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Hip replacement and hip revision

Published by Bupa’s Health Information Team, August 2010.

This factsheet is for people who are planning to have a hip replacement operation or hip revision surgery, or who would like information about it.

Hip replacement operation involves replacing a hip joint that has been damaged or worn away, usually by arthritis or injury. Hip revision (or repeat hip replacement) involves replacing an artificial hip joint that has become loose, infected or worn out.

You will meet the surgeon carrying out your particular procedure to discuss your care. It may differ from what is described here as it will be designed to meet your individual needs.

How a hip replacement is carried out

 

About hip replacement

Your hip is a ball and socket joint. Normally, the ball at the top of your thigh bone (femur) moves smoothly in the socket of your pelvis (hip) on a lining of cartilage. The cartilage stops the bones from rubbing together. If the cartilage is worn away, the underlying bone is exposed and your joint becomes painful and stiff. As a result walking and moving around becomes painful.

A new hip joint can help to improve your mobility and reduce pain.

Illustration showing a hip with arthritis and a hip with a replaced joint

Types of artificial hip

Artificial hip parts can be made of metal, ceramic or plastic. Hip joints can be fixed in place using a special substance called ‘bone cement’. Alternatively, they may be designed so that your own bone grows onto the metal. These ‘uncemented’ hips can be coated with a type of bone mineral (hydroxyapatite) or can be made from a material that has lots of tiny holes (porous coating). This encourages your bone to grow into the artificial joint and fix it in place.

Hip revision surgery

During your original hip replacement, your hip joint was replaced with artificial hip parts. These usually last from 10 to 20 years, after which they need replacing.

Renewing an artificial hip joint is more complicated than the original operation because the existing artificial hip joint will need to be taken out before the new one is fitted. If the hip has worn loose then this may not be too difficult for your surgeon, but if it is still bonded to your bone then removing the old components can be a challenge.

You may find that your new joint, although a big improvement on your old joint, may not improve your life as much as your original hip operation. This may be because the muscles can take a long time to recover from the build-up of scar tissue and repeat surgery.

What are the alternatives to hip replacement?

Surgery is usually recommended only if non-surgical treatments, such as taking painkillers (eg paracetamol) or anti-inflammatories (eg ibuprofen), or using physical aids like a walking stick, no longer help to reduce your pain or improve mobility.

Hip resurfacing may be a better option for people with stronger bones. In this operation the surfaces of the ball and socket are covered with metal caps.

Preparing for your operation

Your surgeon will explain how to prepare for your operation. For example, if you smoke you will be asked to stop, as smoking increases your risk of getting a chest and wound infection, which can slow your recovery.

The operation is usually done under general anaesthesia. This means you will be asleep during the operation. Alternatively you may have the surgery under spinal or epidural anaesthesia. This completely blocks feeling from below your waist and you stay awake during the operation. Your surgeon will advise you which type of anaesthesia is most suitable for you. Often people have a combination so that they are asleep, but the spinal/epidural anaesthetic will ease any pain immediately after surgery.

If you’re having a general anaesthetic, you will be asked to follow fasting instructions. This means not eating or drinking, typically for about six hours beforehand. However, it’s important to follow your anaesthetist’s advice.

Your surgeon will discuss with you what will happen before, during and after your procedure, and any pain you might have. This is your opportunity to understand what will happen, and you can help yourself by preparing questions to ask about the risks, benefits and any alternatives to the procedure. This will help you to be informed, so you can give your consent, by signing a consent form, for the procedure to go ahead.

You may be asked to give your consent to have your name on the National Joint Register, which is used to follow up the safety, durability and effectiveness of joint replacements and implants.

You may be asked to wear compression stockings to help prevent blood clots forming in the veins in your legs (deep vein thrombosis, DVT).

About the operation

A hip replacement usually takes around two hours.

Your surgeon will make a cut (20 to 30cm long) over your hip and thigh. He or she will then separate the ball and socket (hip joint).

The ball at the top end of your thigh bone (the femoral head) will be removed and a replacement ball on a stem will be inserted into your thigh bone. Your hip socket will be hollowed out to make a shallow cup and an artificial socket will be placed into it. The two halves of the hip joint are then put back together (the ball is put into the socket).

Your surgeon will close the skin cut with stitches or clips and cover it with a dressing.

It may be possible for your surgeon to make a smaller cut over your hip and thigh. This type of operation (minimally invasive hip replacement) is carried out using specially designed surgical instruments. It isn’t suitable for everyone – ask your surgeon if it’s an option for you.

What to expect afterwards

You will need to rest until the effects of the anaesthetic have passed. You may not be able to feel or move your legs for several hours after a spinal or epidural anaesthetic. You may need pain relief to help with any discomfort as the anaesthetic wears off.

A special pillow may be placed between your legs to hold your hip joint still and stop it from dislocating.

You may be given medicine (injection or tablets) to prevent DVT, such as rivaroxaban or dabigatran. You will be given this shortly after your surgery and then you may need to take it for a few weeks.

A physiotherapist (a health professional who specialises in movement and mobility) will usually visit you each day to guide you through exercises that are designed to help your recovery.

You will stay in hospital until you’re able to walk safely with the aid of sticks or crutches. This is usually about five days. However, if you’re generally fit and well, your surgeon may suggest you do an accelerated rehabilitation programme, where you start walking on the day of the operation and are discharged within one to three days.

When you’re ready to go home, you will need to arrange for someone to drive you.

Your nurse will give you some advice about caring for your hip and a date for a follow-up appointment before you go home.

Most skin stitches or clips will need to be removed after 12 to 14 days. Dissolving skin stitches don’t need to be removed.

Recovering from hip replacement surgery

If you need pain relief, you can take over-the-counter painkillers such as paracetamol or ibuprofen. Always read the patient information that comes with your medicine and if you have any questions, ask your pharmacist for advice.

The exercises recommended by your physiotherapist are a crucial part of your recovery, so it’s essential that you continue to do them.

There are certain movements that you shouldn’t do in the first six weeks. For example, don’t cross your legs or twist your hip inwards and outwards. This is to reduce strain on your scar and to reduce the risk of a dislocation. Your physiotherapist will give you further advice and tips to protect your hip.

You should be able to move around your home and manage stairs. You will find some routine daily activities, such as shopping, difficult for a few weeks and will need to ask for help. You will need to use crutches for about four to six weeks.

You can usually return to light work after about six weeks. But if your work involves a lot of standing or lifting, you may need to stay off for longer.

Follow your surgeon’s advice about driving as the length of time before you’re fit to drive will depend on several factors, including which leg has been operated on and whether your car is automatic.

What are the risks?

Hip replacement is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications.

Side-effects

Side-effects are the unwanted but mostly temporary effects you may get after having the procedure.

Your hip will feel sore for several weeks and you may have some temporary pain and swelling, both in the thigh and also in the ankle.

Complications

Complications are when problems occur during or after the operation. Most people having hip surgery aren’t affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or developing a blood clot, usually in a vein in the leg (deep vein thrombosis, DVT).

Specific complications of hip replacement are uncommon, but can include the following:

  • Infection – you will be given antibiotics during and after surgery to help prevent this.
  • Joint dislocation – this is most likely to happen immediately after your surgery and you may need another operation to treat this.
  • Difference in leg length – your leg may be slightly shorter or longer and you may need to wear a raised shoe on the shorter side to correct your balance.
  • Hip fracture – tiny cracks can occur in your bone while fitting the new joint. These usually heal, but sometimes your bone can fracture and require further surgery.
  • Unstable joint – the hip joint may become loose and you may require further surgery to correct this.
  • Nerve damage – this can quite often result in numbness around your scar, but rarely the sciatic nerve may be stretched and this can leave weakness in the foot (usually temporary).

The artificial hip joint usually lasts between 10 and 20 years, after which you may need to have it replaced.

The exact risks are specific to you and differ for every person, so we haven’t included statistics here. Ask your surgeon to explain how these risks apply to you.

What is the most common complication with hip replacement surgery and why?

Answer

A common complication of hip replacement surgery is dislocation of the joint (it pops out of joint). This happens to up to one in 20 people who have a hip replacement. It’s important to take care of your new hip to prevent it happening.

Explanation

Dislocation is a relatively common complication following a total hip replacement. The risk of dislocation varies depending on the surgical technique used and your general health. For example, if your muscles in the hip area are weak, the joint may become loose. Hip dislocation is more common if you have a repeat hip replacement (an artificial hip joint replaced).

You can dislocate your hip if you bend your hip to more than a right angle, for example, if you sit in a low chair. You can also dislocate your joint if you cross your legs and lean forward, or if you lie down and lift your waist.

Your hip is most likely to dislocate soon after your operation – more than half of dislocations occur within four to 12 weeks. This is because the muscles have not fully healed by this time.

The normal stability of your hip joint is affected during the operation because to get to the hip, surrounding muscles and tissue are moved out of the way. Your hip joint is then dislocated and some bone is removed to fit the new parts.

Your surgeon will repair any damage to muscles and tissues that surround your joint, but your joint will only become stable when the muscles around your hip joint have fully healed.

The exercises recommended by your physiotherapist are a crucial part of your recovery, so it’s essential that you continue to do them.

If your hip dislocates often, you may need surgery or a brace (a fitted support) to stabilise your joint and allow the surrounding tissue to heal.

Are there any sports or activities I shouldn’t do after my hip replacement?

Answer

It’s important to stay active after you have fully recovered from your operation. However, don’t do any high-impact sports that put a lot of pressure on your hips, such as running, squash or tennis.

Explanation

During your recovery your physiotherapist will recommend exercises for you that will improve your strength and range of motion.

As you recover you can start swimming (but don’t do breaststroke as the sideways kicking can cause a dislocation) and do more walking to strengthen your muscles around the joint.

When you have made a full recovery, you can have a more active lifestyle. However, try not to run on hard surfaces or take part in sports that could cause injury, such as football or rugby, or activities that put a lot of pressure on your hip such as squash or tennis. It’s best not to do any sports with a high risk of falling such as skiing or snowboarding.

Regular exercise will help to improve and maintain your mobility. When returning to any sport, it’s important to take your time to re-build your strength, coordination and reflexes. For example, if you play golf, work on chipping and putting before attempting longer distance shots.

Your doctor, surgeon or physiotherapist will be able to give you more information about what activities are suitable for you.

What can I do to make my recovery easier?

Answer

Try to be as fit and healthy as possible before your operation and prepare your home for when you return.

Explanation

If you’re having a hip replacement, it’s a good idea to try and be as fit and healthy as possible before your operation to speed up your recovery.

Your surgeon will explain how to prepare for your operation. For example, if you smoke you will be asked to stop, as smoking increases your risk of getting a chest infection, wound infection or DVT, which can slow your recovery.

If you’re overweight, your doctor may recommend a weight-loss programme.

You can exercise to strengthen your upper body. This will help you to get around after the surgery when using walking aids, such as crutches.

If it’s possible, you should try to strengthen your leg muscles. Strengthening the muscles in your leg will speed your recovery and will make it easier to perform the post-operative exercises.

Your surgeon or physiotherapist will recommend exercises for you.

It’s a good idea to prepare your home for when you return from hospital. This may involve rearranging furniture to make it easier to move around and placing commonly used items at arm level so you don’t have to reach for them. It’s also a good idea to stock up on non-perishable food such as frozen or tinned items, so that you don’t need to go shopping immediately after your surgery.

You may need help after surgery. It’s a good idea to arrange to have a friend or family member stay with you for a couple of weeks after the operation.

Why is hip revision surgery more complicated than the original hip operation?

Answer

Hip revision surgery is more complicated than the original operation because the existing implants plus any cement need to be taken out before a new one is fitted. Your bones are more likely to fracture and there is less bone to hold the new implant in place. As a result, repeat hip operations take longer to complete and have greater risk of complications.

Explanation

Currently the artificial joints used in hip replacement last about 10 to 20 years, after which your artificial joint may become loose and will need to be replaced. The repeat operation is called hip revision surgery.

During a revision hip operation, the original implants and any cement used to hold them in place need to be removed before the new implants can be put in. Your thighbone may have grown into the implant, making it more difficult to remove, and your bones will have grown thinner with age. As a result, your bones are more likely to fracture and your new joint is more likely to become loose because there isn’t enough bone to hold it in place. A hip replacement with a longer stem may need to be used to get a stronger fix.

Your surgeon may have to re-build the bone in your hip using bone taken from another part of your body or from your thigh bone. This is called a bone graft. If you have a bone graft, it may take longer to recover as it may restrict your movement and you might need to use crutches for longer.

Why am I unlikely to walk completely normally after hip revision surgery?

Answer

Hip revision surgery is more complex and has greater risk of complications than the original operation. So, you may find that your new joint, although a big improvement on your old joint, may not improve your life as much as your original hip operation.

Explanation

Repeat hip operations take longer to complete, are more complex and have a greater risk of complications compared with the original operation. Reasons why your mobility may be affected after hip revision surgery are listed here.

  • Infection. With age your immune system weakens and you’re more vulnerable to infection. Infection causes pain and swelling; delays healing and affects your overall health. If antibiotics don’t help clear an infection, the implant may need to be removed.
  • Scarring. During a repeat operation cuts are made over the original scars, so the tissue may not heal as well as before. Any infection may delay healing and cause scar tissue to form. Scar tissue can make your leg muscles feel stiff and affect your walking.
  • Fragile bones. With age your bones become thinner, so they are more likely to fracture and there is less bone to hold the new implant in place. As a result, your joint is more likely to become loose or dislocate and this can affect your mobility.
  • Leg difference. During hip revision surgery more bone is removed because the old implant has to be taken out before the new one is fitted. So you’re more likely to have a shorter leg and a slight limp (this is more common after revision surgery).

Hip revision techniques are improving all the time and there is every chance that you will have a good quality of life afterwards. You may always have a limp, but you should be able to continue to do everyday things, like getting dressed, climbing the stairs, getting in and out of the bath and walking short distances. If you have any concerns about the operation, ask your doctor for advice.

 

For answers to frequently asked questions on this topic, see Common questions.

For sources and links to further information, see Resources.