Patient education: Total hip replacement (Beyond the Basics)

HIP REPLACEMENT OVERVIEW — 

Normally, the hip functions as a "ball-and-socket" joint. The top of the thigh bone, or femur (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).

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

This article will discuss total hip replacement surgery. Information about other treatment options for arthritis is available separately. (See "Patient education: Osteoarthritis treatment (Beyond the Basics)" and "Patient education: Rheumatoid arthritis treatment (Beyond the Basics)" and "Patient education: Psoriatic arthritis (Beyond the Basics)".)

REASONS FOR HIP REPLACEMENT — 

Total hip replacement is only considered when more conservative treatments have not helped and you continue to have significant pain, stiffness, or problems with the function of your hip.

Total hip replacement is typically performed on adults with a deteriorated hip. Because replacement parts can break down over time, 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 caused by osteoarthritis or other conditions. Nonsurgical treatments for people with osteoarthritis include (see "Patient education: Osteoarthritis treatment (Beyond the Basics)"):

●Weight loss or maintenance of a healthy weight

●Physical therapy

●Use of an assistive device (such as a cane or walker)

●Pain-relieving medications

●Glucocorticoid (steroid) or orthobiologic (such as platelet-rich plasma or stem cells) injection into the painful joint

People with inflammatory arthritis (such as rheumatoid arthritis) may benefit from a treatment regimen of antirheumatic or other medications. (See "Patient education: Rheumatoid arthritis treatment (Beyond the Basics)".)

Surgical alternatives — There are few surgical alternatives to total hip replacement once the hip joint has completely deteriorated. Alternative procedures may be considered in people who are very young or in whom a hip replacement may not last (such as people who do heavy-impact loading activities). The best surgical procedure depends on the reasons the joint deteriorated. Alternative procedures include:

●Osteotomy, which involves cutting the bones and putting them in a new position

●Total hip resurfacing, which involves replacing only the surface of the joint

PRESURGERY STEPS TO MAXIMIZE RESULTS — 

Taking certain steps before hip replacement can improve a person's results while also helping avoid complications related to the surgery. This is sometimes called "preoperative optimization." Key components include:

●Quitting smoking (if you smoke).

●Careful diabetes management (if you have diabetes).

●Weight loss (if needed) – Typically, the goal is for your body mass index to be less than 40.

●Screening for obstructive sleep apnea – In a person with sleep apnea, air movement is periodically reduced or stopped because of narrowing or closure of the throat.

●Assessing your risk for deep vein thrombosis – This is a condition in which a blood clot (thrombus) forms in a deep vein in the legs, thighs, or pelvis.

●Addressing any other health conditions you have.

Preoperative physical therapy can also improve postoperative results.

TOTAL HIP REPLACEMENT PROCEDURE — 

Total hip replacement is performed in an operating room after you are given general or regional (epidural or spinal) anesthesia. Your surgeon will typically make a single incision along the posterior (rear), lateral (side), or anterior (front) aspect of the hip. Less invasive hip replacement surgery techniques, which use smaller incisions and specialized instruments, are often used.

The type of prosthesis and the material used for the "bearing surface" (outer layer) depend upon the needs of the particular patient and the surgeon performing the procedure. There are a variety of types of prosthetic bearing surfaces, including metal on plastic, ceramic on plastic, and ceramic on ceramic. An example of one type of prosthesis is shown here (figure 2). Each surface has unique advantages and disadvantages, and your surgeon can discuss which is appropriate for you.

AFTER SURGERY

Management — After surgery, you will be given pain medication through your intravenous line or as pills. You will also be given an antibiotic to prevent infection. Most people can stop taking the antibiotics within 24 hours of a routine hip replacement.

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 that inflate periodically) are often worn to prevent blood clots. Compression stockings may also be recommended.

Many people stay in the hospital for one or two nights after surgery, although shorter stays are becoming more common. Some hip replacements are being done as "outpatient" procedures, meaning you can go home the same day as the surgery.

Rehabilitation — Physical therapy (PT) is an important part of the recovery process. Most people are able to stand and even walk, with the help of a physical therapist, within a few hours after surgery.

After your surgery, you will work with a physical therapist to develop an exercise and rehabilitation program to regain strength and motion. In some situations, it isn't safe to go home immediately, and you will need to stay in the hospital or go to a nursing facility for rehabilitation.

You will continue your therapy 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). Some people work with a physical therapist for the duration of the rehabilitation program; others complete the program on their own.

After several weeks of recovery, you will be encouraged to return to an active lifestyle. Most people can resume their normal activities within weeks to months. With newer surgical techniques, recovery time may be reduced. Continued improvement may be seen up to 12 months following surgery. While high-impact sports such as running and contact sports are not usually recommended after hip replacement, you can typically participate in most other low-impact activities like walking, cycling, and swimming.

With modern implants and bearing surfaces, it is now anticipated that most hip replacements will last well beyond the previous expectation of 10 to 15 years. Most people are very satisfied with their outcome, reporting minimal to no pain and significantly improved function and quality of life.

TOTAL HIP REPLACEMENT COMPLICATIONS — 

Serious complications after hip replacement surgery are not common and can be minimized by choosing a surgeon who is experienced and performs the procedure frequently. In addition, choosing a hospital or facility that specializes in caring for people with joint replacement before, during, and after surgery can also minimize complications.

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 people, the benefits of reduced pain and improved function outweigh the small risk of complications.

The following are some of the complications that can occur during or after hip replacement surgery.

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 surgery.

Blood clots — People who undergo hip replacement are at increased risk for developing blood clots after surgery. Only approximately 1 percent of people will develop a blood clot in the leg (deep vein thrombosis) or lungs (pulmonary embolism) with appropriate preventive treatments, such as early and frequent mobilization (moving around). (See "Patient education: Deep vein thrombosis (DVT) (Beyond the Basics)" and "Patient education: Pulmonary embolism (Beyond the Basics)".)

Infection — Infection following hip replacement is uncommon (between 0.4 and 1.5 percent of cases). Prevention protocols that include preoperative weight loss for people with obesity, smoking cessation, methicillin-resistant Staphylococcus aureus screening, skin preparation/washing, and routine antibiotics (during the first 24 hours only) can all help to minimize the risk of infection. (See "Patient education: Joint infection (Beyond the Basics)".)

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 cases. In most cases, the joint can be put back into place by a doctor while the person is sedated.

To minimize the risk of dislocation, some people may be given specific precautions related to the motion of the hip. The need for precautions depends 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 have been greatly 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 in 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.

WHERE TO GET MORE INFORMATION — 

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). 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 — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Osteoarthritis (The Basics)
Patient education: Hip replacement (The Basics)
Patient education: Deciding to have a hip replacement (The Basics)
Patient education: Avascular necrosis of the hip (The Basics)
Patient education: Hip fracture (The Basics)
Patient education: Paget disease of bone (The Basics)
Patient education: How to use crutches (The Basics)
Patient education: How to use a walker (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Osteoarthritis treatment (Beyond the Basics)
Patient education: Rheumatoid arthritis treatment (Beyond the Basics)
Patient education: Psoriatic arthritis (Beyond the Basics)
Patient education: Deep vein thrombosis (DVT) (Beyond the Basics)
Patient education: Pulmonary embolism (Beyond the Basics)
Patient education: Joint infection (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Complications of total hip arthroplasty
Prevention of venous thromboembolism in adults undergoing hip fracture repair or hip or knee replacement
Prosthetic joint infection: Epidemiology, microbiology, clinical manifestations, and diagnosis
Prevention of prosthetic joint and other types of orthopedic hardware infection
Prevention of venous thromboembolic disease in acutely ill hospitalized medical adults
Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients
Overview of surgical therapy of knee and hip osteoarthritis
Total hip arthroplasty
Surgical management of end-stage rheumatoid arthritis
Prosthetic joint infection: Treatment

The following organizations also provide reliable health information.

●National Library of Medicine

(www.medlineplus.gov/healthtopics.html)

●The Arthritis Foundation

(800) 283-7800

(www.arthritis.org)

●American Academy of Orthopaedic Surgeons

(orthoinfo.aaos.org)

●American Association of Hip and Knee Surgeons

(www.aahks.org)

●The National Institute of Arthritis and Musculoskeletal and Skin Diseases

(www.niams.nih.gov/health-topics/hip-replacement-surgery)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Peter Schur, MD, who contributed to earlier versions of this topic review.