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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.
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 with chronic diseases such as those that result in severe
muscle weakness or Parkinson's disease are more likely than people without chronic
diseases 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.
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. NSAIDs
also include Celebrex* and Vioxx, so-called COX-2 inhibitors that block an enzyme known to
cause an inflammatory response. Many of these medications are available without a
prescription, although a doctor also can prescribe NSAIDs in stronger doses.
* Brand names included in this booklet are provided as examples only and
their inclusion does not mean that these products are endorsed by the National Institutes
of Health or any other Government agency. Also, if a particular brand name is not
mentioned, this does not mean or imply that the product is unsatisfactory.
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.
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.
What Are Possible Complications of Hip
Replacement Surgery?
According to 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?
National Institute of Arthritis and Musculoskeletal and
Skin Diseases Information Clearinghouse
NIAMS/National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484 or 877-22-NIAMS (226-4267) (free of charge)
TTY: 301-565-2966
Fax: 301-718-6366
http://www.niams.nih.gov/
The clearinghouse provides information about various forms of arthritis
and rheumatic disease and bone, muscle, and skin diseases. It distributes patient and
professional education materials and refers people to other sources of information.
Additional information and updates can also be found on the NIAMS Web site.
American Academy of Orthopaedic Surgeons
P.O. Box 2058
Des Plaines, IL 60017
Phone: 800-824-BONE (2663) (free of charge)
www.aaos.org
The academy provides education and practice management services for
orthopaedic surgeons and allied health professionals. It also serves as an advocate for
improved patient care and informs the public about the science of orthopaedics. The
orthopaedist's scope of practice includes disorders of the body's bones, joints,
ligaments, muscles, and tendons. For a single copy of an AAOS brochure, send a
self-addressed stamped envelope to the address above or visit the AAOS Web site.
The Hip Society
c/o Karen Andersen
951 Old County Road, #182
Belmont, CA 94002
Phone: 650-596-6190
Fax: 650-508-2039
www.hipsoc.org
The society maintains a list of physicians who are specialists in problems
of the hip and provides physician referrals by geographic area.
American Physical Therapy Association
1111 North Fairfax Street
Alexandria, VA 22314-1488
Phone: 703-684-2782 or 800-999-2782, ext. 3395 (free of charge)
www.apta.org
This national professional organization represents physical therapists,
allied personnel, and students. Its objectives are to improve research, public
understanding, and education in the physical therapies.
Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
Phone: 404-872-7100 or 800-283-7800 (free of charge)
or call your local chapter (listed in the telephone directory)
www.arthritis.org
This is the major voluntary organization devoted to arthritis. The
foundation publishes pamphlets on arthritis, such as "Arthritis Answers," that
may be obtained by calling the toll-free telephone number. The foundation also can provide
physician and clinic referrals. Local chapters also provide information and organize
exercise programs for people who have arthritis.
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 booklet.
The mission of the National Institute of Arthritis and Musculoskeletal and
Skin Diseases (NIAMS), a part of the National Institutes of Health (NIH), is to support
research into the causes, treatment, and prevention of arthritis and musculoskeletal and
skin diseases, the training of basic and clinical scientists to carry out this research,
and the dissemination of information on research progress in these diseases. The National
Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse is
a public service sponsored by the NIAMS that provides health information and information
sources. Additional information can be found on the NIAMS Web site at http://www.niams.nih.gov/.
NIH Publication No. 01-4907
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