Total Hip Replacement
Use the below links to find answers to some common questions:
What are the symptoms of a painful hip?
What can I do to get rid of my hip pain?
What about intra-articular hip injections?
When should I consider having a hip replacement?
What hip replacement is best for me?
What is soft tissue balancing of the hip?
What types of bearings are there?
What are the possible complications of a total hip replacement?
Will the operation be painful?
How quickly will I recover postoperative?
What is arthritis?
Arthritis is a degenerative condition of a joint, which results in damage to the articular cartilage. Large joints such, as the knee and hip joint are often affected.
Primary osteoarthritis (arthritis without a cause) of the hip is actually very rare. Most patients with osteoarthritis have an underlying cause.
The most common causes for hip arthritis are trauma, avascular necrosis (failed blood supply to the ball of the hip joint), hip dysplasia (abnormally developed hip socket), slipped upper femoral epiphysis (growth plate injury around puberty), Perthe’s disease (avascular necrosis of the femoral head), and infection.
Sometimes, hip arthritis can be secondary to inflammatory conditions such as rheumatoid arthritis, ankylosing spondylitis, Reiter’s disease, psoriasis and other inflammatory joint diseases.
Ultimately the articular cartilage of the joint will be severely damaged which may lead to symptoms of pain, stiffness and loss of function.
What are the symptoms of a painful hip?
Groin pain is the most common presentation of a hip problem. This is often associated with pain going down the thigh and can be associated with referred pain to the front of the knee. The pain is often activity related but can also appear at rest and typically at night. Buttock pain is much less common and may indicate problems with the lower back.
The difference between hip pain and back pain can be very difficult to tell apart. Sometimes special tests are required to make certain where the pain is coming from.
What can I do to get rid of my hip pain?
There are a variety of non-operative treatments that can relieve your symptoms of hip arthritis.
It is good to keep as active as possible, however you may be required to limit certain activities that excercebate the pain. Some patients are overweight and some weight loss is very helpful in relieving symptoms.
Arthritis is often causes cyclical discomfort due to inflammation of the synovial lining of the joint. Regular painkillers may be helpful during that period of worsening of symptoms. Anti-inflammatory medication and pain killers of different strengths may be helpful. Some patients find other ways of obtaining pain relief such as acupuncture, aromatherapy, reflexology or the use of a chiropractor or osteopath.
Dietary supplements such as glucosamine and chondroitin sulphate as well as omega-3-fatty acids now have scientific evidence that they provide symptomatic relief, especially in knee arthritis.
Detailed information on Dietary Supplements can be found here.
Soft shoe inserts, like silicon heel cups, may reduce the forces travelling to the hip. This may make walking more comfortable. A walking stick held in the opposite hand to the painful hip may also reduce pain in an arthritic hip. Eventually, conservative treatment measures may not provide adequate symptomatic relief and a surgical solution may have to be considered.
The decision to proceed to an operation is primarily determined by the patient guided by the expert knowledge of the surgeon.
What about intra-articular hip injections?
For certain people the hip joint is not quite bad enough to warrant a joint replacement procedure. In that case an injection, either with local anaesthetic and a long acting steroid, such depo-medrone or cortisone can be very helpful.
Another alternative is the use of hyaluronic acid. Sometimes PRP (platelet rich plasma) can be used but the evidence for its use is still equivocal. In some patients the benefits of an injection can last for months or indeed years. Unfortunately in some patients the benefits are only short lived.
When should I consider having a hip replacement?
Arthritis of the hip joint has affected mankind ever since we assumed an upright posture. The body’s natural way to deal with a joint that is arthritic is to restrict it’s movement, and make it stiff. After all it is the movement that causes the pain most of the time!
Damage to the cartilage is seen as narrowing of the joint, on the X-Ray. Extra bone known as osteophytes develop, which is the body’s attempt to increase the surface area and so reduce the pressure per surface area of the joint. Ultimately when the destruction of the joint is so extensive, the joint fuses. Fusion of the joint, also known as “ankyloses”, will stop it from moving and will therefore stop the pain!
The evolution of joint replacement has meant that whereas in the past a patient with an arthritic hip joint would be in pain and have restricted function until the joint fused; now we are able to replace a hip joint and relieve pain and maintain a level of function very similar to the native joint
Hip replacement, is one of the most successful and cost effective medical intervention known to mankind. 95% of patients who have a hip replacement will still have a functioning hip 10 years after surgery and about 85% of patients will still have their hip replacement at 20 years.
For patients older than 65 who have a hip replacement 85-90% of patients should not require any further surgical procedure on that hip. It is worth remembering that having an arthritic hip is not a life threatening condition.
The hip replacement operation is a quality of life procedure. The success rate is very high and the chance of a complication very low.
Before deciding on surgery, the patient should be aware, that if a complication should occur it may cause him or her to be worse off. Fortunately the chances of that happening are quite rare.
In the majority of patients the best indication for proceeding to replacement surgery is when the symptoms fail to respond to conservative management and the patient is no longer willing to tolerate the symptoms associated with arthritis.
What hip replacement is best for me?
Like all things in life most people would like to have the best if possible. So what is the Rolls Royce of all hip replacements? This is a difficult question to answer, as there are many variables involved.
As more studies are being published, it appears that there are a great number of different hip systems that can provide good long term outcomes. In the UK the largest database which looks at how well hip replacements last is the National Joint Register.
The most common types of hip replacement in use are:
Cemented THR Hybrid THR (cup uncemented, stem cemented) Uncemented THR.
Each type of hip replacement used today is experimental to some degree. The companies that produce the implants make some small modifications from time to time. After all, if the Volkswagen Golf was the same each year who would buy it after a while?
Your surgeon will discuss what type of hip replacement is best suited for you and he will also discuss the reasons why. Many options are available to each patient and the optimal solution is often reached after discussion with your surgeon.
There is however one certainty. The outcome of a hip replacement is directly related to the correct positioning of the implant and therefore related to the skill of the surgeon.
It is the aim during surgery to recreate the exact biomechanical environment that existed when the patient’s original, well-functioning, hip was still in place.
This process is called “soft tissue balancing” of the hip.
By doing this the hip joint will be as strong as possible, it will restore the leg length, if there is a discrepancy, and it will reduce the chance of hip dislocation.
It is becoming apparent that fixation of the socket and the femoral stem, whether cemented or uncemented, can last a long time.
The main weakness of a hip replacement, that most often causes it to fail, is the articulation between the ball and the socket also known as the bearing.
What is soft tissue balancing of the hip?
Your surgeon will try as best as possible to place the new replacement hip in the same “position” as the native hip before it got worn out. This process is known as “soft tissue balancing” of the hip.
This process will allow the replaced hip to function as best as possible by allowing the muscles around the hip to work optimally. It also will allow for deformities, such as leg length problems, to be corrected which in turn reduce the risk of post-operative dislocation of the hip.
There are a number of ways by which the surgeon can optimise “soft tissue balancing”.
At the time of the initial consultation the leg length discrepancy and other deformities are noted both on clinical and X-Ray examination.
Prior to performing your operation your surgeon will “template” the X-Ray. This is the planning of the operation to determine what size of implants are required, where they need to be positioned and what intra-operative corrections need to be made.
During the operation a number of tests are carried out to make sure that the pre-operative plan has been successfully executed. This may involve the use of a small jig which allows for the offset and leg length to be measured during the operation.
Templating of the X-Ray, in order to plan the operation. A side arm jig is used to measure the restoration of leg length and offset during the operation. (Soft tissue balance of the hip).
This 71 year old lady has osteoarthritis of the hip with protrusio (the femoral head has migrated toward the pelvis). Using the patient’s own femoral head as graft material, the centre of rotation, leg length and offset have been restored.
What types of bearings are there?
The bearing of the hip replacement is the junction between the artificial femoral head and the socket. This is the area where “wear” will occur. Wear is the most common cause of long term failure of the artificial hip joint.
Every time the patient with a hip replacement takes a step, some wear occurs between the ball and the socket. This produces wear particles which can, via a complex biological reaction in the body, ultimately lead to bone resorption and loosening of the joint replacement.
Over the last number of years newer types of bearing material have been introduced to see if they are an improvement over the traditional ones, in the hope that they will wear less, and theoretically last longer.
The popular bearings at the moment are of three basic types. These are metal head on a polyethylene socket, Oxinium (ceramicised metal) or ceramic on a polyethylene socket and a ceramic head on a ceramic socket.
Each bearing couple has their own advantages and disadvantages. The jury is still out in deciding which one is the best.
Metal on poly-ethylene bearing (Hybrid THR, Cemented Exeter stem with uncemented socket with screws)
Oxinium (Ceramicised metal) on poly-ethylene bearing (Uncemented Titanium tapered stem with uncemented socket)
Ceramic on ceramic bearing (Uncemented Titanium tapered stem with uncemented socket)
Hard (Metal or Ceramicised metal) on polyethylene bearing
On the socket side a polyethylene bearing has been used almost since the popularisation of total hip replacement. The manner in which these bearing wear is fairly predictable, and unfortunately it is the bearing that produces more wear particles than any other bearing. However, if revision of the replacement is required the techniques are well established.
A more modern type of polyethylene is called highly cross-linked polyethylene. Most manufacturers of implants produce a slightly different type of “highly cross-linked” polyethylene. At least in the laboratory this type of polyethylene has shown improved wear characteristics over standard polyethylene. Some early publications using this material are now becoming available showing some medium term (5-10 years) promising results.
The “hard” part of the bearing relates to the femoral head. The most commonly used materials for making the artificial femoral head have been cobalt chrome and stainless steel. More commonly now harder material such as ceramics are being used.
A more recent material that is used to make the femoral head is Oxinium. This is a metal bearing that has been “ ceramicised” on the surface. This material is used in the oil drilling and nuclear fuel industry, because it is very hard and scratch resistant.
It has been shown in the laboratory and in clinical practice to have reduced wear of the bearing.
Ceramic on ceramic bearing
Ceramic is the hardest bearing with the least wear. Unfortunately it is also brittle and may not be ideal for patient who intend to run or do impact sports. Fractures of this bearing have been reported although with the latest design of implants this is rare and occurs in only 0.004% of patients. A revision operation following a ceramic fracture however does not always have a good long term outcome. It is however a very good a popular bearing to use.
What are the possible complications of a total hip replacement?
The chances of a major complication for a patient undergoing a total hip replacement is between 1-2 %. Anaesthetic complications are rare.
For total hip replacement the 5 most common complications are:
Infection
Dislocation of the hip joint
Injury to the nerves and blood vessels
Deep vein thrombosis and possible pulmonary embolism
Problems with restoration of leg length.
With ceramic bearing, rarely a squeaking noise from hip can occur. For uncemented total hip replacement there is a 0.3% chance of persistent thigh pain after the operation. Major surgery can sometimes be followed by other unexpected medical problems including a heart attack, stroke, poor kidney function, the gut temporarily failing to function, constipation or poor bladder function.
Will the operation be painful?
Of course we expect some discomfort with every operation. However with modern modalities of pain control discomfort will be limited. Mr Busch has published on a method of injecting around the total hip or knee replacement during the time of surgery which makes the peri-operative time very comfortable and allows for early mobilisation.
Publication on peri-articular infiltration
How long will the operation take?
A standard total hip replacement operations take between 1-1 ½ hours. There is quite a bit involved!
A total hip replacement performed in under a minute! (NB This clip contains images that some people may find disturbing)
How quickly will I recover postoperative?
Most patients will be out of hospital in 2-5 days. Some even sooner! For some patients the hip replacement can be done with them going home the same day. The majority of patients have control of their car at 4-6 weeks and some leisurely sport can be started at 3 months.
By 6 to 9 months most patients will start to forget that they had an operation. The function will continue to improve and will reach the maximum at 1 year to 14 months. Most people will be able to take part in normal walking, playing bowls, golf and tennis. Most patients have no problems with doing gardening. Certain patients will be able to ski and run. Running is not recommended.
Mr Busch wrote a small article for a local private hospital about the topic of “Enhanced recovery“. This is a process by which each individual step in the joint replacement procedure is optimised so that the recovery following surgery can be as efficient and quick as possible.
What does enhanced recovery mean?
Over the last few years the recovery following total joint replacement, specifically total hip replacement, has been much improved. A combination of advancement in the anaesthetic techniques, perioperative pain relief, implant technology, surgical technique, rehabilitation programs and managing patient’s expectations, has led to the inpatient stay having become much shorter.
In fact, in some certain selected cases total joint replacement of the hip and knee can be performed as a day case. Day case total joint replacement is not for everybody, and is something that your surgeon will discuss with you and decide if you could be a good candidate, for a day case procedure.
Early mobilisation 4 hours after left total hip replacement
Bilateral simultaneous total hip replacement with enhanced recovery protocol.
What can I do with my hip replacement?
A replacement of any joint is not the same as your own original joint. It is however a very good second best! As the longevity of the joint replacement is almost completely dependent on the wear of the bearing surface it is logical to look after the replaced joint as much as possible. If we can compare a hip joint to a car engine we can speculate that if an engine has a million miles to run, a patient can drive all the miles available in just a few years, or by being a little more cautious, can have many years of trouble free motoring.
On the other hand we must not forget that the joint replacement is often performed in order to resume activities which the patient was unable to participate in, because of the arthritic joint became very symptomatic. Most activities can be performed by patients who have a joint replacement. Bearing in mind however that the longevity of a joint replacement depends on the rate of wear, the avoidance of dislocation and infection, any activity that the patient wishes to take part should be viewed within these confines.
Sports such as golf, tennis and skiing are possible with both hip and knee replacement. It is however worthwhile to take some simple actions to stop excessive wear of the replaced joint by perhaps taking a buggy whilst playing golf, to stay on the easier ski runs and to restrict the number of games of tennis played during the week!