Who needs a total hip replacement?
Patients who are candidates for a total hip replacement (also called total hip arthroplasty) have hip pain, usually affecting the groin area. It can radiate down into the leg and affect the outside of the hip or the lower back. The pain is aggravated by weight-bearing activities such as walking or climbing stairs.
Patients have usually undergone conservative treatment such as anti-inflammatories (NSAIDs) like ibuprofen, Motrin, or Aleve; physical therapy; or hip injections.
When these management options aren’t providing significant relief and you still have trouble walking and completing your day-to-day activities, total hip arthroplasty is generally a good option for you.
Total hip arthroplasties historically provide very good outcomes for patients with significant hip osteoarthritis: over 98% of patients are happy following total hip arthroplasties. They have been performed for many years in many types of facilities, including inpatient stays at hospitals, same day surgeries at hospitals and now same-day surgeries at surgery centers.
Two approaches to hip replacement
The two most popular approaches for hip replacement are the anterior approach and the posterior approach. The anterior approach means that the incision is over the front of the hip and the posterior approach means that the incision is over your gluteus (backside).
The posterior approach has stood the test of time. It allows surgeons to do more if needed and is appropriate for more severe cases or revision cases (replacing a replacement).
I prefer the anterior approach for routine total hip replacements. Typically, the incision is smaller and more discreet. During the immediate post-operative period, particularly in the first two to six weeks, patients who have an anterior approach total hip replacement progress with their post-operative mobility and reduce pain quicker than patients who have a posterior approach. One of the main reasons for this difference is the anterior approach is a muscle-sparing approach, where we can move the muscles out of the way instead of cutting or detaching them. Moving muscles instead of cutting them means less irritation and inflammation in the muscles and less time spent waiting for them to heal.
The anterior approach also allows us to use imaging more efficiently to help position the components of your total hip arthroplasty. For example, I need to place the cup portion of the implant in the correct position in your pelvis to keep the ball in the socket. Using the anterior approach allows me to use fluoroscopy, like an x-ray, to aid me in positioning the cup precisely. Fluoroscopy also allows me to dial in the leg lengths by looking at preoperative x-rays and intraoperative fluoroscopy views to ensure that the legs are as close in length after surgery as they were before surgery.
Steps of a total hip arthroplasty
If you’ve failed conservative treatment and we’ve agreed that a hip replacement is the appropriate surgery to provide you with the relief you’re looking for, what are the next steps?
You’ll speak with your primary care physician and your dentist to make sure that you do not have any underlying illnesses, cavities or other issues that need to be addressed prior to surgery. If you see other specialists such as cardiologists or pulmonologists, you’ll meet with them as well. We make sure that you’re as medically prepared for surgery as possible, which is particularly important nowadays when patients are being sent home the same day.
Day of surgery
You’ll arrive about an hour and a half before the surgery. I’ll see you and answer any last-minute questions. We will verify the correct hip that we’re operating on and then we’ll go to the operating room.
Most of my hip replacements are performed using spinal anesthetic, which I prefer over general anesthetic if possible. Spinal anesthetic provides reliable timing: we can time the anesthetic to wear off when you’re in recovery after surgery and you’re awake enough to start trying to walk.
During the surgery, I have three goals.
- Implants that fit appropriately, so they stay in place and don’t wiggle in the bone.
- Stable joint, with a ball that stays in the socket and doesn’t come out.
- Same leg lengths.
After the surgery, when the spinal anesthetic wears off, you’ll have motor function in your leg. A physical therapist will see you and will help you walk again. The three requirements to be able to go home are to be able to walk, to be able to eat without nausea, and to be able to go to the bathroom.
After the surgery
I close your incision with sutures under the skin and glue and steristrips on top of the skin, with a waterproof dressing over all of it. You’re allowed to shower and water can run down over the dressing, but baths are not allowed immediately after surgery. The waterproof dressing stays on for seven days.
Two weeks after the surgery you’ll have a follow-up appointment in the clinic and you’ll have an x-ray to check how your joint is. Your incision is usually healed by this point, but we’ll check it as well.
We’ll follow you periodically from here. A joint replacement is the start of a long-term relationship. It’s important that we get you through the surgery and immediate post-operative period successfully, but joints are there for life and I’m here to follow you for life. We’ll see you periodically over the years to get an x-ray, check-in, and make sure nothing is changing with the implant. However, if something does change, by providing these every 2- to 3-year screening events, we’ll be able to address the changes before they turn into a more drastic issue.
Frequently asked questions
Can you do a partial hip replacement?
Hemiarthroplasty is a partial hip replacement. Typically, those are reserved for people that have fallen and broken their hip. If you have arthritis, both sides of the hip joint are going to be affected: the acetabular (cup or socket) side and the femoral (ball or hip) side. Since they’re both affected, the most complete way of taking care of that arthritis is to perform a total hip replacement and replace both sides of the joint.
What is physical therapy after an anterior total hip replacement?
Most of my patients don’t do formal physical therapy. Instead, I encourage you to walk multiple times a day. I want you to walk at least 20 minutes 3 times a day. If after two weeks you’re not progressing as we want or want if there is more inflammation to work through, you may be referred to formal physical therapy.
How long is recovery after an anterior hip replacement?
The first two weeks, you’re limited because you have an incision that is healing. After 6 weeks when the incision is healed, you can start to get back to more of everyday life, including things like swimming. At three months after surgery, you’re going to feel very good. Maximum improvement happens between 12 and 18 months after surgery, but after 3 months most patients are going to be back to living life.
Are there any restrictions after surgery, including on sports?
While the posterior hip approach has multiple precautions, the anterior approach only has one restriction. You’ll need to avoid pointing your toe outwards, rotating it and extending your hip like your foot behind your backside. Since this is an uncommon pose, you may hear that there are no real restrictions and you can return to your sports.
Are there exercises that are recommended or not recommended while waiting to get your hip replaced?
A joint in motion is a happy joint, so even if it hurts if you keep moving a joint it will continue to move. Once a joint is stationary it tends to get stiff. So I recommend doing whatever exercises you can tolerate. Don’t push it if an exercise is extremely painful. However, if it is sore but moving, I encourage you to continue to do the exercise until the time of surgery.
What is the risk of blood clots with a hip replacement?
The risk is minimal but present. There have been multiple studies looking at blood clot risk because it used to be a bigger deal and patients had to use long-term anti-coagulant drugs. Now it has been found that 81 milligrams of aspirin greatly decreases the risk of blood clots. However, they are something that we as doctors are concerned about and keep an eye on.