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A patient’s guide to hip replacement

A patient’s guide to hip replacement page 2

Contents

A patient’s guide to hip replacement ............................................................ 1

Contents ......................................................................................................... 2

About this guide ............................................................................................. 3

About Private Healthcare UK .......................................................................... 3

About Intuition Communication ....................................................................... 3

Get a quote for private treatment .................................................................... 3

Who needs a hip replacement? ..................................................................... 4

Do you need hip replacement? ...................................................................... 6

Benefits of private hip replacement ............................................................... 7

A history of hip replacement ......................................................................... 8

Choosing a hip replacement surgeon .......................................................... 9

Choosing a private hospital for your hip replacement ................................. 11

Types of hip prosthesis .............................................................................. 13

Types of hip replacement ........................................................................... 14

The hip replacement operation ................................................................... 15

What is hip revision? ................................................................................... 17

What is hip resurfacing? .............................................................................. 18

What is hip arthroscopy? ............................................................................. 19

Benefits of minimally invasive hip surgery ................................................... 20

Hip replacement complications and risks .................................................... 21

Why hip replacement physiotherapy is so important .................................. 22

The author .................................................................................................... 23

A patient’s guide to hip replacement page 3

About this guide Our guide to hip replacement will help you to decide which is private hospital, clinic or specialist best suits your needs, and gives

practical advice about what you need to do, whether you have health insurance or are paying directly for private treatment.

There's also useful information about the practicalities of having a hip replacement and the benefits and risks.

The Private Healthcare UK guide to hip replacement is sponsored by Spire Healthcare, one of the leading providers of

private surgery and treatment in the UK.

About Private Healthcare UK

www.privatehealthcare.co.uk is one of the UK’s leading online portals for private healthcare.

Private Healthcare UK providea s gateway to private treatment, cosmetic surgery, dentistry, private doctors and services such

as health insurance. Private Healthcare UK helps people make informed decisions by providing extensive information on all

aspects of private healthcare via the web.

About Intuition Communication

Intuition Communication is an online publishing business in the healthcare sector in

the UK. The company’s aim is to help people to make a more informed choice of

private healthcare services by providing information that is independent, up to data

and enables comparison between different services and service providers.

Intuition manages a network of web sites in the healthcare sector, including Private Healthcare UK, the Harley Street Guide and

HarleyStreet.com.

Get a quote for private treatment

If you would like a quote for private surgery or treatment from up to three private hospitals or clinics in your local area, complete

the private surgery enquiry form on Private Healthcare UK. You should receive a response within 48 hours.

A patient’s guide to hip replacement page 4

Who needs a hip replacement? A hip replacement operation can help some patients whose hip joint has become badly worn so that it no longer works properly

and causes them pain. The hip joint consists of a ball and socket joint in which the rounded head of the thigh bone (femur) rotates

within a socket in the hip. When this joint breaks down, through wear and tear, disease (such as hip arthritis) or damage, it can

cause severe pain and significantly restrict the movement of the joint. This can have devastating consequences on mobility and

quality of life.

Over 60,000 hip replacement are performed on the NHS each year; over 20,000 are undertaken in private hospitals. (National

Joint Registry 2012).

What is a hip replacement?

Hip replacement surgery involves removing the worn head of the femur and replacing it with a new ball joint. A new socket is

also created in the hip. The ball joint is usually replaced with metal, such as titanium alloy, while the socket is lined with high-

density polythene. Longer lasting ceramic parts are sometimes used as an alternative.

A hip replacement is a major operation and is only undertaken once a range of other possible treatments have been tried, or

once the pain from hip arthritis becomes intense and impacts too much on the normal activities of daily life.

Reasons for having a hip replacement

Most hip replacements are done as a result of hip arthritis, which can take several forms:

A patient’s guide to hip replacement page 5

Osteoarthritis – hip arthritis caused by wear and tear, which damages the cartilage and connecting tissue and causes

the bones to rub together

Rheumatoid arthritis – hip arthritis caused by a disease which makes the immune system attacks the lining of the

joint

Septic arthritis – hip arthritis caused by infection in the joints

Whatever the root cause, hip arthritis can lead to significant discomfort, restrictions in lifestyle, lack of mobility, loss of sleep and

many other distressing issues. Hip replacement surgery aims to overcome these problems.

Benefits of a hip replacement

The benefits to having a hip replacement include:

Increased mobility - although a replacement hip will not give you quite the same level of movement as your natural

hip.

Reduced pain – recovery and physiotherapy can be uncomfortable in the short term but the aim is to give you a pain

free hip.

Improved quality of life – a new hip helps you to return to a normal life. You may be able to resume many of the

activities that you had stopped doing because of your hip arthritis

A lasting solution – modern hip replacements are designed to last up to 20 years, providing long-term relief from hip

arthritis and other problems.

The decision to have a hip replacement should not be undertaken lightly. A complete hip replacement is a major operation

involving a general anaesthetic, a large wound of around 30cm, at least a week in hospital and many weeks of recovery and

rehabilitation. In the early stages of hip joint damage, using painkilling drugs and having physiotherapy are worth trying and your

surgeon may suggest alternatives such as hip resurfacing or minimally invasive hip replacement surgery, depending on your

circumstances.

A patient’s guide to hip replacement page 6

Do you need hip replacement? The main reason for hip replacement surgery is to treat severe hip arthritis. Breakdown of the hip joint is something that starts

gradually but can then get worse over time.

Recognising the early symptoms of hip arthritis

The early symptoms of hip arthritis include:

Aching around the hip joint and groin area, although pain can also be felt in the knee and back, due to changes in

posture

Pain that remains even when sitting or standing still but that can be relieved by pain killers

Finding it more difficult to move easily; although you can still do your usual daily activities, sports and exercise might

become too uncomfortable

A hip replacement isn’t justified in these early stages as the risks outweigh the benefits. If you are experiencing m ild pain and

can still move fairly well, it is still worth seeing your doctor or orthopaedic surgeon to see if anything can be done to help.

Physiotherapy and exercises, or hip resurfacing are possibilities that can extend the time you have before you might need a

complete hip replacement.

Signs that you need hip replacement surgery

You will know that it is time to consider hip replacement surgery when your pain begins to take over your life. For example:

Your pain wakes you at night or stops you sleeping

Your pain limits your lifestyle choices; some people don’t feel able to go out and do anything

Your pain inhibits the daily activities of life, so cooking, looking after yourself and working becomes more difficult

You no longer feel comfortable with the amount of over-the counter pain killers you need; perhaps you don’t even get

relief from the maximum daily dose

You begin to feel down or depressed by your pain and you feel desperate to find a solution

Diagnostic tests to make sure you need hip replacement surgery

Often, the description of your pain alone is enough to strongly suggest hip arthritis, but your GP or consultant will want to

diagnose your problem using a series of tests that may include X-rays, scans and blood tests before they recommend hip

replacement surgery.

It is possible to experience hip joint pain due to other problems, such as prolapsed vertebral discs, nerve damage around the

hip or inflamed tendons. In such cases, you will not need hip replacement surgery. If you have cartilage damage or loose

material in the hip joint that is causing problems, a hip arthroscopy may help.

Hip replacement surgery – important choices

Hip replacement surgery should always be considered carefully, as it is a major operation that carries significant risks. It is

important to remember that hip replacement surgery is your choice. Each of us has a different pain threshold and only you can

decide when you reach a level of discomfort that you can no longer tolerate.

Take advice from your doctors; the damage to your hip joint can get worse; Although waiting times within the NHS have reduced

a lot over the last few years, you may still face a wait of several months for a hip replacement in some parts of the UK. If you

have private medical insurance, or can afford to pay for the surgery, waiting times for hip replacement surgery in a private

hospital are usually much shorter.

A patient’s guide to hip replacement page 7

Benefits of private hip replacement Private hip replacement surgery accounts for around a third of all arthroplasty operations carried out each year in the UK. In 2012

for example, 25,444 of a total of 86,488 were carried out in independent hospitals.(National Joint Registry Report 2013) This is a

remarkable statistic, considering the fact that a private hip replacement can cost between £7,500 and £15,000 (Private Healthcare

UK Self-Pay Market Study 2013) if you don’t have private medical insurance. Clearly there are significant benefits to ‘going

private’.

Perhaps the biggest advantage of private hip replacement is not having to wait as long for your operation. While waiting times in

the NHS have improved significantly, there are still 3 million people on NHS waiting lists (NHS England 2014). What’s more, you

will have a restricted choice about when you have your surgery, which can be inconvenient, given the lengthy recovery period.

With a private hip replacement, you can usually have your operation within weeks, at a time that suits your schedule, and in the

private hospital of your choice.

Private hip replacement means better facilities

Hip replacement is a major operation and involves a lengthy stay in hospital – from five days. Many people choose private hip

replacement in order to get better facilities during their stay, including a private room, en suite bathroom, open visiting and

higher quality food. With less pressure on beds, many people also feel private hospitals give them more time to recover before

they are discharged.

Other advantages of private hip replacement

There are also many other benefits to having a private hip replacement, rather than the same operation on the NHS. These

include:

Private hip replacement patients have the reassurance of seeing the same surgeon and/or consultant throughout your

treatment. In some cases, this will be the same surgeon you initially saw under the NHS.

You can choose your surgeon based on their success rates and experience. You might not get the same choice with

the NHS.

Private hip replacement patients often get a wider choice of implants. There are over 60 types of implant available but

NHS patients may be offered a limited choice, depending on cost.

You may benefit from more personal, one to one treatment, from nursing care through to individual physiotherapy

sessions after your arthroplasty.

Choosing private hip replacement

Most people will not consider a hip replacement operation until their pain becomes intolerable and begins to have a serious

impact on their daily lives. To discover at this point that you may have to wait for surgery and suffer for many more months of

pain can be devastating. Private hip replacement offers a swift solution, with comfortable facilities, experienced surgeons and

personalised treatment. For many people, this means that private hip replacement represents excellent value for money.

A patient’s guide to hip replacement page 8

A history of hip replacement Hip replacements are so common now that it’s easy to take it for granted that we can have a new joint if our own hips are

damaged by arthritis. This has only been possible for the last 50 years or so – hip replacement surgery really only became

widely available from the 1960s.

The medical term for hip replacement surgery is arthroplasty and the first operations began back in the 1890s and continued

experimentally until the 1960s. Doctors around the world tried different prosthetic joints and femur heads made from ivory or

metal and some operations were certainly successful. Ivory femurs worked very well and, in the late 1960s, the Burmese

orthopaedic surgeon San Baw reported a success rate of 88% in over 300 arthroplasty procedures. The American surgeon

Austin Moore developed a metal hip prosthesis, a modified form of which is still in use today.

John Charnley – hip replacement pioneer

In the early 1960s, the greatest advances in arthroplasty were pioneered by Sir John Charnley, a British surgeon based at

Wrightington Hospital near Manchester. The development of the technique of total hip replacement, which involves implanting a

metal femur head and replacing the socket of the hip joint with a polyethylene cup, was his life’s work.

The idea of combining metal and polyethylene to make a complete artificial hip joint came to Charnley when he was trying to

cure embarrassment in an early hip replacement recipient. The patient could walk well and was relatively pain free but his

acrylic plastic artificial joint squeaked loudly all the time, so loudly that all those around him could hear it. After experimenting

with several lubricants to reduce the friction that was causing the squeak, Charnley realised that the materials needed to make

the prosthetic joint were not working. It took several prototypes but eventually he developed the Charnley hip prosthesis, which

went on to be used in hundreds of thousands of complete hip replacements. (The John Charnley Trust)

Extensive follow up for hip replacements

Charnley’s dedication to improving hip replacement surgery and the prosthetic hips he used is legendary. The success rates

during the early years of arthroplasty surgery were excellent and Charnley always followed up every patient until they died. (The

John Charnley Trust) He wrote to each of them personally to ask if they would mind returning their replacement hip joint to him

after their death. Most agreed and 10, 15, or 20 years later when the patient died, usually of a cause unrelated to their arthritis

or hip replacement surgery, one of Charnley’s colleagues would arrange an operation to remove the hip joint and associated

lymph nodes. By studying how each hip had worn, the changes to the patient’s own bone and muscle, and the inflammatory

response, Charnley and his team were able to constantly learn how to make hip replacement surgery safer and more effective.

Recent developments in arthroplasty

John Charnley died in 1982 but many other orthopaedic surgeons have contributed to the development of better hip prostheses

and new hip replacement operation techniques, for example:

New materials such as ceramics, titanium alloys and cross-linked polymers for longer-lasting prosthetic hip joints

Hip resurfacing – less extensive the arthroplasty to protect the joint from further damage

Minimally invasive hip replacement for faster recovery times

A patient’s guide to hip replacement page 9

Choosing a hip replacement surgeon Having made the decision to have your hip replacement done privately, your next step is to find a hip replacement surgeon. If you

are elderly, with a wide social group, then you may be able to rely solely on personal recommendations. Using first-hand accounts

of the treatment you will have is a good way to make your choice. If you do not know of anyone who has recently had hip

replacement surgery, you will need to do a little research of your own.

Where to look for a hip replacement surgeon

Your local hospital, your GP, and even your medical insurance company, if you have one, will also be able to suggest local hip

replacement surgeons. You can also use the internet. Even if you don’t have this at home, every public library now provides free

access and staff there will help you with the basics of using a computer and the web. A simple web search is a good starting

point, as this will help you find all the private hip replacement surgeons working in your area. From this you can draw up a short

list.

Next, it is vital that you check the credentials of all the surgeons you have identified, making sure that they are listed with the

General Medical Council and the Royal College of Surgeons. You should also make sure that they are orthopaedic surgeons

and preferably specialist hip replacement surgeons.

A patient’s guide to hip replacement page 10

Finally you should filter your list again, eliminating hip replacement surgeons who work in private hospitals too far away from

your home. Remember, you could be in hospital for five days and you don’t want to be so far away you don’t get any visitors.

Once you have your shortlist, you should make appointments with several different hip replacement surgeons to discuss your

operation.

Questions to ask your hip replacement surgeon

When you meet with a potential hip replacement surgeon, it is important to ask the right questions and get answers you feel

happy with. Here are some examples of what to ask:

How many similar operations has the hip replacement surgeon performed and what is their success rate?

Where else do they work, and will your operation be performed on a dedicated day, or after a shift elsewhere such as

the local NHS hospital?

What are the risks associated with the surgery and what will they do to mitigate these risks?

If you are not happy with any of the answers, or feel that the hip replacement surgeon is not right for you for any reason, then

move on to the next on your list. You should always feel comfortable that your surgeon understands your personal

circumstances and has taken the time to explain everything to your full satisfaction. A hip replacement surgeon who rushes his

consultations will not leave you feeling very confident for your operation.

Your money, your choice

Remember, one of the biggest advantages of being a private patient is the right to choose your hip replacement surgeon.

Choosing carefully and making sure you pick someone you feel you can trust completely can make all the difference to your

surgery and recovery experience.

A patient’s guide to hip replacement page 11

Choosing a private hospital for your hip replacement In the same way that choosing a private hip replacement surgeon is important, choosing the right hospital for your private hip

replacement can make a big difference to your experience. You need to feel comfortable in the hospital you choose, confident

that they will give you the levels of care, cleanliness, professionalism and personal attention you would like. Private hip

replacement is an expensive operation, so it is worth taking the time to find the right hospital for you.

Once again, the internet is the perfect place to start your search, supported by advice from your GP and/or your medical

insurance company. The experience of friends and relatives who have used local private hospitals will also be invaluable.

Location, location, location

Perhaps the most important personal consideration when choosing a hospital for your private hip replacement is location. You

will need to visit the hospital several times before your operation, at a time when your mobility could be seriously impaired by

your condition. You will also have to return for post-op checkups on a number of occasions after your private hip replacement.

Therefore it is important to make sure you can get to your chosen hospital easily.

It is also worth bearing in mind that a private hip replacement operation involves a hospital stay of around 5 days, and can be

much longer if you are 70 or olderIt will make you feel so much better if friends and relatives can reach the hospital easily to visit

you during this time.

A patient’s guide to hip replacement page 12

Other factors to consider

When choosing a hospital for your private hip replacement, you should also look up some statistics so that you know that the

hospital has:

A lot of experience with private hip replacement operations

Good success rates with private hip replacements

Low rates of MRSA bacteraemia and other infections

High private hip replacement patient satisfaction scores

Intensive care facilities, or is near to a local NHS unit, in case of an emergency or life threatening complications.

The Care Quality Commission publishes the answers to these and many other measures online for all private hospitals in the

UK. This helps you to compare hospitals on a like for like basis to find the best place for your private hip replacement.

Price considerations

A final, but vital consideration when choosing a hospital for your private hip replacement if you don’t have private medical

insurance is the cost. Naturally the price will vary depending upon the skills and reputation of the surgeon you have chosen, but

there are other factors that you need to think about.

Making sure you understand what is and what is not included in any set price deal is crucial. For example, you should ask if

the fee only covers your private hip replacement operation, or if it covers all your physiotherapy and rehabilitation too. You

should also be clear about who pays for any further treatment that is required should complications arise from your private hip

replacement. You can only compare prices between different private hospitals if you know what is included. Asking the right

questions at the start can also avoid any awkwardness and unexpected expenses later on.

A patient’s guide to hip replacement page 13

Types of hip prosthesis The hip prosthesis has come a long way since the early metal and polythene model developed by John Charnley in the 1960s.

These original artificial hip joints were made from stainless steel with a basic plastic shell, which were heavier than a natural hip

joint. Today, surgeons have a range of materials to choose from and a modern hip prosthesis can weigh in at less than 400

grams. These are the most commonly used materials in modern artificial hip joints:

Metal alloys – the part of the hip prosthesis that acts as the ball of the joint is usually made of a metal alloy. Common

combinations are based on titanium or cobalt and chromium. Different shapes are available and the long stem of the

hip prosthesis can be either porous (for uncemented hip replacement) or non-porous (for cemented hip replacement).

Ceramics – this is a recent development that aims to ensure that the artificial hip joint does not fail over time. A

metal/plastic hip prosthesis tends to have a life of around 15-20 years (Arthritis Research UK), so someone who has a

hip replacement in their 50s or 60s could need a hip revision later in life. Although a ceramic hip prosthesis can be

longer lasting, it is more prone to breaking compared to a metal or metal and plastic artificial hip joint.

Ultra-high molecular weight polyethylene used as the socket part of the hip prosthesis has high strength and is

smooth and long lasting.

Polyethylene plus metal – the socket of the artificial hip joint can be made with a central metal component

surrounded by a ‘skin’ of plastic, as well as from metal alone or plastic only.

For cemented hip replacements, polymethylmethacrylate, which is an acrylic polymer, is most often employed as the cement to

hold the hip prosthesis in place.

What qualities does a hip prosthesis need?

Developing an artificial hip joint has not been an easy task; continually improving the design and the materials used still takes a

lot of research time. Metals, alloys and plastics need to mimic the properties of living tissue very closely. A hip prosthesis has to

take the weight of the body without buckling or snapping but it must be flexible enough not to restrict movement. The materials

used need to be accepted by the body and to allow the artificial hip joint to heal and then function well. Developing a hip

prosthesis that can stand up to the massive wear and tear of constant movement over many years is still a challenge.

Hundreds of thousands of people worldwide have a hip replacement every year (OECD Health at a Glance 2013), so there is a

good incentive for manufacturers of artificial hip joints to produce very high quality products at a reasonable cost.

Which type of hip prosthesis is right for me?

This is a difficult question to answer and will ultimately fall for your surgeon to determine, with your input. He or she will probably

advise that you have a type of hip prosthesis that has been tried and tested and is known to be long-lasting. The new ceramic

hip joints might seem appealing but they are not right for everyone. We still don’t know how these joints will behave in the long

term. (National Joint Registry for England and Wales: Report 2013)

Your surgeon will probably advise a type of hip prosthesis that they have used before, and that have provided good, long-lasting

results. Whether you have a cemented or uncemented hip replacement depends mainly on your age and activity level but most

of the common types of hip prosthesis are available for each of these surgical techniques.

A patient’s guide to hip replacement page 14

Types of hip replacement As well as having several types of prosthetic hip joint to choose from, a surgeon carrying out a hip replacement must also

decide which type of fixation method to use to make sure the hip prosthesis stays in place. There are two choices – the first

method of hip replacement involves using bone cement to fix the hip prosthesis. The other avoids the use of cement and relies

on the porous nature of the hip implant to encourage the body to hold it firm.

Hip replacement with a cemented joint

The bone cement used in hip replacement surgery is carefully formulated to be sterile, non-toxic and unlikely to cause an

allergic reaction. It sometimes comes pre-mixed but is also sometimes mixed from powder during the operation. Some is

injected into the femur before the long tip of the metal part of the hip prosthesis is pushed into place. The cement surrounds the

metal and ‘sets’ so that the joint is secure as soon as the hip replacement surgery is completed. A thinner layer is put over the

bone of the remaining socket before the plastic part of the joint is put into position.

Pros and cons of cemented hip replacement

The major advantage of this type of hip replacement surgery is that you can walk on your new hip prosthesis as soon

as you have recovered from the anaesthetic. It can take the full weight of the body immediately; slower rehabilitation

and a more gradual return to moving around is required when the hip prosthesis is not cemented in place.

The major drawback is that the cement can crack, or be attacked by inflammatory processes in the joint, causing the

hip prosthesis to loosen over time. This rarely happens quickly but is one of the main reasons why some people need a

hip revision 20 years or so after their original hip replacement. (NHS Choices)

Hip replacement without cement

Uncemented hip replacement surgery is carried out using a specially designed hip prosthesis that has a rough, porous surface.

The femur is prepared so that the long tip of the implant fits very tightly in place but no bone cement is added. After the hip

replacement operation, the rough surface of the hip prosthesis stimulates new bone formation by fooling the body into thinking

that it has to heal a broken bone. The new bony ingrowths hold the implanted joint, fixing it more firmly in place over time.

Pros and cons of non-cemented hip replacement

The big plus of this type of hip replacement surgery is that, if it works well, the hip prosthesis is likely to last longer

perhaps making a hip revision operation less likely, even if it is in place for much longer than 20 years. The best results

are seen in younger, more active patients, because their bone growth is greater and faster. (NHS Choices)

There are several disadvantages:

The surgical technique is more difficult because the femur needs to be prepared to exactly fit the hip prosthesis.

Recovery time is slower after uncemented hip replacement surgery as the new hip prosthesis cannot take the weight of

the body straight away.

The replacement hip can still loosen over time if a good connection is not made between the hip prosthesis and the

internal surface of the femur.

Patients report thigh pain more often.

A patient’s guide to hip replacement page 15

The hip replacement operation Over 80,000 hip replacement operations are carried out each year in England, Wales and Northern Ireland. Hip replacement

operations have a high success rate in the UK, with just 1.3% of patients requiring further surgery. (National Joint Registry

2013).

A complete hip replacement operation usually takes around two hours, followed by a stay in hospital of around five days and

recovery at home of around six weeks.

Preparing for a hip replacement operation

As with all major surgery, it is a good idea to do some preparation in advance for your hip replacement operation:

Stop smoking. If you smoke, you will be asked to stop to reduce your risk of chest and wound infections.

Lose weight if you need to. You may also be asked to lose weight as excess weight not only makes hip replacement

surgery more difficult, it can also place unnecessary strain on your new hip joint.

Have an MRSA test. Whether you have your hip replacement operation in an NHS or a private hospital, it is now usual

to have a test to see if you are a carrier of MRSA. This methicillin-resistant form of the bacterium Staphylococcus

aureus is found on some people’s skin; if you have it you will be given antibiotics to make sure you don’t bring it into

the hospital and to prevent a serious wound infection once you have had surgery.

After you are admitted, your surgeon and anaesthetist will still visit you in hospital before the hip replacement operation to

answer any final questions you may have.

A patient’s guide to hip replacement page 16

During hip replacement surgery

Your hip replacement operation will usually be done under general anaesthetic and consists of several stages:

First, your surgeon will make a cut of around 20-30cm in your hip.

The top of the femur (thigh bone) is then separated from the hip joint.

This is removed and a shaft drilled to take the long tip of the replacement femur head.

The new femur head is put in place and secured.

The hip socket is then hollowed out and re-lined with an artificial socket.

The hip replacement operation concludes when the ball and socket joint is matched up and the wound is stitched or

clipped.

A hip prosthesis may be cemented into place using a special bone adhesive. Alternatively, a replacement joint made from

specially coated material, or from rough, porous material, may be used to encourage bone growth around the artificial hip joint

to anchor it in naturally.

After a hip replacement operation

As you come round you may not be able to move very much due to the effects of the anaesthetic and because your legs are

held in a set position by pillows to immobilise your hip to prevent dislocation. You will need painkillers for the first few days, and

drugs to prevent deep vein thrombosis while you are immobile. Don’t expect to be in bed long though; most people are

encouraged to take a few steps on the second day after surgery, if not the first.

Your physiotherapist will visit you several times a day following your hip replacement operation to give you a series of special

exercises to get you moving again. You will need to practice walking using a walker and then crutches. Once you have

mastered going up and down stairs with your crutches, but otherwise unaided, you will be ready to go home.

Most patients are in hospital for around a week following their hip replacement operation, although this increases with age. You

will then require around six weeks to recover at home before you are able to return to work, or to your normal activities such as

driving.

A patient’s guide to hip replacement page 17

What is hip revision? Hip revision is a follow-up hip replacement operation that is performed in people whose initial hip replacement has failed. A hip

revision operation is more difficult for the surgeon, involves a longer stay in hospital and has a longer recovery period than a

first-time hip replacement. The problems are compounded by the fact that most patients who require hip revision are in their

70s, 80s or 90s; older patients who are frail can find such extensive surgery very difficult.

Reasons for a hip revision

Most artificial hip joints last for around 20 years but some start to fail earlier, between 10 and 15 years after the original hip

replacement surgery. Common underlying reasons for needing a hip revision include:

Loosening of the joint. This can be due to cracking or destruction of the cement that holds in the ball part of the

artificial hip joint, or to absorption of the bone near to the artificial joint.

Wear of the socket. It is usual for a hip prosthesis to have a plastic or polyethylene cup that forms the socket of the

artificial hip joint; this can become badly scratched and worn over time.

Constant dislocation of the hip joint. This can occur because the supporting tissues around the joint become slack

with age, or perhaps filled with scar tissue. Supports or braces to keep the joint in place can help but do not work well

for very elderly patients, or those with some form of dementia.

Infection in the bone of the hip joint. Infection is not always due to the surgery; late infection can also occur several

years later, destroying a well-functioning joint.

What does a hip revision involve?

There is more to a hip revision than simply removing the old hip prosthesis and putting in a new one. This may be possible in

cases where the cement has failed, but the rest of the joint and the underlying bones are in good condition.

It is more usual for loosening of the artificial joint to be accompanied by bone changes; the femur and bone of the pelvic socket

have become thin, brittle and weak and bone grafting may be necessary to provide enough healthy bone to attach a new hip

prosthesis. Where bone condition is very poor, metal pins, plates and cages can be used to give additional strength.

Dislocation causes damage to the muscles, ligaments and tendons and so repeat hip replacement may not always prevent

further dislocation. A locking socket may become necessary, particularly if the hip revision is done in someone with poor

mobility, or who is affected by dementia and is unable to do post-surgery physiotherapy.

Hip revision after infection

This is the most challenging form of hip revision and often needs at least two operations. The first stage is to remove the hip

prosthesis, and to provide a temporary replacement while antibiotics are given to clear up any infection. Deep seated bacterial

infections in bone can take three months to treat. Once the infection is gone, a hip revision can take place but the removal of the

first hip prosthesis may have caused extensive damage to the bones (infected joints are rarely loose), so grafting and the use of

metal attachments are often needed.

Hip revision success rates

As you might expect, these are lower than with first-time hip replacements. A patient having a hip revision is older and therefore

is less likely to recover quickly from surgery, particularly if it is difficult. Nevertheless, hip revisions are done successfully,

particularly by skilled surgeons who have a lot of experience in the techniques required. After the recovery period, a hip revision

can provide many years of reduced pain and increased mobility.

A patient’s guide to hip replacement page 18

What is hip resurfacing? One of the problems associated with hip arthritis at an early age is that hip replacement is unlikely to be a life-long solution.

People under 55 who are given a hip prosthesis can find that their artificial hip fails. Part of the problem is that all artificial hips,

particularly those made with a plastic component wear out. The more active you are, the faster this happens, so younger, more

active people have a greater chance their replacement hip only lasting about 10 years, making it necessary for them to have a

hip revision.

This second operation is technically more difficult, and success rates are lower in terms of movement and quality of life.

The alternative of hip resurfacing

Since the 1990s, hip resurfacing has been developed as an alternative to complete hip replacement and has been put forward

as a better option for younger patients. Hip resurfacing is carried out at an earlier stage of hip arthritis; metal covers are placed

over the ball of the joint and inside the socket to prevent further bone damage.

After several years, if a complete hip replacement is needed this can be done more easily; the head of the femur is removed,

along with its metal cap, and the entire joint is replaced. Evidence shows that the most likely person to benefit from hip

resurfacing is an active man under 55 years old. (American Academy of Orthopaedic Surgeons)

Long term data on hip resurfacing

As with all developments in hip arthritis therapy, new surgical methods need to compare well to the tried and trusted complete

hip replacement technique. All data from patients who receive either hip resurfacing or complete hip replacement is collected by

the UK National Joint Registry; their latest data shows that the use of hip resurfacing has now fallen to 1% of patients. Hip

resurfacing in people who are suitable candidates does produce good results – hip revision rates are low and patients are happy

with the outcome.

Taking advice on hip resurfacing

If your surgeon thinks that hip resurfacing is right for you after completing detailed examinations, then it probably is. However,

patients that suggest or even insist on hip resurfacing when their orthopaedic specialist says that a complete hip replacement,

done in the traditional way, is the better option are inviting problems.

If hip resurfacing is likely to be beneficial, it is wise to choose a surgeon to do the operation who is very experienced in the

technique and whose patients have low rates of hip revision. Private hip resurfacing is well worth considering; one of the main

advantages of private orthopaedic treatment is that it offers far greater choice for you the patient in terms of who will do the

surgery and where it will take place.

A patient’s guide to hip replacement page 19

What is hip arthroscopy? Hip arthroscopy is a completely different technique to hip replacement; it is used to diagnose and treat a range of conditions that

occur in younger patients. Older people with hip arthritis generally do not benefit from hip arthroscopy.

The procedure has only become possible since the early 1990s. As it has advanced, hip arthroscopy has provided new

information about hip joint problems in young people, particularly young athletes. Today, it is possible to have a hip arthroscopy

within the NHS and in many private hospitals. This surgical technique rarely involves an overnight stay in hospital and enables

several different hip conditions to be diagnosed and treated successfully. Many of these would previously have gone

unrecognised and put down to ‘general groin injuries’, causing long-term mobility problems and chronic pain in promising young

athletes.

What does hip arthroscopy involve?

To say hip arthroscopy is a difficult technique would be something of an understatement. It is much more technically challenging

than the more common knee arthroscopy and the learning curve for a surgeon new to hip arthroscopy is extremely steep. The

gap between the ball and socket of the hip joint is very small; as recently as 1931, doctors thought that it was impossible to

place a needle here. Today it has become possible to view the inside of the hip joint using a keyhole technique and a tiny

endoscopy camera. Tiny surgical instruments can also be introduced to carry out treatments.

The operation is specialised and is usually done under general anaesthetic as the position of the hip joint is crucial to a

successful procedure. A very fine and long needle is first used to get into the joint, avoiding the main nerves. Then around 40ml

of sterile saline is pumped in to open up the joint to provide access for the other instruments. Recovery time is fast; this is a

minimally invasive technique that does not disturb the major muscles, tendons and ligaments that support the hip joint.

Using hip arthroscopy for diagnosis

Hip arthroscopy can be useful in younger people and active athletes who experience symptoms such as groin pain, a feeling of

‘clicking’ inside the hip joint, unexplained hip joint stiffness, poor performance due to hip problems, having one of the legs just

‘give way’ for no reason. Before hip arthroscopy was developed, X-rays were routinely used but early changes in the hip joint do

not show up well. Problems such as internal cartilage tears or loose material within the joint are clearly visible in the images

produced by a hip arthroscopy, which examines every surface of the inside of the hip joint.

Hip arthroscopy treatments

Hip arthroscopy can be used to treat several conditions that can result from sports injuries, avoiding the need for more extensive

hip surgery:

Acetabular labral tears – ruptures in the ring of cartilage that surrounds the socket of the hip joint can be seen easily

during a hip arthroscopy and most can be repaired during the procedure. (Mayo Clinic)

Chondral injuries – damage to the smooth cartilage that lines the hip joint, either on the socket side or on the ball

side, may be repaired during hip arthroscopy.

Loose bodies – these are identified and removed.

Snapping hip syndrome – can occur when the tendon at the front of the hip joint snaps over the bone. This can be

treated during hip arthroscopy by loosening the tendon or by treating an underlying tear in the cartilage that is

responsible for tendon tightening.

A patient’s guide to hip replacement page 20

Benefits of minimally invasive hip surgery Hip replacement surgery techniques are tried and tested and, although hip replacement carries some risks, it is regarded as one

of the safest types of surgery to have. The risk of serious complications is low – estimated to be less than 1 in a 100. (NHS

Choices). Surgeons still aim to improve how hip replacement is done – using longer-lasting materials and different fixing

techniques for the hip prosthesis, for example.

One thing that orthopaedic specialists would certainly like to improve is the recovery and rehabilitation time for patients who

have a hip replacement. The traditional surgical technique involves a long incision – 15 to 30cm is typical. The hip joint is

prepared and the hip prosthesis is put in place with the whole joint exposed, so the surgeon can see exactly what is going on.

What is minimally invasive hip surgery?

This is a pioneering technique that has become possible thanks to advances in technology. It is now possible for orthopaedic

surgeons to use X-ray and imaging assisted equipment that show pictures of the inside of the joint in real time on a large

computer screen in the operating theatre. This enables them to position the hip prosthesis without completely opening the joint.

Instead, they work from two much smaller incisions, preparing the damaged bone of the joint and inserting the hip prosthesis

using a type of keyhole hip replacement surgery.

The benefits of minimally invasive hip surgery

The major advantages of minimally invasive hip surgery is that patients experience less blood loss, less pain after surgery and a

lower level of surgical complications. They need to spend less time in hospital and their recovery and rehabilitation time is

shorter. This is mainly because this method of hip replacement has less impact on the muscles that support the hip joint.

Is minimally invasive hip surgery good in the long term?

Although hip replacement that involves less disruption to the tissues of the hip joint is beneficial in the short term, we do not yet

know the long term results. Use of minimally-invasive surgery is greatest in cementless procedures, although it was used in less

than 5% of all hip replacements. However, there is no data available that compares pain levels, mobility and quality of life in the

longer term and some experts believe that traditional hip replacement still allows the hip prosthesis to be positioned more

accurately during surgery.

For this reason, minimally invasive hip surgery is not routinely offered at most centres in the UK. The National Institute for

Health and Care Excellence has reviewed the evidence from clinical trials of the technique. The systematic review of 1205

patients reported that:

“the overall rate of complications was not significantly different between patients treated by minimally invasive surgery

and those who had standard-incision procedures.”

“there was no significant difference in the mean change of Harris hip score (which assesses functional ability and hip

dynamics)…. in patients treated by mini-incision total hip replacement compared with those treated by the standard-

incision approach.”

A patient’s guide to hip replacement page 21

Hip replacement complications and risks Many thousands of hip replacements are done each year in the UK with no complications whatsoever, giving a new lease of life

to people who have been suffering the debilitating pain of hip arthritis. That doesn’t mean that hip replacement complications

don’t happen and you should be aware of the risks before you decide to go ahead.

As with any major surgery involving a general anaesthetic, there are risks associated with the surgery itself. These include

having a reaction to the anaesthetic, excessive bleeding, heart problems and blood clots. These problems only occur in a very

small number of cases . Untoward intra-operative events were reported in 1.3% of procedures, according to the National Joint

Registry. The risk of these hip replacement complications can be reduced still further losing weight or cutting out smoking before

surgery.

Potential hip replacement complications

While most operations are problem free, several common hip replacement complications may occur, including:

Wound infection – with modern sterile operating theatres, infections are rare. However, if the infection spreads to the

prosthesis, it may require a second operation to remove and replace it. Private-sector hospitals have a significantly

lower incidence of healthcare-acquired infections - 2.2%, compared to NHS hospitals - 6.5% (Health Protection Agency

2012).

Dislocation – these hip replacement complications are most likely to occur in the first few days. In many cases the

joint can be re-aligned under anaesthetic, but you may require further surgery if it keeps happening.

Blood clots – there is a risk of blood clots and deep vein thrombosis whenever someone is immobile. Your hospital

will provide special stockings, drugs and exercises to reduce the risk of these hip replacement complications.

Nerve damage – with any invasive procedure there is always the risk of nerve damage. Occasional hip replacement

complications include numbness around the scar and damage to the sciatic nerve.

Later hip replacement complications

As well as hip replacement complications at the time of your operation, you may encounter problems many years later. Hip

replacements are designed to last around twenty years, although the actual life may vary from ten to thirty years, depending on

the material used and other factors such as your age and health.

Over time, there is a risk that the prosthesis may come loose in the shaft of the femur as the bones change with age. If this

occurs, a second operation, a hip revision or revision hip replacement, will be needed to correct it.

There is also a risk of hip replacement complications due to the breakdown of the prosthetic parts themselves. As they age and

begin to wear down, debris from the prosthetics can cause problems in the surrounding tissue. These hip replacement

complications can be treated with anti-inflammatory drugs, but in severe cases revision surgery may be required.

A patient’s guide to hip replacement page 22

Why hip replacement physiotherapy is so important Soreness and discomfort experienced following surgery usually fades soon. Within 2-3 weeks, many patients have little pain or

may be pain free, will be more mobile and are able to start enjoying life again.

The first few weeks after hip replacement surgery are crucial and it is up to you to do all of your hip replacement physiotherapy

and aftercare you can to regain your strength as quickly as possible.

Hip replacement physiotherapy

Your hip replacement physiotherapy could start as early as the day of your operation. As soon as it is safe for you, the hospital

team will get you out of bed and on your feet again. Just taking your weight on your new hip is an important phase of hip

replacement physiotherapy.

You will begin with just a few steps, most likely with a frame or a stick, and build steadily from there. You will be given a range of

hip replacement physiotherapy exercises that you can do on your bed, standing up or leaning against a chair. It is important to

get moving again as quickly as possible to prevent the new joint stiffening up and to promote healing.

Avoiding dislocation after a hip replacement

One of the most important elements of hip replacement physiotherapy is to teach you how to take care of your new hip. It takes

around 12 weeks for new protective fibres to grow around your hip, and until they do, you will be vulnerable to dislocation.

To protect your new hip, your hip replacement physiotherapy will include a range of exercises that contain movements that do

not twist or stress the joint. You will have to adapt the way you walk too. For example, you will be taught to turn with steps rather

than pivot around and you will be told not to cross your legs.

Carrying on with hip replacement physiotherapy

If you follow the regime suggested for hip replacement physiotherapy, you should be up and moving around within a few days

and discharged from hospital soon after. You should not require any further professional help from a hip replacement

physiotherapy specialist, but you will need to continue with the exercises you are given at home to rebuild your strength and to

get fully mobile again.

You will still need to take care when going up and coming down stairs, and when getting into a car. Most people master this

quite easily and you will be able to drive yourself about six weeks after your hip replacement surgery.

To protect your hip, it is advisable to avoid contact sports or sports involving sudden jerky movements, such as squash, even if

you feel physically able to play. You should also avoid pastimes with a high risk of falls, such as skiing or horse riding.

A patient’s guide to hip replacement page 23

The author The guide to hip replacement has been written by Dr Kathryn Senior, an experienced medical journalist and Director and Senior

Writer at Freelance Copy with input from Keith Pollard at Intuition Communication.

Intuition Communication is a web publishing business that specialises in providing information online for consumers of private

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