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HIP REPLACEMENT
What
Is a Hip Replacement?
Hip replacement,
or arthroplasty, is a surgical procedure in which the diseased
parts of the hip joint are removed and replaced with new, artificial
parts. These artificial parts are called the prosthesis. The
goals of hip replacement surgery are to improve mobility by
relieving pain and improve function of the hip joint.
Who
Should Have Hip Replacement Surgery?
The most common reason
that people have hip replacement surgery is the wearing down
of the hip joint that results from osteoarthritis. Other conditions,
such as rheumatoid arthritis (a chronic inflammatory disease
that causes joint pain, stiffness, and swelling), avascular
necrosis (loss of bone caused by insufficient blood supply),
injury, and bone tumors also may lead to breakdown of the hip
joint and the need for hip replacement surgery.
Before suggesting
hip replacement surgery, the doctor is likely to try walking
aids such as a cane, or non-surgical therapies such as medication
and physical therapy. These therapies are not always effective
in relieving pain and improving the function of the hip joint.
Hip replacement may be an option if persistent pain and disability
interfere with daily activities. Before a doctor recommends
hip replacement, joint damage should be detectable on x rays.
In the past, hip
replacement surgery was an option primarily for people over
60 years of age. Typically, older people are less active and
put less strain on the artificial hip than do younger, more
active people. In recent years, however, doctors have found
that hip replacement surgery can be very successful in younger
people as well. New technology has improved the artificial parts,
allowing them to withstand more stress and strain. A more important
factor than age in determining the success of hip replacement
is the overall health and activity level of the patient.
For some people who
would otherwise qualify, hip replacement may be problematic.
For example, people who suffer from severe muscle weakness or
Parkinson’s disease are more likely than healthy people to damage
or dislocate an artificial hip. Because people who are at high
risk for infections or in poor health are less likely to recover
successfully, doctors may not recommend hip replacement surgery
for these patients.
What
Are Alternatives to Total Hip Replacement?
Before considering
a total hip replacement, the doctor may try other methods of
treatment, such as an exercise program and medication. An exercise
program can strengthen the muscles in the hip joint and sometimes
improve positioning of the hip and relieve pain.
The doctor also may
treat inflammation in the hip with nonsteroidal anti-inflammatory
drugs, or NSAIDs. Some common NSAIDs are aspirin and ibuprofen.
Many of these medications are available without a prescription,
although a doctor also can prescribe NSAIDs in stronger doses.
In a small number
of cases, the doctor may prescribe corticosteroids, such as
prednisone or cortisone, if NSAIDs do not relieve pain. Corticosteroids
reduce joint inflammation and are frequently used to treat rheumatic
diseases such as rheumatoid arthritis. Corticosteroids are not
always a treatment option because they can cause further damage
to the bones in the joint. Some people experience side effects
from corticosteroids such as increased appetite, weight gain,
and lower resistance to infections. A doctor must prescribe
and monitor corticosteroid treatment. Because corticosteroids
alter the body’s natural hormone production, patients should
not stop taking them suddenly and should follow the doctor’s
instructions for discontinuing treatment.
If physical therapy
and medication do not relieve pain and improve joint function,
the doctor may suggest corrective surgery that is less complex
than a hip replacement, such as an osteotomy. Osteotomy is surgical
repositioning of the joint. The surgeon cuts away damaged bone
and tissue and restores the joint to its proper position. The
goal of this surgery is to restore the joint to its correct
position, which helps to distribute weight evenly in the joint.
For some people, an osteotomy relieves pain. Recovery from an
osteotomy takes 6 to 12 months. After an osteotomy, the function
of the hip joint may continue to worsen and the patient may
need additional treatment. The length of time before another
surgery is needed varies greatly and depends on the condition
of the joint before the procedure.
What
Does Hip Replacement Surgery Involve?
The hip joint is
located where the upper end of the femur meets the acetabulum.
The femur, or thigh bone, looks like a long stem with a ball
on the end. The acetabulum is a socket or cup-like structure
in the pelvis, or hip bone. This “ball and socket” arrangement
allows a wide range of motion, including sitting, standing,
walking, and other daily activities.
During hip replacement,
the surgeon removes the diseased bone tissue and cartilage from
the hip joint. The healthy parts of the hip are left intact.
Then the surgeon replaces the head of the femur (the ball) and
the acetabulum (the socket) with new, artificial parts. The
new hip is made of materials that allow a natural, gliding motion
of the joint. Hip replacement surgery usually lasts 2 to 3 hours.
Sometimes the surgeon
will use a special glue, or cement, to bond the new parts of
the hip joint to the existing, healthy bone. This is referred
to as a “cemented” procedure. In an uncemented procedure, the
artificial parts are made of porous material that allows the
patient’s own bone to grow into the pores and hold the new parts
in place. Doctors sometimes use a “hybrid” replacement, which
consists of a cemented femur part and an uncemented acetabular
part.
Is
a Cemented or Uncemented Prosthesis Better?
Cemented prostheses
were developed 40 years ago. Uncemented prostheses were developed
about 20 years ago to try to avoid the possibility of loosening
parts and the breaking off of cement particles, which sometimes
happen in the cemented replacement. Because each person’s condition
is unique, the doctor and patient must weigh the advantages
and disadvantages to decide which type of prosthesis is better.
For some people,
an uncemented prosthesis may last longer than cemented replacements
because there is no cement that can break away. And, if the
patient needs an additional hip replacement (which is likely
in younger people), also known as a revision, the surgery sometimes
is easier if the person has an uncemented prosthesis.
The primary disadvantage
of an uncemented prosthesis is the extended recovery period.
Because it takes a long time for the natural bone to grow and
attach to the prosthesis, people with uncemented replacements
must limit activities for up to 3 months to protect the hip
joint. The process of natural bone growth also can cause thigh
pain for several months after the surgery.
Research has proven
the effectiveness of cemented prostheses to reduce pain and
increase joint mobility. These results usually are noticeable
immediately after surgery. Cemented replacements are more frequently
used than cementless ones for older, less active people and
people with weak bones, such as those who have osteoporosis.
What
Can Be Expected Immediately After Surgery?
Patients are allowed
only limited movement immediately after hip replacement surgery.
When the patient is in bed, the hip usually is braced with pillows
or a special device that holds the hip in the correct position.
The patient may receive fluids through an intravenous tube to
replace fluids lost during surgery. There also may be a tube
located near the incision to drain fluid and a tube (catheter)
may be used to drain urine until the patient is able to use
the bathroom. The doctor will prescribe medicine for pain or
discomfort.
How
Long Are Recovery and Rehabilitation?
On the day after
surgery or sometimes on the day of surgery, therapists will
teach the patient exercises that will improve recovery. A respiratory
therapist may ask the patient to breathe deeply, cough, or blow
into a simple device that measures lung capacity. These exercises
reduce the collection of fluid in the lungs after surgery.
A physical therapist
may teach the patient exercises, such as contracting and relaxing
certain muscles, that can strengthen the hip. Because the new,
artificial hip has a more limited range of movement than an
undiseased hip, the physical therapist also will teach the patient
proper techniques for simple activities of daily living, such
as bending and sitting, to prevent injury to the new hip. As
early as 1 to 2 days after surgery, a patient may be able to
sit on the edge of the bed, stand, and even walk with assistance.
Usually, people do
not spend more than 10 days in the hospital after hip replacement
surgery. Full recovery from the surgery takes about 3 to 6 months,
depending on the type of surgery, the overall health of the
patient, and the success of rehabilitation.
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How to
Prepare for Surgery and Recovery
People can
do many things before and after they have surgery to make
everyday tasks easier and help speed their recovery.
Before
Surgery
- Learn
what to expect before, during, and after surgery. Request
information written for patients from the doctor or
contact one of the organizations listed near the end
of this fact sheet.
- Arrange
for someone to help you around the house for a week
or two after coming home from the hospital.
- Arrange
for transportation to and from the hospital.
- Set up a
“recovery station” at home. Place the television remote
control, radio, telephone, medicine, tissues, waste
basket, and pitcher and glass next to the spot where
you will spend the most time while you recover.
- Place items
you use every day at arm level to avoid reaching up
or bending down.
- Stock up
on kitchen staples and prepare food in advance, such
as frozen casseroles or soups that can be reheated and
served easily.
After
Surgery
- Follow the
doctor’s instructions.
- Work with
a physical therapist or other health care professional
to rehabilitate your hip.
- Wear an
apron for carrying things around the house. This leaves
hands and arms free for balance or to use crutches.
- Use a long-handled
“reacher” to turn on lights or grab things that are
beyond arm’s length. Hospital personnel may provide
one of these or suggest where to buy one.
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What
Are Possible Complications of Hip Replacement Surgery?
According the American
Academy of Orthopaedic Surgeons, approximately 120,000 hip replacement
operations are performed each year in the United States and
less than 10 percent require further surgery. New technology
and advances in surgical techniques have greatly reduced the
risks involved with hip replacements.
The most common problem
that may happen soon after hip replacement surgery is hip dislocation.
Because the artificial ball and socket are smaller than the
normal ones, the ball can become dislodged from the socket if
the hip is placed in certain positions. The most dangerous position
usually is pulling the knees up to the chest.
The most common later
complication of hip replacement surgery is an inflammatory reaction
to tiny particles that gradually wear off of the artificial
joint surfaces and are absorbed by the surrounding tissues.
The inflammation may trigger the action of special cells that
eat away some of the bone, causing the implant to loosen. To
treat this complication, the doctor may use anti-inflammatory
medications or recommend revision surgery (replacement of an
artificial joint). Medical scientists are experimenting with
new materials that last longer and cause less inflammation.
Less common complications
of hip replacement surgery include infection, blood clots, and
heterotopic bone formation (bone growth beyond the normal edges
of bone).
When
Is Revision Surgery Necessary?
Hip replacement is
one of the most successful orthopaedic surgeries performed—more
than 90 percent of people who have hip replacement surgery will
never need revision surgery. However, because more younger people
are having hip replacements, and wearing away of the joint surface
becomes a problem after 15 to 20 years, revision surgery is
becoming more common. Revision surgery is more difficult than
first-time hip replacement surgery, and the outcome is generally
not as good, so it is important to explore all available options
before having additional surgery.
Doctors consider
revision surgery for two reasons: if medication and lifestyle
changes do not relieve pain and disability; or if x rays of
the hip show that damage has occurred to the artificial hip
that must be corrected before it is too late for a successful
revision. This surgery is usually considered only when bone
loss, wearing of the joint surfaces, or joint loosening shows
up on an x ray. Other possible reasons for revision surgery
include fracture, dislocation of the artificial parts, and infection.
What
Types of Exercise Are Most Suitable for Someone With a Total
Hip Replacement?
Proper exercise
can reduce joint pain and stiffness and increase flexibility
and muscle strength. People who have an artificial hip should
talk to their doctor or physical therapist about developing
an appropriate exercise program. Most exercise programs begin
with safe range-of-motion activities and muscle strengthening
exercises. The doctor or therapist will decide when the patient
can move on to more demanding activities. Many doctors recommend
avoiding high-impact activities, such as basketball, jogging,
and tennis. These activities can damage the new hip or cause
loosening of its parts. Some recommended exercises are cross-country
skiing, swimming, walking, and stationary bicycling. These exercises
can increase muscle strength and cardiovascular fitness without
injuring the new hip.
What
Hip Replacement Research Is Being Done?
To help avoid unsuccessful
surgery, researchers are studying the types of patients most
likely to benefit from a hip replacement. Researchers also are
developing new surgical techniques, materials, and designs of
prostheses, and studying ways to reduce the inflammatory response
of the body to the prosthesis. Other areas of research address
recovery and rehabilitation programs, such as home health and
outpatient programs.
Where
Can People Find More Information About Hip Replacement Surgery?
American
Academy of Orthopaedic Surgeons
6300 North
River Road
Rosemont,
IL 60018-4262
847/823-7186
800/346-AAOS
Fax: 847/823-8125
World Wide
Web address: http://www.aaos.org
The Hip Society
c/o Richard
B. Welch, M.D.
One Shrader
Street, Suite 650
San Francisco,
CA 94117
415/221-0665
Fax: 415/221-4023
The Society maintains
a list of physicians who are specialists in problems of the
hip and provides physician referrals by geographic area.
Acknowledgments
The NIAMS gratefully
acknowledges the assistance of Charles A. Engh, M.D., of the
Anderson Orthopaedic Research Institute, in Arlington, Virginia;
James Panagis, M.D., M.P.H., of the National Institutes of Health;
and Clement B. Sledge, M.D., of Brigham and Women’s Hospital,
in Boston, Massachusetts, in the review of this fact sheet.
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