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Total Hip Replacement

Total hip replacement is a surgical procedure in which the damaged cartilage and bone is removed from the hip joint and replaced with artificial components. The hip joint is one of the body's largest weight-bearing joints, located between the thigh bone (femur) and the pelvis (acetabulum). It is a ball and socket joint in which the head of the femur is the ball and the pelvic acetabulum forms the socket. The joint surface is covered by a smooth articular cartilage which acts as a cushion and enables smooth movements of the joint.

A number of diseases and conditions can cause damage to the articular cartilage. Total hip replacement surgery is an option to relieve severe arthritis pain that limits your daily activities.

Disease Overview

Arthritis is inflammation of the joints resulting in pain, swelling, stiffness and limited movement. Hip arthritis is a common cause of chronic hip pain and disability. The three most common types of arthritis that affect the hip are:

• Osteoarthritis : It is characterized by progressive wearing away of the cartilage of the joint. As the protective cartilage wears down, the bone ends rub against each other and cause pain in the hip.
• Rheumatoid arthritis: This is an autoimmune disease in which the tissue lining the joint (synovium) becomes inflamed. This leads to loss of cartilage causing pain and stiffness.
• Traumatic arthritis : This is a type of arthritis resulting from a hip injury or fracture. Such injuries can damage the cartilage and cause hip pain and stiffness over a period of time.

Symptoms

The most common symptom of hip arthritis is joint pain and stiffness resulting in limited range of motion. Vigorous activity can increase the pain and stiffness which may cause limping while walking. As the arthritis progresses, night pain becomes a feature.

Diagnosis

The diagnosis is made by evaluating your  medical history, physical examination and X-rays. Occasionally a MRI scan is needed.

Non-Surgical Management

Severe joint pain due to arthritis can detract greatly from feelings of well-being and quality of life. Many successful treatments consist of a combination of approaches designed to take account of your own individual circumstances, needs and lifestyle, focusing on identifying ways to manage your discomfort and improve joint function. Non-surgical treatments are frequently considered first in most instances of hip pain - therapies include: 

• Exercise and physical therapy
• Weight management
• Medication

Exercise and low-impact physical therapy can help the functioning of the joint through increasing its strength and range of motion. Secondary benefits may include a raised sense of physical wellbeing through improved flexibility, heart rate and blood flow. Activities prescribed may include gentle stretches, cycling using an exercise bike, walking or water-based exercise such as swimming or water aerobics, which allow for mobility whilst removing weight-bearing stresses.
Weight management  Joint pain can be aggravated by excessive weight - a healthy diet and weight loss may help alleviate symptoms of arthritis by reducing stress on the joints and increasing function. Heavy lifting should also be avoided. Your doctor may recommend using an assistive device such as a walking stick, to help reduce stress on the hip.
Medication  Medication such as painkillers and non-steroidal anti-inflammatory drugs (NSAIDs) may be used to treat the symptoms of arthritis. Medications though may only provide temporary relief as they do not prevent further damage to the joint. Read More

Surgical Procedure

When non-surgical treatments no longer offer sufficient pain relief and the discomfort and disability are having very serious effects on your daily activities and disturbs your sleep, it may be time to consider surgery. Alternative operations are available to you depending on how badly your hip joint is damaged or worn. Treatments include arthroscopy (e.g. keyhole surgery to clear away loose tissue or resculpt bone abnormalities inside the joint), and traditional hip replacement.
Hip replacement surgery has been demonstrated to be a successful procedure for many patients and is expected bring long-term benefits for people who undergo it. Some people delay surgery however due to fear, misinformation or a lack of awareness about their treatment options. There is no cure for osteoarthritis though and it is also degenerative - meaning that any pain and limited mobility are likely to get worse over time.
It is important to weigh up the risks and benefits before deciding to proceed with surgery. Potential benefits may be significant, including the removal of pain, an improvement in mobility and a return to a more active lifestyle.

Generally aimed at patients with more advanced signs of arthritis, a traditional total hip replacement (THR) consists of a surgical procedure in which parts of an arthritic or damaged joint are removed and replaced. The resultant artificial joint is designed to move just like a healthy hip.
In a THR, the head of the femur (thigh bone) and the acetabulum (hip socket) are both replaced. The metal stem of the new hip is implanted into the damaged portion of the femur. The femoral head is replaced with an artificial ball at the top of the femur, attached to the metal stem, typically made of metal or ceramic. The hip socket (into which the ball fits) is covered with an artificial liner made of ceramic or polyethylene (a durable, wear-resistant plastic) backed with a metal shell. These surfaces are known as '˜bearings'. The liner allows for smooth and painless movement of the ball in the socket. 
The artificial joint may be cemented in position or press-fit securely in place without cement. In a '˜cementless' fixation, the surface of the implant is covered in a special bone-like coating (hydroxapetite). Over time, the patient's natural bone grows through the pores of the coating, attaching the artificial joint to the hip's natural remaining bone structure (much like the two ends of a broken bone healing). This "biological" bonding takes 6-12 weeks to fully strengthen - the same rate as fracture healing.
Cemented THRs are most suitable for elderly patients who have soft bones. Hybrid THRs combine the use of a cemented femoral stem with an uncemented acetabular cup. This combination can suit elderly and still active patients. Uncemented implants are commonly used in patients who have a more active lifestyle and are used in patients from their late teens through to late eighties (if they have strong bones).
The length of stem used in THR also varies. Traditional stems are longer, sitting further down inside the femur. These types of implant are very well established and have been in use for many years. However shorter stems, such as Corin's MiniHip™, have also come into use in recent years, offering a more bone conserving option. These provide a solution for today's more active, demanding patients, particularly those who are at risk of requiring more than one hip joint replacement over the course of their lifetime.
THR has been demonstrated to be a successful procedure. It is commonplace in terms of the numbers of operations carried out and as reported by the National Joint Registry (NJR), around 65,000 hip replacements are conducted in the UK each year - around 200 every working day.
 

Post-operative care

You will see the physiotherapist during your hospital stay and he/she will help you to get moving again, also advising on exercises to strengthen your muscles. You will receive guidance on the standard ‘dos and don’ts’ following hip surgery – for example, how to get in and out of bed, climb stairs, use the shower, etc. It is very important that you follow this advice to minimise straining the muscles around your hip.
The exercises recommended by your physiotherapist are a crucial part of your recovery, so it is essential that you continue to do them. There are certain movements that you should not do during early recovery (such as bending your hip more than a right angle) – your physiotherapist will give you further advice and tips to protect your new joint.
The physiotherapist will provide information on whether you need any help at home and offer advice on how to maintain independence in your daily life. He/she will assess how physically capable you are and assess your circumstances at home when you are about to leave hospital – they may also be able to provide specialised devices to help around the home.

After undergoing total hip replacement, you must take special care to ensure proper healing. Some of the common precautions to be taken for the first 6 weeks include:

• Avoid excessive combined movement of bending your hip and turning your foot inwards
• Avoid cross your legs and bending your hips past a right angle (90) 
• Avoid sitting on low chairs  
• Use an elevated toilet seat for 4-6 weeks

The First Few weeks

Once you return home, you may need to continue to take your painkillers if this is advised by your surgeon. You may also be advised to continue to wear compression stockings that you will have been given for a further few weeks. These can be difficult to put on and take off, so you may need someone to help you with this.
Some patients experience swelling of the thigh on the operated side, but this usually disappears quite quickly. A few patients may experience clicking or other sounds from their new hip, but this rarely causes serious problems and usually disappears after a few months.
You must be patient and not try to test your new joint to see how far it will go. Initially you will tire.
Walking without the aid of a stick is often possible from four to six weeks after surgery - although this will be determined by your confidence and progress and you should follow the advice of your surgeon or physiotherapist. Even if your have no pain, you should use crutches for 4 weeks to avoid damaging the healing biological bond that is forming in uncemented hips. Your return to driving will be determined by your surgeon, often 2-4 weeks. Your return to work will also be determined by your surgeon.

Leaving Hospital

It is quite natural to feel apprehensive after your surgery and you should make sure that you have been given full instructions about post-operative recovery. The post-operative regime, including whether you should use walking aids or how soon you can fully bear weight on the operated hip varies from surgeon to surgeon. How quickly you return to ‘normal’ will depend on the individual – your age, overall state of health, muscle strength, etc.
Before you leave, you will be given an appointment. This appointment is a routine check-up to ensure that you are making satisfactory progress. It is likely that you will also be offered physiotherapy to aid in your rehabilitation and improve your recovery time. Set aside a rest period each afternoon. You should contact your doctor immediately in the case of any undue pain, severe redness around the operation site or drainage from the wound.

The First Year

Improvements can continue for a year or more, depending on your condition prior to surgery. It is important that you take regular exercise to build up the strength of the muscles around your new hip. However, it is essential that you listen to the advice of your physiotherapist as to the suitability of different forms of activity so as to avoid straining the muscles around your hip.
By around 8 - 12 weeks it should be possible to resume low impact, weight-bearing activities such as walking, swimming, golf or gentle cycling. Avoid rigorous high impact sports that put undue stress on the joint. Typically you will be able to return to almost all previous normal pastimes within a year of your operation. Ask your physiotherapist or surgeon if you are unsure about the suitability of any activity.

Risks

As with any major surgical procedure, there are certain potential risks and complications involved with total hip replacement surgery. The possible  but uncommon complications after total hip replacement include:

• Infection
• Dislocation
• Fracture of the femur or pelvis
• Injury to nerves or blood vessels
• Formation of blood clots in the leg veins
• Leg length inequality
• Hip prosthesis may wear out
• Failure to relieve pain
• Scar formation

Total hip replacement is one of the most successful orthopaedic procedures performed for patients with hip arthritis. This procedure can relieve pain, restore function, improve your movements at work and play, and provide you with a better quality of life.