Hip replacements are one of the most performed orthopedic surgeries, often as a treatment for arthritis. Arthritis affects 91 million people, with over a third of those people having degenerative osteoarthritis.
Osteoarthritis doesn’t have a single cause. Causes include anatomy, biology, genetics, lifestyle, and overuse, among others.
A normal functioning joint is like a new hinge. A healthy joint has good cartilage, is well-lubricated, has a full range of motion, and is pain-free. An arthritic hip is like a rusty hinge: it loses its range of motion or develops pain with motion. Arthritic hips don't have that lubricating synovial fluid that helps move them smoothly and so you start having problems requiring treatment.
To diagnosis arthritis, your doctor will take a medical history, do a physical exam and look at x-rays. On an x-ray, a normal-looking hip has well-maintained joint space and smooth joint surfaces, a nice rounded ball with a nice rounded cup, and no bone spurs or extra bone in the hip joint. An arthritic hip on an x-ray is starting to lose that well-rounded ball and joint space. The ball is flatter, and there is extra bone added which helps support the bone but is also a sign of irritation and aggravation in the bone. The bones will start to get cysts, seen on x-ray as little circles in the bone, caused by joint fluid being pushed into the bone. Finally, there are bone spurs around the edge as your body tries to offload some of the force.
Treatments for Hip Arthritis
A hip replacement is not the first treatment for hip arthritis.
- Weight loss. Your hip gets more force on it than your body weighs, so reducing your overall weight reduces the force on your hip. Like the shocks of a car, the more weight that goes across your joint, the quicker the cartilage will wear out. Additionally, surgery has fewer complications at lower weights.
- Activity modification. If you change some of your activities, you’ll be able to have less pain and keep your quality of life. For example, you might swim or bike instead of running.
- Medications, injections and supplements. Anti-inflammatory medications are the most common, both topical and oral. Please talk with your doctor before starting them, as not all medications are right for all patients. Steroid injections are the most common type of injections for hip arthritis, but lubricating injections and PRP injections may also be available. Your doctor can talk about the right kind for you. Many supplements are reported as helpful for arthritis. They’re not proven so we can’t recommend them, but if they help you and don’t interact with any other medications you’re taking you may take them.
Surgery for Hip Arthritis
A good surgical joint replacement candidate is someone who has failed to have adequate relief with conservative (non-surgical) measures, is medically safe to have surgery, and is informed and understands what goes into the surgery in terms of risks, benefits, and recovery expectations.
The first goal of surgery is to relieve pain. Often, it is to improve range of motion and mobility. Overall, the goal is to get you back to the more active lifestyle before the joint pain started getting in the way of those things that you cherish and hold dear.
Once you and your surgeon have decided on surgery, your primary care doctor will evaluate you and make sure it’s safe for you to have surgery. You may need to have appointments with specialists like cardiologists, pulmonologists, or endocrinologists for their approval. You’ll also have education about the surgery, which may include classes and handouts.
What is a hip replacement?
A hip replacement resurfaces the diseased joint area. In most cases, a hip replacement includes four parts.
- The shell or cup that replaces the acetabular (top) side of your ball and socket joint.
- Plastic liner inside the cup.
- Metal stem that goes inside the thigh bone, after the ball from the ball and socket joint is removed.
- Ball that goes on top of the metal stem, to act as the new ball for the ball and socket joint.
Why the anterior approach?
The anterior approach is an incision that goes on the front of the leg instead of the side or the back. The surgeon works between the muscles in the anterior approach, instead of cutting them. X-ray machines can be used along with specialized operating room tables to make sure that the implants are positioned precisely.
Additionally, the anterior approach allows for a smaller incision and gives the surgeon a better way to get to the hip joint. It’s less traumatic for your body, so healing can be faster. In the first six weeks after surgery, patients who had the anterior approach have higher post-operative satisfaction and higher post-operative functional scores. Long-term the approaches are equal, but I think the advantages in the first six weeks matter for patients.
Finally, patients have fewer restrictions on movement and range of motion after the surgery, allowing for better mobility and fewer concerns from the patients. With smaller incisions there’s potentially less pain and less need for pain medication, reducing side effects. It’s a faster surgery, so the risk of complications goes down.
Using x-rays during the operation is very helpful. We can take x-rays of the leg being operated on and the leg not being operated on and overlay them on top of each other, to make sure that we’re recreating the same anatomy on the leg that is not being operated on. Additionally, if I have an x-ray machine right, I can confirm that my components go exactly where I want them. If I put in part of an implant and I don’t like how it looks on the x-ray, I can reposition it until it is perfect.
You’re out of surgery and going home the same day you have surgery. You’re able to immediately put weight on it, with no range of motion restrictions. Physical therapy starts immediately after surgery, and you’ll transition away from using forearm crutches or a walker within the first couple of weeks.
We usually apply a waterproof dressing over your surgical wound so you can shower immediately after surgery. The incision is usually closed with sutures under the skin that gradually absorb into your body, and the skin is closed with surgical glue to hold it together until everything heals.
Our modern protocols include a multimodal recovery protocol, which involves anesthesia and injections during operating as well as an efficient, precise surgery to minimize the overall anesthesia you receive. A physical therapist will help get you moving right after surgery as well.
Hip replacements now last 20-25 years, and then the plastic may wear out. Once the bone grows into the implant they are relatively stable. A revision surgery is not guaranteed at 20 or 25 years, but it becomes more likely.
Frequently Asked Questions
Is anterior hip replacement covered by insurance?
You may need to do some paperwork or get authorizations ahead of time, but hip replacements are one of the most common surgeries performed in the United States and they are covered by most insurance plans. For details, please talk to your insurance company.
Who is eligible for an anterior total hip replacement?
Most patients can have an anterior approach total hip replacement. A few patients may not be able to due to previous surgeries or anatomy. Patients who have osteoarthritis, including who have advanced “bone on bone” arthritis, as well as patients with other arthritis like rheumatoid arthritis or with lupus, can get an anterior approach. The anterior approach is a great option for patients who have more laxity or inflammation in their soft tissues.
How soon can you go back to work after surgery?
If you have a sedentary desk job, you can go back to work within a week or two. Your job will probably require you to be off narcotic pain killers before you go back, which may influence your start date. You may still need an assistive device such as crutches or a walker, but you’ll be able to sit at a desk.
If you do manual labor, the wait before working again is longer. Some people can get back to a manual labor job in six to eight weeks, while others need three months. The exact length depends on the job and on the patient. We prefer to err on the side of caution, so plan to be out longer and then be satisfied and happy when you’re able to return sooner than expected.
How soon can you travel after surgery?
There’s no strict limitation, but you’ll need to understand the risk, the pain and the symptoms you may have. I have had patients who have flown the day after surgery. Some people may choose to drive instead of flying after surgery, but the trip in the car will take longer overall than a flight will. For both types of travel, I encourage people to get up and walk during the journey. If you’re driving, you’ll need to stop and walk at least every couple of hours. In a plane, once you’re allowed to move around, you’ll need to walk in the aisle. Walking helps prevent stiffness and minimizes your risk of blood clots. If you’re flying, we’ll keep you on blood thinners during the flight to further reduce the risk of blood clots.
If someone is in their 40s or 50s with severe hip arthritis, should they have a hip replacement now or put it off as long as possible?
The specifics depend upon the patient, but there are arguments on both sides. Joint replacements do wear out, and if you’re younger, you’ll probably need revision surgery at some point in the next few decades to get a new replacement. However, it’s a trade-off: how much pain are you in now? What will be the impact on your quality of life if you delay having the surgery? What are the risks and benefits of moving forward with surgery now? You would get back the years you would otherwise lose to being nonfunctional, being able to do the activities you want to do with your family. On the other hand, you would be likely to need revision surgery when you’re older.
If you have osteoporosis is there a risk of the bone shattering or breaking during the surgery?
Unfortunately, breaking bones is always a risk, regardless of if you have osteoporosis. All surgeons do techniques to minimize the risk of a fracture during surgery. The weaker your bone, the higher the risk, so for older patients or patients with severe osteoporosis a different type of hip implant is used. Regular implants are wedged into place, but this implant is instead glued into place with special bone cement.