The damage to the hip joint from arthritis is relentless and almost always, an irreversible process. What happens is that the arthritis wears away increasing amounts of the white gristle (articular cartilage) which lines the ball and socket shaped bones that together comprise the hip joint.
This cartilage normally performs the function of making the bone ends slippery and this helps the joint to move smoothly without friction as well as functioning as a shock absorber. Over time, an increasing proportion of the underlying bone-end is exposed until finally there arises the situation where bone is rubbing against bone.
Whilst the patient starts experiencing some pain quite soon after the onset of the arthritis, it is usually only in the later stages that it gets worse and becomes quite constraining on the patient's everyday life and mobility. The patient may well find that his or her mobility is reduced and even day to day jobs such as walking to the local shops, going up and down stairs and getting up from a chair become increasingly painful. In the final stages the arthritic hip may cause pain at night in bed and stop the patient from sleeping.
The hip replacement operation is one of the most reliable and well-tested operations in orthopaedic surgery and a consistent outcome is that it reduces or eliminates the pain of the arthritis in patients.
The pain of the operation itself improves very much within the first ten days after the hip replacement procedure and is almost gone after 2 to 3 weeks. The artificial hip often improves the movements in a hip joint that has become increasingly stiff from the effects of long term arthritis and this permits the patient to resume at first gentle activity and then their favourite leisure hobbies - golf, here we come.
So, a hip replacement surgery can not only improve the mobility, independence of arthritis sufferers, but also the quality of life of most people with otherwise disabling hip arthritis. The results is that the patients can then get greater exercise and this can help in a strengthening of the effected leg and lead to a feeling of much greater well being.
Often patients who suffer from arthritis in both hips are so pleased after their first operation that they ask for the second one to be brought forward to be carried out as soon as possible.
Hip replacement surgery is a commonly performed and generally safe surgical procedure, and for most people, the benefits are far greater than the disadvantages. (For example 50,000 arthroplasties as they are professionally named are conducted in the UK every year).
However, in order to make a well-informed decision and to give your consent, you should be aware of the possible side-effects and also understand the risk of complications.
After a hip replacement procedure, the area is likely to be uncomfortable for at least several weeks. There may also be some temporary pain and swelling in the knee and ankle which is a result of the trauma of the operation on your body.
Specific complications of hip replacement surgery are rare but can include those listed below:
The chance of problems depends on the exact type of operation you are having and other factors such as your general health. You should speak to your surgeon or medical adviser.
Loosening of the joint, especially after about ten years, has been a major problem that has so far defied solution. The shaft of the prosthesis becomes loose in the hollow of the thigh-bone or becomes dislocated. Re-operation (revision surgery) is necessary in around 10% of all total hip replacement cases.
Because of the tendency to loosening, and because this is more likely if the joint is heavily stressed, hip replacement is not commonly performed in young and physically active patients. Some surgeons reserve total hip-joint replacement for patients over 60.
After the operation you will be cared for in the RAnother common later complication of hip replacement surgery is inflammation due to a reaction to particles that have worn off the artificial joint surfaces and absorbed by surrounding tissue. The bone may get eroded causing the implant to become loose. Anti-inflammatory drugs may stop the problem, but if not, revision surgery may be advised.
Less common complications include:
Very little information is available on the long-term safety and reliability of MoM hip resurfacing as it is a relatively new technique. A National Joint Registry will monitor people who have had MoM hip resurfacing to see if it meets a target of less than 1 in 10 devices needing replacing after 10 years. Your surgeon should explain the risks and benefits associated with MoM hip resurfacing if you are suitable to have this operation.
Preparing yourself for Hip Replacement Surgery
Nobody looks forward to a major operation without some trepidation. Although, this hip surgery is very common, it is a major operation that "stresses" your body. Making some preparation for the surgery can help ease the impact of the procedure.
Hip Replacement Surgery is a serious operation even if it is common and well established in terms of best practices.
In this section we try to guide you through your experience of the process so you can understand it and be mentally prepared for it.
Most patients are admitted to hospital on the day before hip replacement surgery. You will normally be transported direct from the airport to the hospital where you will undergo some preliminary tests and of course meet the surgeon.
At that time:
A schedule of the actual Day of the hip replacement schedule
On the day of the hip replacement operation you will be taken to the operating theatre on a hospital trolley usually accompanied by a nurse from your ward. After arriving at the theater area, a member of the operating team will ask you another long list of questions many of which you will have already answered previously. However, these answers are a means of doublechecking that all the safety precautions about your hip replacement surgery have been taken before the surgery begins. The nurse will then escort you to the anaesthesia room where you will be given an anaesthetic (put to sleep) and then transferred to the operating theatre where the surgery will take place.
After the operation you will be cared for in the Recovery area where nurses trained in the care of patients waking up from general anaesthesia will look after you. After you have 'woken up' sufficiently, which is usually 2-3 hours later, you will be transported back to your ward or to the ICU (Intensive Care Unit). You will be experiencing some discomfort in the hip at this time, but regular painkillers will keep your pain under control. You may also be asked to keep the oxygen mask over your face to help your recovery from the anesthesia. You will almost certainly be receiving an intravenous drip through the first night after the operation to make up for the blood lost during the surgery. It may also be necessary to give you a blood transfusion.
About 6 hours after the end of the hip replacement surgery you will be allowed to take some liquids by mouth and if your are not feeling too nauseous, you may be given a light meal if you choose. The nursing staff will monitor you closely, for example makeing frequent checks of your pulse, temperature and blood pressure. They will also remove your surgical stockings for a short period to check your heels for signs of undue pressure.
Each evening, starting from the day of the operation, you will receive an injection of a blood thinner (this is often low molecular weight heparin, but may be another similar drug). The injection reduces the risk of forming a blood clot in the veins. You will also receive two injections of antibiotics at about 8 and 16 hours after your operation to reduce the risk of developing an infection in your operated hip. There is more information about DVT policies here.
The Anesthesia room where you will be taken before being wheeled into theatre provides a quieter environment for the anaesthetist to work in. You will see your anaesthetist and there will also be the ODA or Operating Department Assistant who is there to help the anaesthetist. All the medicines and tools required to 'put you to sleep' for the operation are in the room which is where the anaesthetist will give you your general anaesthetic.
First three plastic patches will be applied to your chest. These are connected to a heart tracing machine ( or ECG) and enable the anaesthetist to continously monitor your heart during the hip replacement surgery. A needle will also be inserted into a vein, usually on the forearm so that different drugs can be injected directly into the vein without the need to puncture the skin on each occassion.
Then, the anaesthetist will place a breathing mask on your face and you will find yourself drifting off to sleep. After you have been 'put-out', a breathing tube will be inserted into the throat area which will allow oxygen and other anaesthetic drugs enter your lungs.
A rubber tube is also inserted into your bladder so that the activity of your kidneys can be checked during the operation. This tube is usually left in place for at least 24 hours afterwards so that you do not have to worry about emptying your bladder. Once all this has all been completed you will be wheeled into the operation theatre itself for the actual hip replacement operation.
In the operating theatre, you will first be turned onto your 'good' side (ie onto the side that does not need surgery) and supports will be placed in front and back to maintain this position during the surgery. The leg to be operated upon will be cleaned with antiseptic and sterile drapes placed around your hip. The surgery is then carried out by the surgeon and one or two assistants. A scrub nurse who handles all the required instruments for the operation is also an essential member of the team. In addition, a circulating nurse is present in theatre to help. Other people who may be present on occasion in theatre can include, trainee nurses, medical and physiotherapy students and visiting surgeons.
Incision
A cut about 6-8 inches long is made through the skin on the outer aspect of the hip and upper thigh.
Soft tissue
The fat, muscles and deeper tissues are then carefully separated moving them forwards and backwards to expose the bones of the hip.
Bone work
The hip joint is then dislocated, i.e., the ball of the thigh bone is slipped out from the socket of the pelvis. The natural ball end of the bone is removed. The socket is then prepared for inserting the artificial socket by removing a thin layer of bone. The artificial socket is then implanted in one of two ways. Either your specialist will use bone cement to fix a special plastic socket into the bone of the pelvis or use a metal socket without cement. In the latter case, the socket is held in place by jamming a slightly oversized component into the bone with additional screws if necessary. A plastic liner is then inserted into the metal shell. In both these instances, the bearing surface of the socket is of plastic.
The next step in the operation is to replace the natural worn out ball also called the femoral head, with an artificial one. The femoral head is removed by cutting through with a saw and then the upper end of the thigh bone is shaped to conform to the stem of the artificial ball. A trial implant is then temporarily placed in the femur bone and the function of the hip checked. If all is satisfactory, an exact replica of the trial implant for permanent fixation is then inserted into the thigh bone. Usually bone cement is used to anchor the artificial ball into the thigh but sometimes it may be necessary to use an implant that can be inserted without cement. Once this is completed, the ball is replaced into the socket and that completes the bone work.
Finishing
The soft tissue coverings of the hip joint are then stitched layer by layer. Usually two plastic tubes are placed into the hip joint and brought out through the skin and connected to plastic drainage bottles. Bulky dressings are applied to the wound after which the patient is woken up and transferred to the bed and taken to the Recovery area. Once awake, the patient is taken to the ward.
The operation takes about 2 hours to perform. When it is finished, a bulky dressing is applied to the wound and a foam wedge (abduction pillow) placed between your legs. The wedge reduces the risk of dislocation (slippage of the ball out of the socket in the hip joint) of the hip. You will then be taken into the Recovery area.
First day after your hip replacement operation:
You will be checked by one of the team doctors. A blood test will be taken in the morning and repeated on the next two days. This is to check that any loss of blood or body salts is being recovered naturally by the body. You will be encouraged to take more liquids and solids by mouth if you are not feeling too sick or nauseous. If you are able to take food and liquids "by mouth", the intravenous drip will be removed.
The nurses will help to wash you and the physiotherapist will help you to get out of bed. If you haven't already, you may notice two plastic tubes emerging from the wound dressings which empty into bottles. These have been inserted to help remove any excess bleeding after the surgery. The physio will encourage you to take a few steps with the help of a walking frame and take some weight through the operated leg. You will then be sat out of bed in a high chair with your operated leg elevated on a foot stool.
The physiotherapist will also supervise you in carrying out a number of exercises for your legs and arms as well as in helpful breathing exercises. The latter are important in removing any extra secretions that may have collected in your lungs during the operation. If these secretions are not removed they can increase the risk of getting a chest infection. The physio will also emphasise the precautions to be taken to avoid dislocating your new hip.
These precautions include:
The catheter inserted into your bladder will be removed. The support stockings will be removed for about half an hour once every 6 to 8 hours. You will also be prescrbed a number of medications which include iron to help build up the level of blood in your body, as well as painkillers and laxatives.
On the Second day after your hip replacement:
The plastic tubes draining your wound will be removed by the nurse. This is a simple procedure that may cause a little discomfort, but you will be glad to have one less attachment! It is unlikely that you will require any more pain killing injections though you will still be on pain killing tablets.
The physiotherapist will help you up and and instruct you on the best techniques for moving safely from bed to chair and back. The physiotherapist will get you walking a little. You will be instructed in the use of the 'helping hand' which is a long stick like device with a grasper at the end that you can use to reach for and pick various items. It is important to use this implement as it enables you to avoid bending your new hip excessively.
Your blood tests will be reviewed on the second day and you may need to have a blood transfusion depending upon the results.
Third day after hip replacement surgery:
With each day the therapist will encourage you to increase your activity. As your strength and confidence grows, you will graduate from using the frame to using two crutches and then to two sticks. Gradually, you will learn to walk further and eventually also climb and descend stairs. Your dressings will be changed and you will undergo an X-Ray of the new hip to check its position.
Fourth day after hip replacement surgery:
You will be encouraged to dress in your own clothes and work towards increasing your independence. Your wound will be regularly dressed until it heals over.
Over the next few days:
About a week or so from your operation you will be able to go home depending upon your progress. You should also take your surgical stockings home with you and wear them until your first follow-up appointment which will be at about six weeks. Until that visit you should be using two sticks.
You will be given strong painkillers to help relieve any discomfort as the anaesthetic you were given during the operation wears off. If you have had an epidural anaesthetic (ie not general anaesthetic), you will not be able to feel or move your legs for several hours after your operation. Some people may want to be given something to help them sleep during this phase.
Special pillows may be placed between your legs to keep the new joint still and stable and help prevent dislocation.
A couple of days after your operation, a physiotherapist will visit you every day to help you do exercises intended to promote recovery.
Patients generally stay in hospital for around 5 days but you may need to stay for up to 10 days depending on your age or condition. After this, you will be able to walk with sticks or crutches.
Before you are discharged, your nurse will give you advice about looking after your stitches, hygiene and bathing.