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Publication Date: January 2001
Questions and Answers about Hip Replacement
What Is a Hip Replacement?
Hip replacement, or arthroplasty, is a surgical procedure
in 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 of hip replacement surgery are to improve mobility by relieving
pain and improve function of the hip joint.
Who Should Have Hip Replacement Surgery?
The most common reason that people have hip replacement
surgery is the wearing down of the hip joint that results from osteoarthritis.
Other conditions, such as rheumatoid arthritis (a chronic inflammatory
disease that causes joint pain, stiffness, and swelling), avascular
necrosis (loss of bone caused by insufficient blood supply), injury,
and bone tumors also may lead to breakdown of the hip joint and the
need for hip replacement surgery.
Before suggesting hip replacement surgery, the doctor
is likely to try walking aids such as a cane, or non-surgical therapies
such as medication and physical therapy. These therapies are not always
effective in relieving pain and improving the function of the hip joint.
Hip replacement may be an option if persistent pain and disability interfere
with daily activities. Before a doctor recommends hip replacement, joint
damage should be detectable on x rays.
In the past, hip replacement surgery was an option primarily
for people over 60 years of age. Typically, older people are less active
and put less strain on the artificial hip than do younger, more active
people. In recent years, however, doctors have found that hip replacement
surgery can be very successful in younger people as well. New technology
has improved the artificial parts, allowing them to withstand more stress
and strain. A more important factor than age in determining the success
of hip replacement is the overall health and activity level of the patient.
For some people who would otherwise qualify, hip replacement
may be problematic. For example, people with chronic diseases such as
those that result in severe muscle weakness or Parkinson's disease are
more likely than people without chronic diseases to damage or dislocate
an artificial hip. Because people who are at high risk for infections
or in poor health are less likely to recover successfully, doctors may
not recommend hip replacement surgery for these patients.
What Are Alternatives to Total Hip Replacement?
Before considering a total hip replacement, the doctor
may try other methods of treatment, such as an exercise program and
medication. An exercise program can strengthen the muscles in the hip
joint and sometimes improve positioning of the hip and relieve pain.
The doctor also may treat inflammation in the hip with
nonsteroidal anti-inflammatory drugs, or NSAIDs. Some common NSAIDs
are aspirin and ibuprofen. NSAIDs also include Celebrex,* one of the
so-called COX-2 inhibitors that block an enzyme known to cause an inflammatory
response. Many of these medications are available without a prescription,
although a doctor also can prescribe NSAIDs in stronger doses.
* Brand names included in this booklet are provided as
examples only and their inclusion does not mean that these products
are endorsed by the National Institutes of Health or any other Government
agency. Also, if a particular brand name is not mentioned, this does
not mean or imply that the product is unsatisfactory.
In a small number of cases, the doctor may prescribe corticosteroids,
such as prednisone or cortisone, if NSAIDs do not relieve pain. Corticosteroids
reduce joint inflammation and are frequently used to treat rheumatic
diseases such as rheumatoid arthritis. Corticosteroids are not always
a treatment option because they can cause further damage to the bones
in the joint. Some people experience side effects from corticosteroids
such as increased appetite, weight gain, and lower resistance to infections.
A doctor must prescribe and monitor corticosteroid treatment. Because
corticosteroids alter the body's natural hormone production, patients
should not stop taking them suddenly and should follow the doctor's
instructions for discontinuing treatment.
If physical therapy and medication do not relieve pain
and improve joint function, the doctor may suggest corrective surgery
that is less complex than a hip replacement, such as an osteotomy. Osteotomy
is surgical repositioning of the joint. The surgeon cuts away damaged
bone and tissue and restores the joint to its proper position. The goal
of this surgery is to restore the joint to its correct position, which
helps to distribute weight evenly in the joint. For some people, an
osteotomy relieves pain. Recovery from an osteotomy takes 6 to 12 months.
After an osteotomy, the function of the hip joint may continue to worsen
and the patient may need additional treatment. The length of time before
another surgery is needed varies greatly and depends on the condition
of the joint before the procedure.
What Does Hip Replacement Surgery Involve?
The hip joint is located where the upper end of the femur
meets the acetabulum. The femur, or thigh bone, looks like a long stem
with a ball on the end. The acetabulum is a socket or cup-like structure
in the pelvis, or hip bone. This "ball and socket" arrangement allows
a wide range of motion, including sitting, standing, walking, and other
daily activities.
During hip replacement, the surgeon removes the diseased
bone tissue and cartilage from the hip joint. The healthy parts of the
hip are left intact. Then the surgeon replaces the head of the femur
(the ball) and the acetabulum (the socket) with new, artificial parts.
The new hip is made of materials that allow a natural, gliding motion
of the joint. Hip replacement surgery 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 is referred to as a "cemented" procedure. In an uncemented procedure,
the artificial parts are made of porous material that allows the patient's
own bone to grow into the pores 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 Prosthesis
Better?
Cemented prostheses were developed 40 years ago. Uncemented
prostheses were developed about 20 years ago to try to avoid the possibility
of loosening parts and the breaking off of cement particles, which sometimes
happen in the cemented replacement. Because each person's condition
is unique, the doctor and patient must weigh the advantages and disadvantages
to decide which type of prosthesis is better.
For some people, an uncemented prosthesis may last longer
than cemented replacements because there is no cement that can break
away. And, if the patient needs an additional hip replacement (which
is likely in younger people), also known as a revision, the surgery
sometimes is easier if the person has an uncemented prosthesis.
The primary disadvantage of an uncemented prosthesis is
the extended recovery period. Because it takes a long time for the natural
bone to grow and attach to the prosthesis, people with uncemented replacements
must limit activities for up to 3 months to protect the hip joint. The
process of natural bone growth also can cause thigh pain for several
months after the surgery.
Research has proven the effectiveness of cemented prostheses
to reduce pain and increase joint mobility. These results usually are
noticeable immediately after surgery. Cemented replacements are more
frequently used than cementless ones for older, less active people and
people with weak bones, such as those who have osteoporosis.
What Can Be Expected Immediately After
Surgery?
Patients are allowed only limited movement immediately
after hip replacement surgery. When the patient is in bed, the hip usually
is braced with pillows or a special device that holds the hip in the
correct position. The patient may receive fluids through an intravenous
tube to replace fluids lost during surgery. There also may be a tube
located near the incision to drain fluid and a tube (catheter) may be
used to drain urine until the patient is able to use the bathroom. The
doctor will prescribe medicine for pain or discomfort.
How Long Are Recovery and Rehabilitation?
On the day after surgery or sometimes on the day of surgery,
therapists will teach the patient exercises that will improve recovery.
A respiratory therapist may ask the patient to breathe deeply, cough,
or blow into a simple device that measures lung capacity. These exercises
reduce the collection of fluid in the lungs after surgery.
A physical therapist may teach the patient exercises,
such as contracting and relaxing certain muscles, that can strengthen
the hip. Because the new, artificial hip has a more limited range of
movement than an undiseased hip, the physical therapist also will teach
the patient proper techniques 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, a patient may be able to sit on the edge
of the bed, stand, and even walk with assistance.
Usually, people do not spend more than 10 days in the
hospital after hip replacement surgery. Full recovery from the surgery
takes about 3 to 6 months, depending on the type of surgery, the overall
health of the patient, 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
document.
- 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.
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What Are Possible Complications of Hip
Replacement Surgery?
According to the American Academy of Orthopaedic Surgeons,
approximately 120,000 hip replacement operations are performed each
year in the United States and less than 10 percent require further surgery.
New technology and advances in surgical techniques have greatly reduced
the risks involved with hip replacements.
The most common problem that may happen soon after hip
replacement surgery is hip dislocation. Because the artificial ball
and socket are smaller than the normal ones, the ball can become dislodged
from the socket if the hip is placed in certain positions. The most
dangerous position usually is pulling the knees up to the chest.
The most common later complication of hip replacement
surgery is an inflammatory reaction to tiny particles that gradually
wear off of the artificial joint surfaces and are absorbed by the surrounding
tissues. The inflammation may trigger the action of special cells that
eat away some of the bone, causing the implant to loosen. To treat this
complication, the doctor may use anti-inflammatory medications or recommend
revision surgery (replacement of an artificial joint). Medical scientists
are experimenting with new materials that last longer and cause less
inflammation.
Less common complications of hip replacement surgery include
infection, blood clots, and heterotopic bone formation (bone growth
beyond the normal edges of bone).
When Is Revision Surgery Necessary?
Hip replacement is one of the most successful orthopaedic
surgeries performed--more than 90 percent of people who have hip replacement
surgery will never need revision surgery. However, because more younger
people are having hip replacements, and wearing away of the joint surface
becomes a problem after 15 to 20 years, revision surgery is becoming
more common. Revision surgery is more difficult than first-time hip
replacement surgery, and the outcome is generally not as good, so it
is important to explore all available options before having additional
surgery.
Doctors consider revision surgery for two reasons: if
medication and lifestyle changes do not relieve pain and disability,
or if x rays of the hip show that damage has occurred to the artificial
hip that must be corrected before it is too late for a successful revision.
This surgery is usually considered only when bone loss, wearing of the
joint surfaces, or joint loosening shows up on an x ray. Other possible
reasons for revision surgery include fracture, dislocation of the artificial
parts, and infection.
What Types of Exercise Are Most Suitable
for Someone With a Total Hip Replacement?
Proper exercise can reduce joint pain and stiffness and
increase flexibility and muscle strength. People who have an artificial
hip should talk to their doctor or physical therapist about developing
an appropriate exercise program. Most exercise programs begin with safe
range-of-motion activities and muscle strengthening exercises. The doctor
or therapist 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 loosening of its parts. Some recommended exercises
are cross-country skiing, swimming, walking, and stationary bicycling.
These exercises can increase muscle strength and cardiovascular fitness
without injuring the new hip.
What Hip Replacement Research Is Being
Done?
To help avoid unsuccessful surgery, researchers are studying
the types of patients most likely to benefit from a hip replacement.
Researchers also are developing new surgical techniques, materials,
and designs of prostheses, and studying ways to reduce the inflammatory
response of the body to the prosthesis. Other areas of research address
recovery and rehabilitation programs, such as home health and outpatient
programs.
Where Can People Find More Information
About Hip Replacement Surgery?
National Institute of Arthritis and Musculoskeletal
and
Skin Diseases Information Clearinghouse
NIAMS/National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484 or 877-22-NIAMS (226-4267) (free of charge)
TTY: 301-565-2966
Fax: 301-718-6366
http://www.niams.nih.gov/
The clearinghouse provides information about various forms
of arthritis and rheumatic disease and bone, muscle, and skin diseases.
It distributes patient and professional education materials and refers
people to other sources of information. Additional information and updates
can also be found on the NIAMS Web site.
American Academy of Orthopaedic Surgeons
P.O. Box 2058
Des Plaines, IL 60017
Phone: 800-824-BONE (2663) (free of charge)
www.aaos.org
The academy provides education and practice management
services for orthopaedic surgeons and allied health professionals. It
also serves as an advocate for improved patient care and informs the
public about the science of orthopaedics. The orthopaedist's scope of
practice includes disorders of the body's bones, joints, ligaments,
muscles, and tendons. For a single copy of an AAOS brochure, send a
self-addressed stamped envelope to the address above or visit the AAOS
Web site.
The Hip Society
c/o Karen Andersen
951 Old County Road, #182
Belmont, CA 94002
Phone: 650-596-6190
Fax: 650-508-2039
www.hipsoc.org
The society maintains a list of physicians who are specialists
in problems of the hip and provides physician referrals by geographic
area.
American Physical Therapy Association
1111 North Fairfax Street
Alexandria, VA 22314-1488
Phone: 703-684-2782 or 800-999-2782, ext. 3395 (free of charge)
www.apta.org
This national professional organization represents physical
therapists, allied personnel, and students. Its objectives are to improve
research, public understanding, and education in the physical therapies.
Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
Phone: 404-872-7100 or 800-283-7800 (free of charge)
or call your local chapter (listed in the telephone directory)
www.arthritis.org
This is the major voluntary organization devoted to arthritis.
The foundation publishes pamphlets on arthritis, such as "Arthritis
Answers," that may be obtained by calling the toll-free telephone number.
The foundation also can provide physician and clinic referrals. Local
chapters also provide information and organize exercise programs for
people who have arthritis.
Acknowledgments
The NIAMS gratefully acknowledges the assistance of Charles
A. Engh, M.D., of the Anderson Orthopaedic Research Institute, in Arlington,
Virginia; James Panagis, M.D., M.P.H., of the National Institutes of
Health; and Clement B. Sledge, M.D., of Brigham and Women's Hospital,
in Boston, Massachusetts, in the review of this booklet.
The mission of the National Institute of Arthritis and
Musculoskeletal and Skin Diseases (NIAMS), a part of the National Institutes
of Health (NIH), is to support research into the causes, treatment,
and prevention of arthritis and musculoskeletal and skin diseases, the
training of basic and clinical scientists to carry out this research,
and the dissemination of information on research progress in these diseases.
The National Institute of Arthritis and Musculoskeletal and Skin Diseases
Information Clearinghouse is a public service sponsored by the NIAMS
that provides health information and information sources. Additional
information can be found on the NIAMS Web site at http://www.niams.nih.gov/.
NIH Publication No. 01-4907