Treatment - How can I help

Total Hip Replacement (THR)

Other popular names

Who does it affect?

Osteoarthritis of the hip is the most common reason for a hip replacement. Osteoarthritis is caused by the wear and tear of aging. It causes the cartilage covering the joint surfaces to wear out, resulting in pain and stiffness.
Other conditions that can cause destruction of the hip joint include loss of the blood supply to the head of the thighbone (osteonecrosis), rheumatoid arthritis, injury, infection, and developmental abnormalities of the hip. Patients with arthritis may also have brittle bones (osteoporosis), but there is no direct relationship between bone density and the development of arthritis of the hip.

Symptoms

Hip arthritis typically causes pain that is dull and aching. The pain may be constant or it may come and go. Pain may be felt in the groin, thigh, and buttock, or there may be referred pain to the knee. Walking, especially for longer distances, may cause a limp.
Some patients may need a cane, crutch, or walker to help them get around. Pain usually starts slowly and worsens with time and higher activity levels.

Patients with hip arthritis may have difficulty climbing stairs. Dressing, tying shoes, and clipping toenails can be difficult or impossible. Pain may also interfere with sleep.

Diagnosis

Your consultant will readily be able to diagnose hip arthritis.  This will be done through a physical examination, supported by X-ray.  The x-ray may show loss of the cartilage space in the hip socket and a "bone-on-bone" appearance. Bone spurs and bone cysts are common.
Depending upon the extent of your condition, you may be referred for an MRI, which will provide a greater level of detail to your consultant.

Non-surgical treatment

Hip arthritis is never life threatening, the main aim of treatment is therefore symptomatic for pain and to try to keep mobility and range of movement of the joint. Treatment follows a progression from simple measures to major surgical intervention.  There are a range of non-surgical approaches to be exhausted prior to the need for surgical intervention:

Surgical treatment

Pain and mobility may worsen with hip osteoarthritis, even when all of the recommended nonsurgical treatments have been tried. If this happens, your consultant may recommend surgery. Surgical options include:

More often, you will require hip replacement.  There are a number of options available and types of implants. 

Traditional Hip Replacement

Traditional hip replacement surgery involves making a 10- to 12-inch incision on the side of the hip and takes 60 – 90 minutes. The muscles are split or detached from the hip, allowing the hip to be dislocated.

Once the joint has been opened up and the joint surfaces exposed, the surgeon removes the ball at the top of the thighbone, or femur. The hip socket is prepared by removing any remaining cartilage and some of the surrounding bone. A cup-shaped implant is then pressed into the bone of the hip socket. It may be secured with screws. A smooth plastic bearing surface is then inserted into the implant so the joint can move freely.

Next, the femur is prepared. A metal stem is placed into the femur to a depth of about 6 inches. The stem implant is either fixed with bone cement or is implanted without cement. Cementless implants have a rough, porous surface. It allows bone to adhere to the implant to hold it in place. A metallic ball is then placed on the top of the stem. The ball-and-socket joint is recreated.

(Left) The individual components of a total hip replacement. (Center) The components merged into an implant. (Right) The implant as it fits into the hip.

X-rays before and after total hip replacement. In this case, non-cemented components were used.

Minimally Invasive Hip Replacement

Minimally invasive hip replacement surgery allows the surgeon to perform the hip replacement through one or two smaller incisions.

Candidates for minimal incision procedures are typically thinner, younger, healthier, and more motivated to have a quick recovery compared with patients who undergo the traditional surgery.

The artificial implants used for the minimally invasive hip replacement procedures are the same as those used for traditional hip replacement. Specially designed instruments are needed to prepare the socket and femur and to place the implants properly.

The surgical procedure is similar, but there is less soft-tissue dissection. A single minimally invasive hip incision may measure only 3 to 6 inches. It depends on the size of the patient and the difficulty of the procedure.

The incision is usually placed over the outside of the hip. The muscles and tendons are split or detached, but to a lesser extent than in the traditional hip replacement operation. They are routinely repaired after the surgeon places the implants. This encourages healing and helps prevent dislocation of the hip.

Two-incision hip replacement involves making a 2- to 3-inch incision over the groin for placement of the socket. A 1- to 2-inch incision is made over the buttock for placement of the stem.

To perform the two-incision procedure, the surgeon may need guidance from X-rays. It may take longer to perform this surgery than it does to perform traditional hip replacement surgery.

Benefits of minimally invasive hip replacement include:

Post-surgery rehabilitation

For traditional hip replacement, hospital stays average 3 to 5 days. Many patients need extensive rehabilitation afterward. With less-invasive procedures, the hospital stay may be as short as 1 or 2 days. Some patients can go home the day of surgery.

Early studies suggest that minimally invasive hip replacement surgery streamlines the recovery process, but the risks and long-term benefits of less-invasive techniques have not yet been documented.

The anaesthetic will wear off after approximately 6 hours.  Simple analgesia (pain killers) usually controls the pain and should be started before the anaesthetic has worn off.  Typical post-surgery may be:

Dressings

The large is normally removed 24-48 hours after surgery.

Sutures are removed after 10 days.

Return to normal routine

Bathing and showering

The wounds should be kept clean and dry until the wound has sealed. Showering is fine and the waterproof dressings can be changed afterwards. Bathing is best avoided until the wounds are sealed, typically 10 days after surgery.
In summary, whilst the wounds are wet - keep them dry and when the wounds are dry, you can get them wet!
 
Rehabilitation

Surgery is followed by a prolonged course of physiotherapy. This requires a commitment to undertake this rehabilitation in order to achieve the best possible result (at least half an hour per day for 6 months).  It is vitally important to stay within the post-operative activity restrictions an physiotherapy guidelines to avoid damaging stretching your reconstructed ligament.
 
Return to work

The timing of your return to work depends on the type of work and your access, however, the following is a general guide:

Driving

When you can walk without crutches or a limp and be in control of your vehicle (about 4-6 weeks).

Failure of Hip Replacement

Hip replacements can fail in the early stage because of infection and this can occur within the first two years and requires further surgery to remove the infection and then implant a new hip.

A previously well-functioning hip replacement that then becomes painful in later years fails either because the bearing surface wears out or the implant becomes loose from the bone.

Wear -  As can be seen in this X-ray here – the plastic bearing is actually very thin at the top.

Aseptic loosening -  This presents with a hip replacement that was pain free for many years and then pain develops in the groin and the thigh. The X-ray shows the left hip socket has actually flipped out of the bone altogether. In this example, the stem is loose from the cement and has sunk within the bone, the cement has fractured and the femur is weak (lytic).

Treatment Options - With aseptic loosening and wear of the component the only treatment option is surgery and this is very commonly done and very successfully done and Mr Tony Maury spent a very enjoyable year in Toronto, Canada working for a world expert in revision joint surgery.

The following X-ray shows how the loose joint can be replaced and the area of thin bone can be bypassed with modern contemporary devices:

Risks

Hip replacement surgery, whilst being one of the most successful operations in the whole of surgery, is still a major operation with complications.

Nonetheless, the vast majority of patients are delighted with the outcome because their pain goes and they can expect at least ten to twenty pain free years before further surgery is necessary.

There are risks of:

All these risks are uncommon and in total, the chance of you or your hip being worse off in the long term is about or less than 1%.

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