ball and socket. Eventually, the hip can lose so much cartilage that bone touches bone, which can be very painful.
Early arthritis of the hip may not show up on an X-ray. In these cases, other studies, such MRI or CT scans, or an operation called hip arthroscopy, can help diagnose arthritis.
Where does one feel the pain of an arthritic hip?
Typically, pain from an arthritic hip will be felt in front of the thigh, to the buttock, or to the outside of the thigh. Pain may also travel to the knee due to overlapping nerves in the hip and knee joints. The pain and stiffness can usually be reproduced by rotating the leg. A painful hip can feel like a pulled groin muscle, or like a toothache in the groin.
Does hip arthritis always develop with old age?
Most people never develop hip arthritis, no matter their age. That said, everything in the body wears down with age, and hip cartilage is no exception. Those who need hip replacement surgery generally have a faster progression of hip arthritis because of injury, underlying inflammatory problems, genetic predisposition to arthritis, or a congenital abnormality of the hip joint.
What keeps the hip ball from popping out of the socket?
Muscles, tendons, and ligaments hold the ball in the socket, preventing it from slipping or dislocating. Hip dislocation, usually associated with severe physical trauma, is a serious condition requiring immediate medical treatment.
Rarely, the hip joint is predisposed to dislocation and premature arthritis due to a congenital deformity. Newborns are now routinely checked to make sure their hip joints are properly formed.
What is a degenerative hip joint?
A hip joint is referred to as degenerative when the cartilage is damaged due to injury or a disease process, such as osteoarthritis or rheumatoid arthritis.
How does the hip joint get lubricated?
The hip joint is sealed in a capsule. This capsule is a tough tissue envelope surrounding the hip joint, much like the rubber seal surrounding a steering or suspension joint in a car. Cells inside the hip capsule secrete synovial fluid, which is a natural lubricant. In a healthy hip joint, there is always a small amount of this synovial fluid. The fluid serves as biological grease, and lubricates the joint.
Can hip pain be coming from other places?
Yes. What people think of as hip pain can come from other sources, like poor circulation to the leg, an arthritic back, an arthritic knee, painful sacroiliac joints, and other abdominal or pelvic problems. In other words, the problem may be elsewhere, but the patient may sense pain in the hip.
In older patients, hip pain can reflect more than one problem. For example, hip arthritis and back arthritis can occur together. In such patients, hip replacement surgery may help one source of pain, but other areas may also need treatment later.
Another word for an X-ray, which shows a silhouette of the skeleton. Although helpful for seeing bone, X-rays do not show muscles, tendons, and ligaments. An X-ray is usually the first imaging study of the hip joint when arthritis is suspected.
Also called a CAT scan. This is a computer-driven study that shows the three-dimension-al bone anatomy of the hip in greater detail than an X-ray, which is two dimensional. With contrast dye, CT scans can even show soft-tissue structure.
A specialized imaging study that can diagnose subtle infections in the joints, especially after the hip has been replaced with prosthetic components
Magnetic Resonance Imaging
Also called MRI, this study shows soft tissues such as tendons, muscles, and ligaments surrounding the joint.
In this type of study, a radioisotope is injected into the body, with the goal of detecting infection, fracture, or related inflammatory conditions of bone.