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Hip replacement

If your specialist has recommended that you have a total hip replacement, this leaflet provides some standard information and advice about the procedure. However, you should always follow the instructions of your own specialist.

If you have any unanswered questions or concerns, please do not hesitate to ask your specialist or nurse for more information. It is natural to feel anxious, but often knowing what to expect can help.

This information was published by Bupa's health information team and is based on reputable sources of medical evidence. It has been peer reviewed by Bupa doctors. The content is intended for general information only and does not replace the need for personal advice from a qualified health professional.  

Hip replacement

The hip is a ball and socket joint. The "ball" is formed by the top of the thigh bone (femur), which fits into a "socket" (acetabulum), which is part of the pelvis. For a total hip replacement, the head of the femur is removed and a replacement ball on a stem is inserted into the center of the thigh bone. A plastic or metalbacked plastic cup is frequently used to replace the socket.

An artificial joint will usually last for at least 10 years, after which it may need to be replaced.

The operation is usually performed under a general anaesthetic, which means you will be asleep during the procedure. However, in some patients an epidural (using local anaesthetic) is preferable. Your specialist will discuss which is best for you. For more information on anaesthesia please see the separate leaflets.

Your specialist or hospital will talk to you about admission procedure, however before you come into hospital for your hip replacement, you will also be asked to:

  • attend a pre-assessment clinic for routine tests two or three weeks before your operation. This will also be an opportunity for you to ask questions, and for a physiotherapist to talk to you about your home requirements, so that any arrangements for aids and services can be made in advance of your admission
  • have a bath or shower on the day of your admission
  • remove any make-up, nail varnish and bulky or sharp jewellery. Rings and earrings that you would prefer not to remove can usually be covered with sticky tape
  • follow any fasting instructions given to you. Typically, you must not eat or drink for about six hours before the operation. However, some anaesthetists allow occasional sips of water until two hours beforehand

After you have been shown to your room, your nurse will check you have been well since the pre-assessment. Your surgeon and anaesthetist will also visit you. The surgeon will clearly mark the leg to be treated. This is a good time to ask any outstanding questions about your treatment.

The nurse will help you prepare for theatre and will do some simple tests such as taking your blood pressure and pulse, and may ask you for a urine sample. You may be asked to put on compression stockings to help prevent blood clots from forming in the veins of your legs.

Consent

You will be given a consent form to sign. By doing this, you confirm that you understand what the procedure involves, including the benefits and risks, and give your permission for it to go ahead.

Please see later for further information about the possible side-effects and complications of this procedure. You need to know about these in order to give your informed consent.

About the operation

An incision, usually around 6-12 inches (15-30 cm) long is made along the hip and thigh. When the joint has been replaced, your consultant closes the incision with stitches or clips. Fine plastic drainage tubes may be left in for up to 48 hours after the operation. A special pillow may be placed between the legs to hold the new joint still and prevent dislocation.

The operation usually takes one to two hours, so your relatives should expect you to be away from your room for at least three hours.

After your operation

You will be taken from the operating theatre to a recovery room, where you will come round from the anaesthetic under close supervision.

After this, you will be taken back to your room, where a nurse will make you comfortable. When you feel ready, you can begin to drink and eat, starting with clear fluids such as water or apple juice.

Back on the ward

You will need to stay in hospital for five to seven days after your operation. During this time, every effort is made to keep any discomfort to an acceptable level. Your anaesthetist will discuss pain relief with you. After the first week, you will probably only need mild painkillers in tablet form.

The physiotherapist will visit you every day to guide you through exercises to help you recover. You will generally be encouraged to move your new hip from the first day after the operation. By the time you go home, you will be able to walk with sticks or crutches and will have learned how best to move about and manage daily tasks.

Going home

You will need to make arrangements to be driven home. Before you go home, a nurse will advise you about caring for surgical wounds, hygiene and bathing. A follow-up appointment in the outpatient clinic will be arranged for you.

After you return home

If you need them, continue taking painkillers as advised by your specialist or the hospital.

You will be able to move around your home and manage stairs, but you will find that some routine daily activities are difficult for a few weeks and you will need to ask for help. For example, you will not be able to go shopping for the first few weeks.

When you are not walking or doing your exercises, you can sit in an upright chair. You will not be able to drive until your specialist advises you that it is safe.

It is crucial that you continue with the exercises that have been recommended by the physiotherapist, as these will promote healing and help you recover more quickly. Your new hip will continue to get better for at least six months.

 

 

A planned hip replacement is generally a safe surgical procedure. However, all surgery does carry some element of risk. This can be divided into the risk of side-effects and the risk of complications.

Side-effects

These are the unwanted but mostly temporary effects of a successful treatment. Examples of short-lived side-effects include feeling sick as a result of the general anaesthetic and painkillers, and having a poor appetite to begin with. After a hip replacement operation, the new joint is likely to be uncomfortable for several weeks. There may also be some temporary pain and swelling in the knee (caused by the handling of the leg during the operation) and it is quite common to have a swollen ankle for up to three months afterwards.

Complications

This is when problems occur during or after the operation. Most patients will not be affected.

The main possible complications of any surgery are excessive bleeding during or soon after the operation, infection, and an unexpected reaction to the anaesthetic.

The main specific complications of a hip replacement are listed.

  • damage to the nerves that control the leg. This is usually very slight and rarely permanent. Most patients do not notice it
  • occasionally, tiny cracks are made in the bone while fitting the new joint. These usually mend by themselves but on rare occasions a fracture can result, needing additional treatment
  • the operated leg is slightly longer than the other. When this occurs, the difference may be hard to notice, but sometimes its necessary to wear a raised shoe on the shorter side
  • the new joint dislocates. This is most likely to happen immediately after the operation and is easily dealt with. Occasionally, dislocation happens repeatedly and another operation may be needed
  • the bowels and urinary system are close to the hip joint and may be affected by the surgery. The bowels may take a while to become active again and there may be difficulty passing urine. A urinary catheter (a thin flexible tube) may be inserted to enable urine flow. A urinary tract infection, requiring antibiotic treatment, is also possible
  • for up to six weeks after the operation its possible to develop a blood clot (known as a deep vein thrombosis, or DVT) in the veins of the leg. This clot can break off and cause a blockage in the lungs. In the majority of cases, this is treatable, but it can be a dangerous condition. You may be given preventive drugs or compression stockings

1. What is the most common complication with hip replacement surgery and why?

A common complication of hip replacement surgery is dislocation of the joint (it pops out of joint). This happens to up to one in 20 people who have a hip replacement. It's important to take care of your new hip to prevent it happening.

Dislocation is a relatively common complication following a total hip replacement. The risk of dislocation varies depending on the surgical technique used and your general health. For example, if your muscles in the hip area are weak, the joint may become loose. Hip dislocation is more common if you have a repeat hip replacement (an artificial hip joint replaced).

You can dislocate your hip if you bend your hip to more than a right angle, for example, if you sit in a low chair. You can also dislocate your joint if you cross your legs and lean forward, or if you lie down and lift your waist.

Your hip is most likely to dislocate soon after your operation - more than half of dislocations occur within four to 12 weeks. This is because the muscles have not fully healed by this time.

The normal stability of your hip joint is affected during the operation because to get to the hip, surrounding muscles and tissue are moved out of the way. Your hip joint is then dislocated and some bone is removed to fit the new parts.

Your surgeon will repair any damage to muscles and tissues that surround your joint, but your joint will only become stable when the muscles around your hip joint have fully healed.

The exercises recommended by your physiotherapist are a crucial part of your recovery, so it's essential that you continue to do them.

If your hip dislocates often, you may need surgery or a brace (a fitted support) to stabilise your joint and allow the surrounding tissue to heal.

2. Are there any sports or activities I shouldn't do after my hip replacement?

It's important to stay active after you have fully recovered from your operation. However, don't do any high-impact sports that put a lot of pressure on your hips, such as running, squash or tennis.

During your recovery your physiotherapist will recommend exercises for you that will improve your strength and range of motion.

As you recover you can start swimming (but don't do breaststroke as the sideways kicking can cause a dislocation) and do more walking to strengthen your muscles around the joint.

When you have made a full recovery, you can have a more active lifestyle. However, try not to run on hard surfaces or take part in sports that could cause injury, such as football or rugby, or activities that put a lot of pressure on your hip such as squash or tennis. It's best not to do any sports with a high risk of falling such as skiing or snowboarding.

Regular exercise will help to improve and maintain your mobility. When returning to any sport, it's important to take your time to re-build your strength, coordination and reflexes. For example, if you play golf, work on chipping and putting before attempting longer distance shots.

Your doctor, surgeon or physiotherapist will be able to give you more information about what activities are suitable for you.

3. What can I do to make my recovery easier?

Try to be as fit and healthy as possible before your operation and prepare your home for when you return.

If you're having a hip replacement, it's a good idea to try and be as fit and healthy as possible before your operation to speed up your recovery.

Your surgeon will explain how to prepare for your operation. For example, if you smoke you will be asked to stop, as smoking increases your risk of getting a chest infection, wound infection or DVT, which can slow your recovery.

If you're overweight, your doctor may recommend a weight-loss programme.

You can exercise to strengthen your upper body. This will help you to get around after the surgery when using walking aids, such as crutches.

If it's possible, you should try to strengthen your leg muscles. Strengthening the muscles in your leg will speed your recovery and will make it easier to perform the post-operative exercises.

Your surgeon or physiotherapist will recommend exercises for you.

It's a good idea to prepare your home for when you return from hospital. This may involve rearranging furniture to make it easier to move around and placing commonly used items at arm level so you don't have to reach for them. It's also a good idea to stock up on non-perishable food such as frozen or tinned items, so that you don't need to go shopping immediately after your surgery.

You may need help after surgery. It's a good idea to arrange to have a friend or family member stay with you for a couple of weeks after the operation.

4. Why is hip revision surgery more complicated than the original hip operation?

Hip revision surgery is more complicated than the original operation because the existing implants plus any cement need to be taken out before a new one is fitted. Your bones are more likely to fracture and there is less bone to hold the new implant in place. As a result, repeat hip operations take longer to complete and have greater risk of complications.

Currently the artificial joints used in hip replacement last about 10 to 20 years, after which your artificial joint may become loose and will need to be replaced. The repeat operation is called hip revision surgery.

During a revision hip operation, the original implants and any cement used to hold them in place need to be removed before the new implants can be put in. Your thighbone may have grown into the implant, making it more difficult to remove, and your bones will have grown thinner with age. As a result, your bones are more likely to fracture and your new joint is more likely to become loose because there isn't enough bone to hold it in place. A hip replacement with a longer stem may need to be used to get a stronger fix.

Your surgeon may have to re-build the bone in your hip using bone taken from another part of your body or from your thigh bone. This is called a bone graft. If you have a bone graft, it may take longer to recover as it may restrict your movement and you might need to use crutches for longer.

5. Why am I unlikely to walk completely normally after hip revision surgery?

Hip revision surgery is more complex and has greater risk of complications than the original operation. So, you may find that your new joint, although a big improvement on your old joint, may not improve your life as much as your original hip operation.

Repeat hip operations take longer to complete, are more complex and have a greater risk of complications compared with the original operation. Reasons why your mobility may be affected after hip revision surgery are listed here.

  • Infection. With age your immune system weakens and you're more vulnerable to infection. Infection causes pain and swelling; delays healing and affects your overall health. If antibiotics don't help clear an infection, the implant may need to be removed.
  • Scarring. During a repeat operation cuts are made over the original scars, so the tissue may not heal as well as before. Any infection may delay healing and cause scar tissue to form. Scar tissue can make your leg muscles feel stiff and affect your walking.
  • Fragile bones. With age your bones become thinner, so they are more likely to fracture and there is less bone to hold the new implant in place. As a result, your joint is more likely to become loose or dislocate and this can affect your mobility.
  • Leg difference. During hip revision surgery more bone is removed because the old implant has to be taken out before the new one is fitted. So you're more likely to have a shorter leg and a slight limp (this is more common after revision surgery).

 

Hip revision techniques are improving all the time and there is every chance that you will have a good quality of life afterwards. You may always have a limp, but you should be able to continue to do everyday things, like getting dressed, climbing the stairs, getting in and out of the bath and walking short distances. If you have any concerns about the operation, ask your doctor for advice.

Further information

 

Sources

  • Osteoarthritis. Arthritis Research UK. www.arthritisresearchuk.org, accessed 13 April 2010
  • Total hip replacement. American Academy of Orthopaedic Surgeons. www.orthoinfo.aaos.org, accessed 13 April 2010
  • Single mini-incision hip replacement. National Institute for Health and Clinical Excellence (NICE), 2006. Interventional Procedure Guidance 152. www.nice.org.uk
  • Hip surgery. Arthritis Research UK. www.arthritisresearchuk.org, accessed 13 April 2010
  • Guidance on the selection of prostheses for primary total hip replacement. National Institute for Health and Clinical Excellence (NICE), 2000. Technology Appraisal Guidance 2. www.nice.org.uk
  • Parker MJ, Handoll HGH. Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD000086. DOI: 10.1002/14651858.CD000086.pub2.
  • Guidance on the use of metal on metal hip resurfacing arthroplasty. National Institute for Health and Clinical Excellence (NICE), 2002. Technology Appraisal Guidance 44. www.nice.org.uk
  • Khan F, Ng l, Gonzalez S, et al. Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004957. DOI: 10.1002/14651858.CD004957.pub3.
  • Bluecross Blueshield Association. Metal-on-metal total hip resurfacing. Tec 2007;22(5). www.bcbs.com
  • Minimally invasive two-incision surgery for total hip replacement. National Institute for Health and Clinical Excellence (NICE), 2005. Interventional Procedure Guidance 112. www.nice.org.uk
  • Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults. National Institute for Health and Clinical Excellence (NICE), 2009. Technology Appraisal Guidance 170. www.nice.org.uk
  • Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults. National Institute for Health and Clinical Excellence (NICE), 2008. Technology Appraisal Guidance 157. www.nice.org.uk
  • Surgery and arthritis. Arthritis Care. www.arthritiscare.org.uk, accessed 15 April 2010
  • Physiotherapy rehabilitation after total knee or hip replacement: An evidence-based analysis. Ontario Health Technology Assessment Series 2005;5(8). www.health.gov.on.ca
  • Yun AG. Sports after total hip replacement. Clin Sports Med 2006;25:359-64
  • Personal communication, Mr Roger M Tillman, MB, ChB FRCS, FRCS Orth. Consultant Orthopaedic Surgeon, Royal Orthopaedic Hospital, Birmingham, 16 June 2010
  • Physiotherapy rehabilitation after total knee or hip replacement: An evidence-based analysis. Ontario Health Technology Assessment Series 2005;5(8). www.health.gov.on.ca

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