Hip Replacement Surgery
1. Introduction
Hip replacement surgery is a common operation where a damaged joint is replaced with an artificial one. Joint replacements are nearly always carried out because of pain that cannot be controlled by other methods such as painkillers, physiotherapy or other surgery. It is major surgery, therefore is only recommended when physiotherapy has not helped to reduce the pain and improve mobility and it is affecting the quality of life.
Hip replacements are either completed under general anaesthetic or, more frequently, an epidural injection (numbs from the waist down). The surgery usually takes 1-2 hours to complete.
There are different types of implants and materials that can be used, depending on your age and the condition of your joint, as well as differing techniques. Your surgeon will be able to best advise you on this (3).
Any surgery comes with risks and therefore the decision to follow through with surgery is not taken lightly. These are considered low risks due to how common the operation is and include: infection (less than 1%), risk of dislocation, deep vein thrombosis (DVT), leg length discrepancies and damage to the nerves/tissues (2).
The final decision to have an operation or not remains with the patient. It will be based on the risks and benefits of having a hip replacement or choosing not to; these choices should be made clear. It may be that other options are available including, but not limited to, medication, physiotherapy, weight loss or other lifestyle changes.
Frequently Asked Questions
- Hip replacement surgery involves a complete replacement of the ball and socket joint, typically as a result of wear and tear in the hip joint that has led to pain and stiffness becoming unmanageable.
- Hip replacement surgery is a very common operation.
- 32,715 hip procedures were completed in the NHS alone in 2020, with 101,651 replacement procedures recorded in 2015 both in the NHS and private settings (2).
- No.
- When required, hip replacement surgery is a common procedure with success rates reported of approximately 95% (1).
- People aged 60+, however, it is becoming more common in younger, more active patients (3).
- In 2016, osteoarthritis was recorded as the main indication for surgery in 90% of hip replacement patients (3).
Typical symptoms leading to surgery include:
- Hip pain – general pain in your groin that can refer to the front of your thigh and/or buttock.
- Difficulty walking.
- Stiffness and limited movement in your hip.
Typical symptoms post-surgery include:
- A short period of pain around the surgical site from the procedure.
- You will be mobile on the same day.
- The movement will be restricted initially but this will typically improve quickly.
- Physiotherapy can significantly improve symptoms before and after surgery to help with mobility and strength (9).
- Modifying your activity.
- Keeping active.
- Occupational health – advice around potential workplace adaptations.
- If you are overweight, losing weight may help.
- Recovery post hip replacement will vary.
- Speed of recovery can be influenced by age, how long you have had your hip pain, the condition of your joints/muscles, your general fitness levels and the job or activities you do (10).
- Typically, you will be able to return to normal daily activities within 3 months and a complete recovery can be experienced within 6 months.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Location of symptoms – symptoms vary and can be mild to severe, normally affecting one hip, to begin with, but can be present in both. Groin pain is often described and can refer down the front of the thigh.
- Restriction of movement in the hip, such as difficulty putting on shoes and socks.
- Disturbed sleep – sleep can be affected.
- Aggravating movements – pain may be worse on weight-bearing activities, such as walking and using the stairs, or finding difficulty with specific movements such as putting socks on or getting out of a car that requires bending/rotation at the hip.
- Daily pattern – pain may be worse in the morning and especially worse on weight-bearing activities.
3. Causes
The most common reason for hip replacement surgery is a damaged hip joint through age-related changes called osteoarthritis. In 2016, osteoarthritis was recorded as the main indication for surgery in 90% of hip replacement patients. You are more likely to have the condition if there is a family history of it (3).
Estimates suggest that up to 8.5 million people in the UK are affected by joint pain that may be attributed to osteoarthritis. The second most common cause is rheumatoid arthritis (an autoimmune inflammatory disease that affects the synovial lining of joints). Around 400,000 people in the UK have rheumatoid arthritis (6).
4. Risk Factors
This is not an exhaustive list, but these factors may increase the likelihood of someone requiring a total hip replacement as they can all directly affect and damage the joint. It does not mean everyone with these risk factors will develop symptoms.
- Those aged 60+.
- Being overweight.
- Rheumatoid arthritis.
- A family history of osteoarthritis.
- Previous trauma to the hip.
- Abnormal bone growths as a child such as hip dysplasia.
- Septic arthritis.
5. Prevalence
Hip replacement surgery is a very common surgical procedure whereby 32,715 hip procedures were completed in the NHS alone in 2020. A total of 101,651 hip replacement operations were reported to the National Joint Registry in 2016 (2).
Although patients having total hip replacements are becoming younger, consultants are cautious of performing a hip replacement too early due to the risk of requiring further surgery later on in life. Over time, implants can wear and need to be revised, often due to loss of function or pain. The need to require a revision of implants for patients aged 50–54 years is estimated to be 29%, but only 5% in patients aged 70 years and above (4).
Other reasons for revision surgeries can be due to infection, fracture/dislocation and implant loosening (10).
6. Assessment & Diagnosis
Favourable outcomes can be expected with appropriate physiotherapy treatment both pre-operatively and post-operatively, positively influencing pain, physical function and quality of life (6, 8, 9).
A physiotherapist can provide an accurate and timely diagnosis by obtaining a detailed history of symptoms. A series of physical tests might be performed as part of the assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your physiotherapist will want to know how your condition affects your day-to-day life so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made.
With mild symptoms, particularly in those with a more recent onset of symptoms, further investigations are not normally required as symptoms of hip osteoarthritis are often easily identifiable and can be managed well with good physiotherapy management and advice. Persistent cases that have not responded to appropriate physiotherapy input may require further investigations to confirm the diagnosis and severity with an X-ray and a referral for a surgical opinion to orthopaedics through your GP practice.
Condition-specific exercise forms a pivotal element of the treatment plan to ensure optimal recovery to improve mobility and strength around your hip. (6, 8, 9).
7. Self-Management
There are certain things you can try to help you self-manage your condition, or whilst you await surgery. These may include the following:
- Medication to manage your pain and thereby impacting how much you are able to do.
- If you are overweight, losing weight might have a positive impact on your hip symptoms and your overall general health.
- Activity modification (avoiding or modifying activities of daily living, inclusive of work, that aggravates symptoms).
- If you work for an organisation that has an Occupational Health department and your symptoms are aggravated by work, it would be advisable to seek their input. They will be well placed to suggest work placed adaptations to facilitate continued working whilst best managing symptoms.
- Keeping active as much as you are able to, helps keep the joints strong and mobile.
8. Rehabilitation
Recovery post hip replacement will vary. Speed of recovery can be influenced by age, how long you have had your hip pain, the condition of your joints/muscles, your general fitness levels and the job or activities you do (10). Typically, you will be able to return to normal daily activities within 3 months and a complete recovery can be experienced within 6 months.
You will be mobilising and weight-bearing on your new hip as soon as your spinal/general anaesthetic has worn off. The physiotherapists on the ward will guide you and give you a walking aid to start. They will progress walking and complete stairs if required to ensure that you are safe to return home. You will return home generally between 12 hours-5 days. It is normal at this point to have pain around your surgical wound, with swelling and bruising into your hip and leg. The swelling should be managed by elevating the leg when lying down flat and you may find you also need to elevate the leg overnight to help the swelling go down.
Over the next few days and weeks, you should gradually build up the amount of walking you do, slowly weaning from your walking aids as you feel able to. You should feel that you are able to do more activities around the home in the next few weeks. You may have been given some standing exercises to do to improve your mobility and strength in your new hip.
You will be able to return to driving after 6 weeks (this may vary depending on your consultant’s instructions). Generally, you will be able to return to light duties at work for 6 weeks. If you do a manual job, you may want to return slowly and gradually build up to your normal duties from 3 months.
You may or may not get a follow-up from a physiotherapist post-operatively in an outpatient setting therefore you may feel that you want a follow-up to progress your rehabilitation and mobility. Our musculoskeletal physiotherapists will be able to guide you through this to achieve your goals.
9. Hip Replacement Surgery
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on exercises to promote a range of movement in the hip and to start the process of getting muscles to re-engage after surgery. Pain should not exceed 4/10 on your perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This is the next progression. Here we begin to challenge the muscles around the hip more to increase the strength of these muscles. Pain should not exceed 3/10 on your perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This programme is a further progression with the aim of returning to more normal strength levels and regaining the ability to do day-to-day tasks. Pain should not exceed 3/10 on your perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you might require advanced rehabilitation. As part of a comprehensive treatment approach, your physiotherapist may use a variety of other pain-relieving treatments to support symptom relief and recovery.
Whilst recovering, you might benefit from a further assessment to ensure you are making progress and to establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and return to full fitness. Your consultant will also advise you on when you are able to return to certain activities however, generally, you will be able to return to most sports from 3–6 months.
11. Other Treatment Options
Alongside exercise and appropriate advice, your physiotherapist might utilise various forms of hands-on treatment skills in the form of joint mobilisations, soft tissue techniques and acupuncture. These techniques can be useful to restore function and alleviate symptoms whilst you continue to strengthen and mobilise the limb.
12. Links for Further Reading
References
- Learnmouth et al. (2007). The Operation of the Century: Total Hip Replacement. The Lancet. [https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60457-7/fulltext]
- National Joint Registry. (2020). NJR Stats Online. https://www.njrcentre.org.uk/njrcentre/Healthcare-providers/Accessing-the-data/StatsOnline/NJR-StatsOnline.
- National Joint Registry. (2017). Public and Patient Guide to NJRs 14th Annual Report in 2017. Hip Replacement Edition. https://www.njrcentre.org.uk.
- Evans et al. (2019). How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. The Lancet. https://www.sciencedirect.com/science/article/pii/S0140673618316659
- Sodhi, N. & Mont, M. (2019). Survival of Total Hip Replacements. The Lancet. https://www.sciencedirect.com/science/article/pii/S0140673618318592#bib9.
- Ibrahim et al. (2013). Enhanced Recovery in Total Hip Replacement: A Clinical Review. The British Editorial Society of Bone and Joint Surgery. https://online.boneandjoint.org.uk/doi/epub/10.1302/0301-620X.95B12.31303
- NICE. (2014). Total Hip Replacement and Resurfacing Arthroplasty for End-stage Arthritis of the Hip. National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/ta304/chapter/2-Clinical-need-and-practice
- NICE. (2020). Osteoarthritis: Care and Management. National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/cg177/chapter/1-Recommendations
- Czyżewska et al. (2014). Effects of Preoperative Physiotherapy in Hip Osteoarthritis Patients Awaiting Total Hip Replacement. Archives of Medical Science. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4223143/
- NHS Website: Hip replacement. (2019). Hip Replacement. https://www.nhs.uk/conditions/hip-replacement/recovery/
Other Conditions in
Hips & Pelvis, Long Term Conditions, Orthopaedics, Pain
Sacroiliac Joint Dysfunction
Pain originating from the sacroiliac joint at the base of your back where the spine joins the pelvis.
Proximal Hamstring Tendinopathy
Pain and weakness under the buttock or the back of your upper thigh caused by tendon issues.
Pelvic Girdle Pain
Typically seen in pregnancy causing pain, instability and limitation of mobility and functioning of the pelvic joints.
Pelvic Floor Dysfunction
The inability to effectively control the muscles of your pelvic floor, leading to issues with continence and pain.
Lumbar Disc Injury
Lumbar discs sit between each of the bones of the spine. Problems can occur when these discs become irritated.
Low Back Pain and Sciatica
Sciatica is a symptom describing pain and/or pins and needles down the back of the leg.
Iliotibial Band Syndrome
Presents as pain on the outside of the knee, normally occurring because of overload due to prolonged or repeated bouts of exercise.
Hip Osteoarthritis
Common age-related changes to the structure of the hip joint may be associated with pain, stiffness and loss of function.
Greater Trochanteric Pain Syndrome
A condition affecting the tendons that insert into outside of the hip. A common cause of pain felt around the hip and pelvis.
Femoroacetabular Impingement
A condition that results in pain in the groin, hip and down the front of the thigh.
Femoral Nerve Radiculopathy
This is where the nerve that supplies the front of the leg is irritated and causes pain/numbess.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Adolescent Hip Dysplasia
A result of an abnormality of the hip joint anatomy resulting in pain in the hip with occasional instability.
Adductor-Related Groin Pain
Localised discomfort to the inner upper thigh and groin.