Hip replacement is a surgical solution used to renew a hip joint that is severely damaged or arthritic. In fact, this operation has about 70 years of successful history. It especially eliminates pain, limping and leg length discrepancy in young patients with hip dislocation or vascularization problems. In this article we will examine in detail everything you need to know about total hip replacement surgery, who it is performed on, and the postoperative process for total hip replacement.
What Is Total Hip Replacement and How Does It Work?
Definition and purpose of the hip prosthesis
Total hip arthroplasty is the procedure of replacing a damaged or severely arthritic hip joint with an artificial joint. In fact, this surgical method has been performed since the 1960s. Thanks to advances in technology, surgical techniques and materials used, much more successful results are achieved today.
The primary purpose of the surgery is to relieve pain and restore previous mobility. When the cartilage on joint surfaces is lost, bones rub directly against each other. This causes severe pain and limitations in daily activities. The prosthesis creates an artificial joint by covering these worn joint surfaces with specially made metal and polyethylene components.
Structure and materials of the prosthesis
A hip prosthesis consists of three main components:
Femoral stem: The long metal component placed into the femur (thigh bone)
Femoral head: The spherical moving part of the hip joint
Acetabular prosthesis: The hemispherical socket component placed into the pelvis (hip bone)
The main components of modern implants that attach to the bone are made of chromium, cobalt, or titanium. The intermediary parts where they articulate can be ceramic, polyethylene, or metal. For example, when referring to a ceramic hip implant, it means the materials used in the articulating components are ceramic. All of these materials are fully biocompatible.
Titanium is often chosen for its light weight and excellent corrosion resistance. Cobalt-chromium alloys have high wear resistance. Ceramic materials provide long-lasting results due to their low coefficient of friction. Polyethylene is commonly used, especially for the socket component.
With appropriate surgical technique and modern designs, implant longevity has now extended to 20–25 years.
Types of prostheses
Hip prostheses are basically divided into two main types: total and partial. In a total prosthesis both the socket and the head are replaced, whereas in a partial prosthesis only the head is renewed. The total prosthesis is the most commonly performed type.
The difference between cemented and uncemented application is important. Uncemented prostheses are preferred in younger patients. In this method the prosthesis is fitted tightly to the bone and bone growth secures the prosthesis by integrating onto it. In elderly patients whose bone quality is not suitable, the prosthesis is fixed with a special filler called bone cement. Therefore, when well performed, cemented prostheses can also yield comparable results.
Cementless applications are now used more frequently. Material combinations vary according to the patient’s age, weight and lifestyle.
Who Is a Candidate for Total Hip Replacement?
Symptoms of Hip Replacement Candidates
Not everyone with hip pain needs surgery. However, if the pain prevents you from performing daily tasks or walking independently, total hip replacement surgery often helps improve quality of life.
The primary factor in deciding on surgery is the severity of the pain and its impact on your quality of life. If you have difficulty with simple bending movements like putting on socks or tying shoes, surgery may be appropriate. You may be a candidate for hip replacement surgery if you experience severe pain when climbing stairs, need to rest during short walks, or have hip pain that wakes you from sleep.
Experiencing hip pain even at rest is an important reason for surgery. If the pain persists despite using a cane and disrupts your sleep, it indicates that it may be time for surgery.
It is a method used for patients who do not respond to physical therapy, medication and injection treatments before surgery. If painkillers no longer work and conservative methods fail, surgical options should be considered . Hip prostheses, used because the patient becomes unable to perform even routine activities, significantly improve quality of life.
Age and overall health status
There is no specific age limit for hip replacement surgery, but it is generally performed on patients between 50 and 80 years old. It is not preferred at younger ages unless necessary. It can be performed in individuals whose bone development is complete. It can be done in all age groups except during periods when the skeleton is immature.
With advances in technology and material quality, it can also be successfully performed on individuals who suffer severe joint damage at a very young age or on very elderly but otherwise healthy patients. After hip replacement surgery at a young age, patients are mobilized the next day.
The patient should undergo a general preoperative evaluation. Surgical success may decrease in severely overweight patients. It is important that candidates for prosthesis are not excessively overweight. If the patient has diabetes, it must be well controlled. Other comorbidities (heart disease, diabetes) should also be under control.
When deciding on surgery, the patient’s pain threshold, social life expectations, occupation and systemic diseases are evaluated together.
Conditions that prevent prosthesis surgery
Surgery must never be performed on patients with an infection in the hip joint. The presence of an active infection, whether local or systemic, is an absolute contraindication. Patients with serious infections are not candidates for total hip replacement.
Surgery is also not possible when there is muscle weakness around the hip joint or insufficient bone stock. Absence of the hip abductor muscle mass causes problems. Insufficient bone stock to allow fixation of the components prevents surgery.
Not suitable for patients with severe vascular diseases or those whose general health is not fit for surgery. Recent myocardial infarction, unstable angina, heart failure, or severe anemia and other serious concomitant medical conditions contraindicate surgery. Vascular disorders of the extremity also pose a problem.
Permanent or irreversible loss of muscle strength without pain, and para/quadriplegia are absolute contraindications. Progressive neurological loss and neuropathic joints are relative contraindications.
For Which Conditions Is Total Hip Replacement Indicated?
Advanced degeneration (osteoarthritis)
The most common reason for hip replacement surgery is osteoarthritis, known as wear-related degeneration. It develops due to wear of the joint cartilage and typically appears at older ages. Over time, the affected joint becomes stiff, rigid, and movement becomes limited.
When the cartilage is completely worn away, the bones begin to rub against each other. This causes severe pain in daily activities such as walking and climbing stairs. When medication, intra-articular injections, and lifestyle changes fail, total hip replacement surgery becomes inevitable.
For prosthetic surgery, the disease being advanced alone is not enough. Surgery is considered if there is night pain, the pain does not respond to medication, and walking distance has shortened.
Hip dislocation and developmental problems
Childhood conditions such as hip dislocation known as developmental hip dysplasia or slipped growth plate are among the reasons requiring hip replacement. Undetected or untreated congenital hip dislocation can necessitate hip replacement surgery in the 20s–30s.
In these patients the affected joint is much smaller than in others because it did not develop in its normal position. There is also leg shortening of three centimeters, sometimes up to five centimeters. During surgery, different techniques are used both to relocate the hip joint to its normal position and to lengthen the shortened leg.
Avascular necrosis and vascular disorders
In cases of femoral head blood supply problems called avascular necrosis, this surgery provides a definitive solution for young patients aged 20–40. Disruption of bone circulation in the femoral head, one of the structures that form the hip joint, leads to death of bone and cartilage tissue.
When blood flow is reduced or completely stops, the bone tissue loses viability. If untreated, it leads to permanent joint damage. In end-stage hip avascular necrosis cases, total hip replacement surgery is performed.
Steroid use, traffic accidents and falls can cause this disease. Especially with increased use of cortisone, avascular necrosis of the hip joint is being diagnosed more frequently.
Rheumatic diseases and inflammatory sequelae
Rheumatic diseases such as rheumatoid arthritis and inflammatory sequelae are among the conditions for which hip replacement is performed. It is a chronic disease that causes persistent inflammation of the joints by the immune system.
It destroys the joint cartilage and bone tissue. In severe cases of rheumatoid arthritis, total hip replacement surgery is performed to restore joint function. Prosthetic surgery may be necessary when the patient has significant joint destruction.
Hip fractures and traumas
Advanced-age hip fractures and post-vascularization problems leading to bone necrosis are among the conditions for which hip prostheses are applied. In the hip joint, intra-articular fractures or traumatic hip dislocations can result in permanent articular cartilage damage.
This condition leads to osteoarthritis of the hip joint. The patient's pain gradually increases, walking capacity decreases, and hip replacement surgery becomes necessary. Hip fractures are especially common in elderly individuals.
How Is Total Hip Replacement Surgery Performed?
Preoperative preparation process
The preparation process for surgery begins weeks in advance. It is essential that you have no active infection anywhere in your body. Conditions such as dental cavities, urinary tract infections, or athlete’s foot must be treated beforehand. Urinary tract infections can be asymptomatic, especially in women, and if overlooked they can spread to the prosthesis.
You will undergo tests such as blood tests, electrocardiogram, and chest X-ray. Your blood type will be determined and one or two units of blood that may be needed during surgery will be prepared. You must inform your doctor of all medications you are taking. Blood-thinning medications like aspirin are discontinued before surgery.
You should pay special attention to personal hygiene the day before surgery. Make home arrangements: remove rugs and obtain a bath/toilet riser. If you are overweight, losing weight before surgery reduces the load on the prosthesis.
Surgical techniques and operative methods
The operation begins under general anesthesia or spinal anesthesia administered in the lower back. The anesthesiologist, who assesses your overall health, determines the type of anesthesia. With spinal anesthesia, the lower part of your body is numbed. Light sedation may be added for comfort in some patients.
During the surgery you will be positioned on your side or on your back. A 10–15 cm incision is made over the hip. Through the incision the damaged femoral head is removed by cutting it away. The socket in the pelvic bone is prepared with special reamers and a metal cup is placed there.
A metal stem is inserted into the femur and a ceramic or metal head is attached to its end. Neuromonitoring is used to preserve the integrity of the nervous system. Thanks to this technique, the risk of leg weakness due to nerve injury is minimized.
Cemented and cementless prosthesis application
There are two methods for fixing the prosthesis to the bone. In cementless prostheses, the implant is press-fit into the bone, and bone grows onto the prosthesis to secure it. It is preferred for younger patients with good bone quality.
In the cemented method, a medical adhesive called bone cement is used. It is applied to patients over 70 years old and those with significant osteoporosis. When performed with correct technique, both methods are equally successful.
Duration of surgery and hospital stay
The surgery duration varies between 1 and 3 hours depending on whether one or both hips are operated on. A standard operation takes about 2 hours. In complex cases such as revision surgery, the duration can extend up to 4 hours.
You will be monitored in the recovery room until you wake from anesthesia after the surgery. The typical hospital stay is usually between 3–5 days. Patients in suitable overall condition are encouraged to start exercising shortly after. In some centers this can be shortened to 2–3 days.
Recovery Process After Total Hip Replacement
What to do in the first days
In the postoperative recovery room, your vital signs such as heart rate and blood pressure are monitored. Painkillers, blood thinners and preventive antibiotics are administered. A few hours after surgery you can get out of bed with assistance. With a physiotherapist, you will take your first steps using a walker.
You should begin exercises within 24 hours after surgery. Early mobilization increases blood circulation and reduces the risk of clot formation. Generally you will be mobilized within 1–3 days after surgery and walking exercises will be started under the supervision of a physical therapy specialist.
On the first day you take small steps to show that the surgery has no side effects. In the following days you begin short walks. By the third day you will be walking more comfortably. Five days after the surgery you can move on your own and will be discharged.
Walking and mobility program
You start walking using a walker or crutch. Extend your operated leg forward with the knee straight and let your heel touch the ground first. As you move your leg forward your knee and ankle will bend.
As your muscle strength improves, you can spend more time walking. You can progress to unaided walking in approximately 4–6 weeks. Young, strong patients may not need a walker even after 1 week. In older patients this period can extend up to 4–6 weeks.
Your physiotherapist will instruct you on what to do in the hospital and at home. Daily exercise for 20–30 minutes, or even 2–3 times a day, is recommended. Ankle pump, leg raise and balance exercises should be performed regularly.
Return to daily activities
When you return home, you should follow a few rules:
Do not bend your operated hip more than 80 degrees
Do not cross your legs
Avoid sitting on low chairs; use a seat-raising cushion
Use an elevated toilet seat
Sleep with a pillow between your legs
You can generally return to your daily activities from the 6th week, and no later than the 3rd month. When the wound has healed, the stitches are removed, usually on day 14. You should choose safe activities such as walking on level ground, cycling, swimming and golf. Avoid high-impact sports such as football, basketball and tennis.
Lifespan of the prosthesis and follow-up
With appropriate surgical techniques and modern prosthesis designs, the lifespan of a hip prosthesis has been extended to 20–25 years. Approximately 90–95% of patients can use their prosthesis without problems for 15 years. This rate may drop to around 80% by 20 years.
Routine follow-ups are performed at 6 weeks, 3 months and 6 months. After that, you should have annual check-ups. Regular monitoring helps detect wear of the prosthesis early. Excess weight can place excessive load on the prosthesis and shorten its lifespan.
Frequently Asked Questions About Total Hip Replacement
Is the surgery painful?
You will not feel any pain during the operation because you are under anesthesia. Intravenous patient-controlled analgesics and combined spinal-epidural regional anesthesia applications are very effective for postoperative pain control. Pain in the first days is normal and is managed with medication. Significant pain usually subsides within 2–3 weeks. Prolonged pain or sudden new pain may require surgical evaluation.
When can I return to normal?
Older patients require close care for about 1 month. During this period, household chores cannot be performed, but you can attend to other daily needs yourself. Young patients need close care for the first 3 weeks after surgery.
After surgery, you can fully return to your normal daily life in 3 months. Generally, you can return to daily activities within 6 to 12 weeks. The full recovery process may extend up to 6 months. However, complete recovery can take 6–12 months. Typically, full recovery is achieved within 3 to 6 months.
How long does the prosthesis last?
The average lifespan of modern hip prostheses is between 15 and 25 years. Hip prostheses have been recorded to reach around 20 years or more. The length of this period is affected by the patient’s lifestyle, weight, and the quality of the surgery. Hip prostheses can be used for up to 30 years if no complications occur.
What are the surgical risks?
Risks include infection, blood clots, prosthesis dislocation, nerve injury and anesthesia-related complications. These risks have been reduced to very low levels with modern surgical techniques. One of the most common complications after prosthesis placement is infection. In cases of deep infection, removal of the prosthesis and revision surgery may be required.
Can I play sports?
Low-impact activities such as swimming, walking, and Pilates are appropriate. You should avoid sports involving jumping, sudden twisting, or heavy loads. Generally, low-impact sports can be resumed after 8–12 weeks. Swimming is one of the safest sports after both hip and knee replacement. Running is generally not recommended because it involves high impact.
