Hip Replacement

Overview

The hip is a ball and socket joint. The ball is the rounded top of the thigh bone (femur), and it sits in a cup-shaped socket in the pelvis called the acetabulum. Both are covered with smooth cartilage. When that cartilage wears out, or the bone underneath collapses, the joint grinds and hurts, and walking, putting on socks or getting out of a car becomes hard.

In a total hip replacement the surgeon replaces both parts. A metal cup goes into the socket, lined with plastic or ceramic. A metal stem goes down inside the thigh bone, and a new ball, made of metal or ceramic, sits on top of it. The parts are either fixed with bone cement or pressed in so that the bone grows onto their rough surface (uncemented). Many surgeons use a mix of the two.

Some patients hear about other options. Hip resurfacing caps the ball instead of removing it and is used only for selected, usually younger, patients. A hemiarthroplasty replaces only the ball and is mainly used after a hip fracture in older people.

People who travel for hip replacement often look at India, Thailand or Malaysia, and hospitals in Turkey and Mexico do the operation too. MediCurage sends your X-rays to hospitals in the countries you are considering and puts their quotes side by side for you.

Who needs it

Hip replacement is usually considered when pain and stiffness from a damaged hip are limiting daily life and other treatment has stopped helping. Common causes include:

• Osteoarthritis, the gradual wearing away of cartilage.
• Avascular necrosis, where the blood supply to the ball is lost and the bone dies and collapses. Long-term steroid use, heavy alcohol use and sickle cell disease are among the causes.
• Rheumatoid arthritis and other inflammatory joint diseases.
• Hip dysplasia, a shallow socket present from childhood, which wears the joint early.
• Some fractures of the top of the thigh bone, and arthritis following an old injury.

Pain in the groin, the outer thigh or the buttock that is worse when you walk and eases with rest is typical. Night pain, a limp and difficulty with shoes are common too.

A surgeon will want any infection treated first, including skin, urine or dental infections. Diabetes should be well controlled, and heart or lung problems need assessment. Smokers are usually asked to stop.

Reports the surgeon will want

• An X-ray of the pelvis showing both hips, and a side view of the painful hip.
• An MRI, if avascular necrosis is suspected, since it shows early changes that X-rays miss.
• Blood tests, an ECG, and heart reports if you have heart disease.
• A list of all your medicines, especially blood thinners and steroids.

How it is done

The operation usually takes one to two hours. Spinal anaesthesia (an injection in the back that numbs the lower body) is common, sometimes with sedation, though some patients have a general anaesthetic.

Surgical approaches

The approach means the route the surgeon takes to reach the joint.

• Posterior approach. The cut is on the side and back of the hip, and the muscles at the back of the joint are moved aside and repaired at the end. It is widely used and gives the surgeon a good view of the joint.
• Lateral (or anterolateral) approach. The surgeon goes in from the side, partly detaching and then repairing some of the muscles that help you walk without a limp.
• Direct anterior approach. The cut is at the front of the hip, and the surgeon works between muscles rather than through them. Some patients walk comfortably a little sooner, but the approach has its own risks, such as numbness on the outer thigh.

Studies have not shown one approach to be clearly better for everyone. Experience matters. A surgeon who does most of their hips one way is more practised with that route than with one they use occasionally.

Throughout the operation, the surgeon checks leg length and the stability of the new joint before closing the wound.

Recovery and how long you stay

Most patients stand with a walking frame on the day of surgery or the next day. The physiotherapist teaches you how to get in and out of bed, walk with a frame and then crutches, and manage stairs. Expect 3 to 5 days in hospital.

Dislocation precautions

In the early weeks, before the tissues around the new joint have healed, the ball can slip out of the socket. After a posterior approach, surgeons traditionally advise you not to bend the hip beyond a right angle, cross your legs or turn the knee inwards, and to use a raised toilet seat and a firm, high chair. After an anterior approach, the positions to avoid are different. Recent research suggests that strict precautions may not be needed for every patient, and many surgeons now give fewer rules. Follow your own surgeon's instructions, which may differ from what a friend was told.

Clots and the flight home

Blood clots in the leg veins are a risk after any hip operation. Hospitals use early walking, compression stockings and blood-thinning medicine, often continued for some weeks after you leave.

Most patients stay in the country for about two to three weeks. Stitches or clips come out at around two weeks. Published advice on long flights after joint replacement varies, and your surgeon sets the date for your case. Surgeons treating patients from abroad usually clear them once the wound is healed and walking is safe, often with blood thinners continuing. On board, an aisle seat with room to keep the hip straight, regular walks, stockings and water are the usual advice. Your coordinator can ask the airline for wheelchair assistance at both airports.

Questions to ask your surgeon

1. Is a total hip replacement right for me, or is another option worth considering?
2. Which approach will you use, and how many hip replacements do you do that way?
3. Will the parts be cemented or uncemented, and what are the bearing surfaces made of?
4. How will you manage my leg length?
5. Which precautions should I follow, and for how long?
6. Which blood thinner will I take, and for how long?
7. When can I sit on a low seat, pray on the floor or drive?
8. When can I take a long flight?

Bring your X-rays to every appointment. Ask for a copy of the operation note and the implant details before you go home, so that any surgeon who sees you in future knows exactly what is in your hip.