Hip Replacement Surgery

 

The hip is one of the largest weight-bearing joints in your body. It is shaped like a ball and socket. Total hip replacement is a surgery to replace the ball at the top of the thigh bone (femur) and the hip socket.
Surgeons use metal, ceramic, and/or plastic replacement parts. They may be attached to the bones in one of two ways:

  • Cemented to the bone
  • Uncemented. These parts have a special porous coating that the bone grows into

Types of surgery

In traditional hip replacement surgery, the doctor makes a 15- to 25-centimetre cut (incision) on the side or the back of your hip. Some muscles and other soft tissues, such as ligaments, are cut so the doctor can get to the hip joint.

Hip replacement can also be done with one or two smaller incisions. This is called minimally invasive surgery. It may cause less blood loss and leave a smaller scar but it can also mean a longer time in surgery, because the surgery is harder to do. And if the new hip can't be fitted properly through the smaller incision, the doctor may have to make a larger cut.

A newer type of surgery is done through a small incision in the front (anterior) of the hip. Anterior hip surgery causes less disruption to muscles than getting to the hip joint from the side or the back. It may help you heal faster and return to activity sooner.

Anterior surgery and minimally invasive surgery require special training and equipment. Your doctor can explain your options and help you understand the risks and benefits of each type of surgery.

Why is it done?

Total hip replacement surgery is usually done when hip pain and loss of function become severe and when other treatments no longer relieve pain. Hip replacement is sometimes done after a hip fracture.

How well it works

Surgery usually works well. You will probably have much less pain and be able to do most of your daily activities more easily but recovery does take time and patience.

Most artificial hip joints will last for 10 to 20 years or longer. It depends on your age, how much stress you put on the joint, and how well your new joint and bones mend. Your weight can make a difference. Every extra kilogram of body weight adds 3 kilograms of stress to your new hip joint. Controlling your weight will help your new hip joint last longer.

Risks

The risks of hip replacement surgery can be divided into two groups:

  1. Risks of the surgery and recovery period. These risks include:
    • blood clots
    • infection
    • fracture (crack in the bone)
    • bleeding (a small number of patients require blood transfusion)
    • nerve injury
    • problems with wound healing
    • problems with anesthesia
    • limp (usually goes away with physiotherapy but may persist in a small number of patients)
    • hip dislocation after surgery
    • difference in leg length. Usually very small and corrected by using a shoe insert
  2. Long-term risks that may occur months to years after the surgery. These risks include:
    • loosening of the hip implant in the bone.
    • infection in the joint.
    • a reaction to the metal in the new hip joint. As metal connections in the artificial joint wear, tiny particles of metal can wear off and sometimes this causes problems such as loosening of the hip prosthesis or issues with the soft tissues (tendons and muscles) around the hip

Pre-operative visit

Most hospitals will ask you to come in several weeks before your joint replacement surgery to review your situation and talk about what will happen. It’s a good idea to bring a family member or friend to this visit to take notes and ask questions. You will be given lots of information, and this can be overwhelming and difficult to remember if you don’t have someone with you.

During the pre-operative visit, the team will talk about what kind of anaesthesia is best for you. This depends on many things, including your age and general health and preference. The team may suggest a regional anaesthesia so you don't feel the area of the surgery, with this option you'll also have medicine that makes you relaxed or lightly asleep but you will breathe on your own. Alternatively, your team may suggest a general anaesthesia that puts you completely asleep during the surgery, with a breathing tube down the throat and attached to a breathing machine.

Preparation

Physical activity

The best way to strengthen your legs in preparation for surgery is to walk regularly. Don’t be afraid to walk while waiting to have your surgery – it won’t harm your knee or hip joint. Follow the “two hour” pain rule: If your joint hurts for longer than two hours after your walk, you have done too much. Do what you can to manage the pain and walk a bit less the next day.

Besides walking, your surgeon may recommend that you do some regular pre-operative exercises. Some are aimed at strengthening your arms and shoulders, which will help you cope with crutches or a walker after surgery. Others will help maintain the strength of your leg muscles. The exercises should take about 20 minutes to complete, and if possible, you should do them twice a day.

Your home

Your house or apartment may need certain changes to meet your needs after your operation. Look around and see what can to be done.

  • Arrange or remove furniture so that you have a clear path around your home wide enough for a walker (on average you'll need about 76 centimetres or 30 inches of clear space).
  • Remove small mats and area rugs. Tape down the edges of larger rugs so you won’t trip over them.
  • During recovery use armchairs because you’ll need the arms to help you sit down and stand up. Make sure you have at least one chair with a strong seat (not too low), a backrest and sturdy arms. Avoid chairs that rock, roll or glide.
  • You can raise chair heights either by using lifts under the legs or by placing a firm pillow on the seat.  
  • Keep rooms and hallways well lit so you can see obstacles.
  • Make sure all stair railings in and outside your home are secure.
  • Keep cords out of the way.
  • Getting in and out of bed can be difficult after joint replacement surgery. It’s important that your bed isn’t too low.
  • The edge of the mattress should be no lower or higher than the backs of your knees. If your bed is too low, you may need to raise it to a better height by having someone place it on sturdy blocks. If it's too high, you may need to adjust the height by adjusting the bed frame.
  • If there is no bathroom nearby or it is on a different level, you may need to purchase or borrow a bedside commode (a chair with a built-in bed pan) for use at night.
  • Install a raised toilet seat
  • Get a rubber (non-skid) mat for your bathtub or shower stall so you don’t slip while bathing. A tub bench is also helpful. Purchase a long, handheld sponge to help you wash your feet without bending over.
  • Even with assistive devices, it’s hard to get into the shower, turn on the water, and adjust the temperature without bending. Plan to have someone help you shower when you first come home.
  • If grab bars around the toilet, tub or shower are necessary, make sure they are installed before your surgery.
  • Put all your bathroom utensils, such as toothbrush, comb, hair dryer, make-up, and razor in a single area so you can reach them without moving around.
  • Organize your kitchen so that items are close by and at waist level – you won’t be able to bend down right after your operation.

What to expect after surgery

Right after surgery

Your pain will be controlled with intravenous (IV) medicine. You will probably also have medicines to prevent infection, blood clots, and nausea. If you had regional anaesthesia, you may have little or no feeling below your waist for a while.

You may have a cushion put between your legs. It helps keep your new hip in the correct position. To help prevent blood clots, you may be wearing compression stockings. And you may have compression sleeves on your legs. These squeeze and release your lower legs to help keep the blood moving.

Lack of activity following surgery and the use of pain medication can cause constipation. If needed, laxatives may be prescribed.

Moving around

On the day of surgery or the day after, you'll get out of bed with help. You will learn how to walk with a walker or crutches. By the time you leave the hospital, you will be able to safely sit down and stand up, dress yourself, use the toilet, bathe, and use stairs.

Within a couple of weeks, you will start physiotherapy. You'll learn exercises to help you get stronger. You will also be shown how to move your body without dislocating your hip. Sometimes you will be asked to limit certain movements, follow the instructions provided by your surgeon.

Leaving the hospital

You will probably stay in the hospital for 1 to 4 days after surgery. You can go home from the hospital if you have care at home and your recovery is going well. It will be very helpful to have someone stay with you for the first few days and you will likely need help with cooking, cleaning and other chores for the first couple of weeks after surgery.

You may go to a rehabilitation centre if you need extra care and are not able to move around safely enough to look after yourself shortly after surgery. You can go home when you've recovered enough to move around safely and care for yourself.

Continued recovery

Call your surgeon or family doctor if:

  • you develop a temperature higher than 38 C. (101 F.)
  • you notice any change in the amount, colour or odour of drainage from your incision or a sudden increase in pain around the incision
  • you notice increased pain, swelling or tenderness in the calf or thigh of either leg
  • you notice that either leg appears pale or bluish in colour
  • you notice that either leg feels unusually cool to the touch
  • you suddenly have trouble walking

During the few weeks after surgery, you will need less and less pain medicine. For several weeks after surgery, you will probably take medicine to prevent blood clots.

You may need a walker, crutches, or a cane for a few weeks or months. As you get your energy back, work up to taking a short walk a few times each day. If you feel any soreness, try a cold pack on your hip.

Don't drive until your doctor says it is okay for you to drive.

Rehabilitation continues after you go home from the hospital. You will get rehabilitation until you are able to function on your own and you get back as much strength in your hip as you can. You will keep working on building strength and endurance. Rehabilitation after surgery will take several months and you may continue to improve (especially strength and endurance) for up to one or one and a half years after surgery. Early recovery may be faster after anterior hip surgery.

For most people, it is safe to have sex about 4 to 6 weeks after a hip replacement. Talk to your doctor about when it is okay to have sex and what positions are safe for your hip. Some positions could increase the risk of dislocating your hip. That means that your doctor may want you to avoid certain positions, especially for the first few months.

Living with a hip replacement

Exercise (such as swimming and walking) is important for building your muscle strength. And it helps you feel better overall. Discuss with your doctor what type of exercise is best for you. You probably will be able to return to most activities that you did before surgery, such as golfing, biking, swimming, or dancing. Your doctor may want you to avoid running, playing tennis, and doing other things that put a lot of stress on the joint.

Your doctor will probably want to see you at least once every few years to check your hip.

For at least 2 years after your surgery, your doctor may want you to take antibiotics before dental work or any invasive procedure. This is to help prevent infection around your hip implant. Speak to your surgeon to decide if you need to take antibiotics.

Frequently Asked Questions (FAQ)

  • What about pain relief after surgery?

    After your joint surgery is over, you will experience some pain, but there are several ways this can be managed. Your surgeon will decide which pain relief method is right for you, based on your medical history and other factors. Here are some possible options, which may or may not be available at your hospital: 

    • Oral medication (pills) taken every few hours may be enough to control your pain. Your doctor will prescribe the drug(s) and dose(s) based on your overall health and level of discomfort. You will likely be given a combination of different medications that work to reduce pain in different ways. Using several different medications can reduce your pain more than simply taking a higher dose of a single strong pain medication. 
    • You may be given a peripheral nerve block to help reduce pain after surgery. This involves injecting an anaesthetic around the major nerves in the area being operated on, which numbs the area for several hours during and after surgery, reducing pain and the need for strong pain medication. This is usually done by a specially trained anaesthesiologist before the surgery starts or by the surgeon during the surgery. 
    • You may be given an injection of local anaesthetic directly into the operative site by the surgeon during your surgery. This can help to numb the area for several hours after surgery, reducing pain and reducing the need for you to take strong pain medications. 
    • You may be given a dose of pain-relieving medication by needle (injection) which goes directly into your IV or into the muscle of your arm, leg or buttock. Injections are typically used when a patient is not able to take anything by mouth.  
    • Patient-Controlled Analgesia (PCA) is sometimes used. This is when you are instructed how to take small doses of pain medication when you need it (either by pushing a button attached to a pump that delivers an IV medication or by taking a pill from a supply left at your bedside). PCA can give you a feeling of control over your pain management, which can relieve anxiety and help reduce pain for some patients. 

    You should always use a combination of other pain medications (such as acetaminophen and anti-inflammatory medications) to address your pain first BEFORE using strong opioid medications. To reduce the risk of overdose or abuse, you should use opioid medications in the smallest possible dose for the shortest possible time. 

  • What is the difference between unilateral (one side) and bilateral (two sides) joint replacement surgery?

    Most people who undergo hip replacement surgery have the procedure done on just one side (either the right or the left). This choice has to do with the fact that their symptoms - usually pain, stiffness and limited mobility - are mostly one-sided. 

    If your symptoms are occurring on both sides, or if tests show serious problems in both joints, your surgeon may recommend you have both hips replaced in a single operation. This is known as "bilateral" joint replacement surgery.  You will need a minimum of six to eight weeks off work whether you have unilateral or bilateral surgery. 

    Here are some things to be aware of around bilateral joint replacement surgery: 

    • You will likely need two crutches and/or canes to help you get around during recovery 
    • You may need to spend time in a rehabilitation hospital after surgery 
    • In-hospital recovery time is usually longer than for unilateral (or one hip replacement) surgery 
  • Will I need a second operation?

    There are many reasons why someone who already has an artificial hip joint might need to have another operation to replace the old joint with a new one. This procedure is known as "revision surgery." 

    Most joint replacements last between 20 and 25 years. If you require revision surgery, it's likely that the first artificial joint has simply worn down or become loose, which can cause pain and dysfunction. Other reasons for revision surgery include an infection in the joint or a fracture around the artificial joint. 

  • What if I need to take a shower or a bath after surgery?

    You should not take a bath until your incision is completely healed. Fresh incisions should not be soaked, which means no baths, swimming, hot tubs, etc. until the incision has healed fully. Some hospitals tell patients they shouldn’t take a full bath – directly sitting on the floor of the tub – until three months after surgery. 

    Here are some general tips for taking a shower or a bath: 

    • DO NOT step out of the shower stall or tub onto a rug or towel. If you want a soft surface, tape a non-skid bath mat securely to the bathroom floor beside the tub. 
    • Until you feel steady on your feet, use a shower bench or seat which rests on a rubber mat or non-skid adhesive surface on the bottom of the tub or stall. 
    • A long-handled sponge or hand-held shower hose can be used to wash your lower legs and feet when you are restricted from bending over. 
    • If you will be using any grab bars beside the tub or on the wall, make sure they have been properly installed and can support your weight.  
    • When getting into the shower or tub, carefully lower yourself on the shower seat. Turn to face the faucets and lift your operated leg over the lip of the shower, followed by your non-operated leg. 
    • A walk-in shower may be a better option until you feel more confident getting in and out of the shower or bathtub.  
  • How do I get up and down stairs after surgery?

    It’s important that all stair railings, both inside and outside your home, are secure. In the first few weeks at home after surgery, limit stair climbing to one round trip per day if possible.  

    • Put your hand on the railing. Hold your crutch or cane in the other hand. 
    • Start UP the stairs with the foot of your non-operated leg. 
    • Step onto the step with your operated leg. 
    • Follow with your cane or crutch. 
    • Take one step at a time. Don’t move until you feel strong and steady. 
    • Always start DOWN the stairs with your cane or crutch 
    • Step down with your operated leg. 
    • Then move the foot of your non-operated leg down onto the same step. 

    TIP: An easy way to think about it is: “Up with the good leg; down with the bad.” 

  • How do I get in and out of bed after hip surgery?

    Some surgeons limit certain movements after surgery, and they will tell you about movement restrictions if they are necessary. 

    Getting into bed after hip surgery: 
    • Back up towards the middle of the bed until you feel the backs of your knees touching the mattress. 
    • Place your operated leg out in front of you. As you sit down on the edge of the mattress, place one hand on your walker/cane and the other on the bed. 
    • Once you are sitting, place both hands behind you. Pushing with your non-operated leg and using your arms, move yourself backwards across the bed until most of your operated leg is on the mattress.  
    • Move your upper body towards your pillow using your arms and non-operated leg. Keep your legs apart and your toes pointed towards the ceiling. 

    Getting out of bed after hip surgery: 

    • Slide yourself over to the edge of the bed, using your arms and pushing with your non-operated leg. Keep your legs apart and your toes pointed toward the ceiling. 
    • Slowly move both legs over the edge of the mattress, gradually coming into a seated position with your hands behind you on the mattress to give you support. 
    • Slide your hips to the edge of the bed and place your operated leg out in front of you. Be sure that the foot of your non-operated leg is flat on floor, ready to take your weight when you stand up. 
    • Place one hand on your walker/cane and then push up from the bed with your other hand until you are standing. 
    • Be sure to keep your body upright and do NOT lean forward at the waist as you stand up. 
  • When can I start driving after surgery?

    How soon you can start to drive depends on many factors: the type of surgery you had, whether your new joint is on your right or left side, and what kind of car you drive. Most patients should wait at least six weeks before driving, although some can start driving a bit sooner than that. Also, strong pain medicines might affect your driving. Do not drive while you are taking these medicines. 

    Before you can get behind the wheel of a car after joint replacement surgery, you MUST have permission from your health care team.  

    Avoid traveling in cars with low bucket seats or trying to climb into the back seat of a two-door vehicle. If you are traveling in a vehicle which sits up higher than most cars (such as a van or sport utility vehicle), you should ask a therapist to instruct you about getting in and out safely. When getting in and out of the car, be sure to move the seat (if possible) to give you as much space as necessary to get in and out comfortably and safely. 

  • How do I use the toilet after surgery?

    Some people who are weak or unsteady after returning home from the hospital arrange to rent a bedside commode (a chair outfitted with a bedpan) for a few days or weeks. This should be sturdy enough to bear your full weight and have non-skid legs.  

    A raised toilet seat with arms may be helpful for those using their own bathrooms. The device fits over your existing toilet seat and is designed to make sitting down and getting up from the toilet easier. 
    • Back up to the toilet seat until you feel it touching the backs of your knees. 
    • Keep one hand on your cane or walker while you reach back with the other hand for the edge of the raised toilet seat. If your seat has arms, reach back for them with both hands. 
    • Keep your operated leg out in front of you so it doesn’t take any weight. Sit down, resting your foot lightly on the floor. 
    When it’s time to get up, reverse the process: 
    • Place one hand on your cane or walker and the other on the edge of the raised toilet seat.  
    • Push yourself up using the arms of the toilet seat and keeping your operated leg out in front of you until you are standing.  
    • Be sure to get your balance before taking hold of your cane or walker. 

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Contributor(s)

This information was last updated September 2017, with expert advice from:

Dr. Sarah Ward, MD, FRCSC
Orthopaedic Surgeon, St. Michael’s Hospital
Lecturer, Department of Surgery, University of Toronto