Hip replacement, or arthroplasty, is a surgical procedurein which the diseased parts of the hip joint are removed and replaced with new,artificial parts. These artificial parts are called the prosthesis. The goals ofhip replacement surgery are to improve mobility by relieving pain and improvefunction of the hip joint.

Who Should Have Hip Replacement Surgery?

The most common reason that people have hip replacementsurgery is the wearing down of the hip joint that results from osteoarthritis.Other conditions, such as rheumatoid arthritis (a chronic inflammatory diseasethat causes joint pain, stiffness, and swelling), avascular necrosis (loss ofbone caused by insufficient blood supply), injury, and bone tumors also may leadto breakdown of the hip joint and the need for hip replacement surgery.

Before suggesting hip replacement surgery, the doctor islikely to try walking aids such as a cane, or non-surgical therapies such asmedication and physical therapy. These therapies are not always effective inrelieving pain and improving the function of the hip joint. Hip replacement maybe an option if persistent pain and disability interfere with daily activities.Before a doctor recommends hip replacement, joint damage should be detectable onx rays.

In the past, hip replacement surgery was an optionprimarily for people over 60 years of age. Typically, older people are lessactive and put less strain on the artificial hip than do younger, more activepeople. In recent years, however, doctors have found that hip replacementsurgery can be very successful in younger people as well. New technology hasimproved the artificial parts, allowing them to withstand more stress andstrain. A more important factor than age in determining the success of hipreplacement is the overall health and activity level of the patient.

For some people who would otherwise qualify, hipreplacement may be problematic. For example, people who suffer from severemuscle weakness or Parkinson's disease are morelikely than healthy people to damage or dislocate an artificial hip. Becausepeople who are at high risk for infections or in poor health are less likely torecover successfully, doctors may not recommend hip replacement surgery forthese patients.

What Are Alternatives to Total HipReplacement?

Before considering a total hip replacement, the doctor maytry other methods of treatment, such as an exercise program and medication. Anexercise program can strengthen the muscles in the hip joint and sometimesimprove positioning of the hip and relieve pain.

The doctor also may treat inflammation in the hip withnonsteroidal anti-inflammatory drugs, or NSAIDs. Some common NSAIDs are aspirinand ibuprofen. Many of these medications are available without a prescription,although a doctor also can prescribe NSAIDs in stronger doses.

In a small number of cases, the doctor may prescribecorticosteroids, such as prednisone or cortisone, if NSAIDs do not relieve pain.Corticosteroids reduce joint inflammation and are frequently used to treatrheumatic diseases such as rheumatoid arthritis. Corticosteroids are not alwaysa treatment option because they can cause further damage to the bones in thejoint. Some people experience side effects from corticosteroids such asincreased appetite, weight gain, and lower resistance to infections. A doctormust prescribe and monitor corticosteroid treatment. Because corticosteroidsalter the body's natural hormone production,patients should not stop taking them suddenly and should follow the doctor'sinstructions for discontinuing treatment.

If physical therapy and medication do not relieve pain andimprove joint function, the doctor may suggest corrective surgery that is lesscomplex than a hip replacement, such as an osteotomy. Osteotomy is surgicalrepositioning of the joint. The surgeon cuts away damaged bone and tissue andrestores the joint to its proper position. The goal of this surgery is torestore the joint to its correct position, which helps to distribute weightevenly in the joint. For some people, an osteotomy relieves pain. Recovery froman osteotomy takes 6 to 12 months. After an osteotomy, the function of the hipjoint may continue to worsen and the patient may need additional treatment. Thelength of time before another surgery is needed varies greatly and depends onthe condition of the joint before the procedure.

What Does Hip Replacement Surgery Involve?

The hip joint is located where the upper end of the femurmeets the acetabulum. The femur, or thigh bone, looks like a long stem with aball on the end. The acetabulum is a socket or cup-like structure in the pelvis,or hip bone. This "ball and socket" arrangementallows a wide range of motion, including sitting, standing, walking, and otherdaily activities.

During hip replacement, the surgeon removes the diseasedbone tissue and cartilage from the hip joint. The healthy parts of the hip areleft intact. Then the surgeon replaces the head of the femur (the ball) and theacetabulum (the socket) with new, artificial parts. The new hip is made ofmaterials that allow a natural, gliding motion of the joint. Hip replacementsurgery usually lasts 2 to 3 hours.

Sometimes the surgeon will use a special glue, or cement,to bond the new parts of the hip joint to the existing, healthy bone. This isreferred to as a "cemented" procedure. In anuncemented procedure, the artificial parts are made of porous material thatallows the patient's own bone to grow into thepores and hold the new parts in place. Doctors sometimes use a"hybrid" replacement,which consists of a cemented femur part and an uncemented acetabular part.

Is a Cemented or Uncemented ProsthesisBetter?

Cemented prostheses were developed 40 years ago.Uncemented prostheses were developed about 20 years ago to try to avoid thepossibility of loosening parts and the breaking off of cement particles, whichsometimes happen in the cemented replacement. Because each person's condition is unique, the doctor and patient must weigh theadvantages and disadvantages to decide which type of prosthesis is better.

For some people, an uncemented prosthesis may last longerthan cemented replacements because there is no cement that can break away. And,if the patient needs an additional hip replacement (which is likely in youngerpeople), also known as a revision, the surgery sometimes is easier if the personhas an uncemented prosthesis.

The primary disadvantage of an uncemented prosthesis isthe extended recovery period. Because it takes a long time for the natural boneto grow and attach to the prosthesis, people with uncemented replacements mustlimit activities for up to 3 months to protect the hip joint. The process ofnatural bone growth also can cause thigh pain for several months after thesurgery.

Research has proven the effectiveness of cementedprostheses to reduce pain and increase joint mobility. These results usually arenoticeable immediately after surgery. Cemented replacements are more frequentlyused than cementless ones for older, less active people and people with weakbones, such as those who have osteoporosis.

What Can Be Expected Immediately AfterSurgery?

Patients are allowed only limited movement immediatelyafter hip replacement surgery. When the patient is in bed, the hip usually isbraced with pillows or a special device that holds the hip in the correctposition. The patient may receive fluids through an intravenous tube to replacefluids lost during surgery. There also may be a tube located near the incisionto drain fluid and a tube (catheter) may be used to drain urine until thepatient is able to use the bathroom. The doctor will prescribe medicine for painor discomfort.

How Long Are Recovery and Rehabilitation?

On the day after surgery or sometimes on the day ofsurgery, therapists will teach the patient exercises that will improve recovery.A respiratory therapist may ask the patient to breathe deeply, cough, or blowinto a simple device that measures lung capacity. These exercises reduce thecollection of fluid in the lungs after surgery.

A physical therapist may teach the patient exercises, suchas contracting and relaxing certain muscles, that can strengthen the hip.Because the new, artificial hip has a more limited range of movement than anundiseased hip, the physical therapist also will teach the patient propertechniques for simple activities of daily living, such as bending and sitting,to prevent injury to the new hip. As early as 1 to 2 days after surgery, apatient may be able to sit on the edge of the bed, stand, and even walk withassistance.

Usually, people do not spend more than 10 days in thehospital after hip replacement surgery. Full recovery from the surgery takesabout 3 to 6 months, depending on the type of surgery, the overall health of thepatient, and the success of rehabilitation.

How to Prepare for Surgery and Recovery

People can do many things before and after they have surgery to make everyday tasks easier and help speed their recovery.

Before Surgery

Learn what to expect before, during, and after surgery. Request information written for patients from the doctor or contact one of the organizations listed near the end of this fact sheet.
Arrange for someone to help you around the house for a week or two after coming home from the hospital.
Arrange for transportation to and from the hospital.
Set up a "recovery station" at home. Place the television remote control, radio, telephone, medicine, tissues, waste basket, and pitcher and glass next to the spot where you will spend the most time while you recover.
Place items you use every day at arm level to avoid reaching up or bending down.
Stock up on kitchen staples and prepare food in advance, such as frozen casseroles or soups that can be reheated and served easily.

After Surgery

Follow the doctor's instructions.
Work with a physical therapist or other health care professional to rehabilitate your hip.
Wear an apron for carrying things around the house. This leaves hands and arms free for balance or to use crutches.
Use a long-handled "reacher" to turn on lights or grab things that are beyond arm's length. Hospital personnel may provide one of these or suggest where to buy one.

What Are Possible Complications of HipReplacement Surgery?

According the American Academy of Orthopaedic Surgeons,approximately 120,000 hip replacement operations are performed each year in theUnited States and less than 10 percent require further surgery. New technologyand advances in surgical techniques have greatly reduced the risks involved withhip replacements.

The most common problem that may happen soon after hipreplacement surgery is hip dislocation. Because the artificial ball and socketare smaller than the normal ones, the ball can become dislodged from the socketif the hip is placed in certain positions. The most dangerous position usuallyis pulling the knees up to the chest.

The most common later complication of hip replacementsurgery is an inflammatory reaction to tiny particles that gradually wear off ofthe artificial joint surfaces and are absorbed by the surrounding tissues. Theinflammation may trigger the action of special cells that eat away some of thebone, causing the implant to loosen. To treat this complication, the doctor mayuse anti-inflammatory medications or recommend revision surgery (replacement ofan artificial joint). Medical scientists are experimenting with new materialsthat last longer and cause less inflammation.

Less common complications of hip replacement surgeryinclude infection, blood clots, and heterotopic bone formation (bone growthbeyond the normal edges of bone).

When Is Revision Surgery Necessary?

Hip replacement is one of the most successful orthopaedicsurgeries performed--more than 90 percent ofpeople who have hip replacement surgery will never need revision surgery.However, because more younger people are having hip replacements, and wearingaway of the joint surface becomes a problem after 15 to 20 years, revisionsurgery is becoming more common. Revision surgery is more difficult thanfirst-time hip replacement surgery, and the outcome is generally not as good, soit is important to explore all available options before having additionalsurgery.

Doctors consider revision surgery for two reasons: ifmedication and lifestyle changes do not relieve pain and disability; or if xrays of the hip show that damage has occurred to the artificial hip that must becorrected before it is too late for a successful revision. This surgery isusually considered only when bone loss, wearing of the joint surfaces, or jointloosening shows up on an x ray. Other possible reasons for revision surgeryinclude fracture, dislocation of the artificial parts, and infection.

What Types of Exercise Are Most Suitable forSomeone With a Total Hip Replacement?

Proper exercise can reduce joint pain and stiffnessand increase flexibility and muscle strength. People who have an artificial hipshould talk to their doctor or physical therapist about developing anappropriate exercise program. Most exercise programs begin with saferange-of-motion activities and muscle strengthening exercises. The doctor ortherapist will decide when the patient can move on to more demanding activities.Many doctors recommend avoiding high-impact activities, such as basketball,jogging, and tennis. These activities can damage the new hip or cause looseningof its parts. Some recommended exercises are cross-country skiing, swimming,walking, and stationary bicycling. These exercises can increase muscle strengthand cardiovascular fitness without injuring the new hip.

What Hip Replacement Research Is Being Done?

To help avoid unsuccessful surgery, researchers arestudying the types of patients most likely to benefit from a hip replacement.Researchers also are developing new surgical techniques, materials, and designsof prostheses, and studying ways to reduce the inflammatory response of the bodyto the prosthesis. Other areas of research address recovery and rehabilitationprograms, such as home health and outpatient programs.

Where Can People Find More Information AboutHip Replacement Surgery?

American Academy of Orthopaedic Surgeons

6300 North River Road

Rosemont, IL 60018-4262

847/823-7186

800/346-AAOS

Fax: 847/823-8125

World Wide Web address: http://www.aaos.org

The Hip Society

c/o Richard B. Welch, M.D.

One Shrader Street, Suite 650

San Francisco, CA 94117

415/221-0665

Fax: 415/221-4023

The Society maintains a list of physicians who arespecialists in problems of the hip and provides physician referrals bygeographic area.

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