Everything You Need to Know About Hip Replacements

Hello and welcome back to the ThreeSpires Physiotherapy blog where we take a look at all things physiotherapy and health related. This blog was originally titled: Ten Things You Need to Know About Hip Replacements but I quickly realised that there are so many more things that anyone considering having a hip replacement needs to know. Also, it follows on nicely from our series of articles about the causes of hip pain and how physiotherapy can help. Just to remind anyone first reading our website: we are a home visit physiotherapy service and all of our physiotherapists visit their patients at home. Our physios are mobile and come out to you at a time and place of your choice.

So, what is the first thing you need to know about a hip replacement. Well it’s probably a good idea to start with some anatomy first as we need to be clear what the hip actually is and where it is.

 

What is the Hip?

When most people think of the hip they will put their hand on the outside of their buttocks and will probably feel a bump of some description and although this is commonly thought of as the hip, as all physiotherapists know the actual hip joint is much deeper inside than this. When you put your hand on “the hip” and feel that bump what you are feeling is something called the “greater trochanter of the femur” and to find the actual hip joint you would need to go inwards quite a long way towards the pelvis itself and the groin. The hip joint consists of two bones: the femur which is the thigh bone and the pelvis itself. The pelvis forms the socket part of the hip joint and this is called the acetabulum. The femur forms a ball at the end of itself and this is called the femoral head. The hip is a ball and socket joint, has an excellent range of motion and enables us to walk, run and jump.

 

What is a Hip Replacement?

Hip replacement is a major piece of surgery that involves replacing the damaged or diseased parts of the hip joint with artificial implants made of metal, ceramic, or plastic. The procedure aims to reduce pain, improve mobility, and restore the natural function of the hip joint. There are two main types of hip replacement surgery that you should be aware of:

1. Total Hip Replacement (THR): In THR, both the acetabulum (hip socket) and the femoral head (the ball-shaped top of the thigh bone) are replaced with prosthetic components.
2. Partial Hip Replacement (Hemi-arthroplasty): In this procedure, only the femoral head is replaced with a prosthetic component, while the acetabulum is left intact. This is also called a half-hip replacement.

Which type of surgery you have depends upon a range of factors including age and the level of wear and tear that is found in the socket. If you are relatively young and the socket is well preserved with good cartilage depth then it is likely you will have a half hip replacement. It is important to know the type of hip replacement you have had because this will affect some of the things that you can and can’t do after your hip replacement. We will look at the differences in rehab and precautions post hip replacement later in this article.

 

What are the Reasons for Having a Hip Replacement?

Now we have an idea of the anatomy and what a hip replacement actually is we should now take a look at why you may potentially have a hip replacement.

1. Osteoarthritis of the hip: for elective surgery (you have made a choice) this is by far the most common reason for having a hip replacement. Osteoarthritis as discussed in previous blog posts is the most common form of arthritis and is a degenerative joint disease that primarily affects the cartilage. This is the protective tissue covering the ends of bones in a joint. Osteoarthritis gradually develops over time and is often associated with aging, though it can also be caused by joint injuries, repetitive stress, or underlying joint abnormalities. In a healthy joint, cartilage acts as a cushion, providing a smooth surface for the bones to move against each other. In osteoarthritis, the cartilage gradually breaks down and wears away, leading to joint pain, stiffness, and reduced mobility. If the osteoarthritis is severe and causing symptoms such as pain and stiffness that are limiting function and quality of life then a hip replacement may be considered.
2. Rheumatoid Arthritis: this is a less common form of arthritis which can affect joints and cause them to degrade and wear over time. It can cause the integrity of the joint to fail and lead to the need for a hip replacement. If the rheumatoid arthritis is severe or left untreated this is likely to lead to the need for a joint replacement.
3. Hip Fractures: if you have a fall and break the neck of the femur then it is highly likely that the joint will need to be replaced. Hip fractures occur mostly in more elderly patients and especially females who are more likely to have osteoporosis (weaker bones) due to hormonal changes.
4. Avascular necrosis: Avascular necrosis, also known as osteonecrosis, occurs when the blood supply to the hip joint is disrupted, causing the bone tissue to die. This can result in pain and collapse of the hip joint, requiring surgical intervention such as hip replacement to restore function.
5. Congenital hip disorders: Some individuals may be born with hip abnormalities or developmental dysplasia, which can lead to degenerative changes in the hip joint over time. Hip replacement surgery may be recommended to address pain and improve hip stability in such cases.
6. Other conditions: Less commonly, hip replacement surgery may be performed to treat conditions such as hip dysplasia, Paget's disease of the bone, or certain types of tumors affecting the hip joint.

Overall, hip replacement surgery is considered when conservative treatments such as medication, physiotherapy, or walking aids no longer provide adequate relief from hip pain and disability. It should be noted that although in the past it was recommended to wait as long as possible before having a hip replacement it is now considered better to have a joint replacement when it starts to affect function and quality of life. This way the patient maintains maximum strength and function in the joint before undergoing surgery.

 

Who Is Likely To Have A Hip Replacement?

Well, clearly anyone with a hip could have a hip replacement but there are some factors that make having a hip replacement more likely.

1. Age: unfortunately as with most things in life age is a factor and a reality of those people that are most likely to have a hip replacement is that they are likely to be older. This is for a number of reasons but the primary reason is that as we age arthritis becomes more common and our joints and the associated cartilage tends to wear making it more likely that the joint will need replacing. Also as we age it becomes more common for us to have a fall and this can sometimes lead to a broken hip, especially if we have osteoporosis (brittle bones)
2. Gender: Women are unfortunately (for them!) more likely to have a hip replacement, there are a few reasons for this. Firstly women tend to live a bit longer than men and therefore for the reasons above as we age we tend to be more likely to need a joint replacement. Being female also makes you more likely to have osteoporosis and therefore makes it more likely that an elderly female that falls will break her hip and need a hip replacement.
3. Congenital Hip Abnormalities: anyone with a congenital (born with) hip defect such as dysplasia (see our previous blog) and FAI due to the way loads are distributed in the joints are more likely to develop osteoarthritis and thus need a hip replacement.
4. Obese Individuals: although you might think that this seems obvious: i.e. the heavier you are the more load you put on your joints and the faster they are likely to wear out. This may be a part of the reason that obesity is linked to osteoarthritis but it is most likely not the most important factor. Research now supports the idea that because individuals who are obese have a high general level of inflammation in their body that this then worsens the inflammation in the joints and leads to arthritis.

Clearly as described earlier anyone with osteoarthritis or rheumatoid arthritis is also much more likely to need a hip replacement than anyone without.

 

What Is The Process For Having A Hip Replacement?

So now we understand what a hip replacement is, the reasons for needing a hip replacement and who is most likely to have a hip replacement we probably need to take a look at the overall process of having a hip replacement. Obviously if you fall and break your hip, then the process simply involves being taken to A&E and then the surgeon will decide if you are suitable for a hip replacement. However, if you have osteoarthritis (the most common reason for a hip replacement) then there will be a process that leads you to your hip replacement and you will have been assessed and helped by many medical professionals. Below is a general overview of a normal process:

1. Beginning to Have Pain: initially you will probably have begun at some point to notice that your hip feels stiff after walking or exercise and that if you do too much you get groin pain and need to sit down. You may also notice that your groin and thigh are sore and stiff first thing in the morning. Often people will persevere for a long period here, just thinking that it is a temporary groin strain and will use analgaesia and anti-inflammatories to manage their symptoms.
2. Initial GP Visit: after persevering for a while many people will visit their GP, who will initially (depending upon age and symptoms) most likely prescribe some stronger painkillers and tell them to see if their symptoms go away in a month or so.
3. Second GP Visit & X-Ray: if the pain does not improve at some point people usually return to their GP who will now most likely order an X-Ray of the hip to have a look at what is going on and to inform the best management options.
4. X-Ray Shows Osteoarthritis: at this point the GP will discuss with the patient their options and will probably refer them to physiotherapy. Some people will go straight to orthopaedics and for a surgical option but most people if their symptoms are not too bad and they are still functioning well will be offered physiotherapy.
5. Physiotherapy: the patient now has an assessment with a physiotherapist and discusses the results of their x-ray. The physio will give the patient a lot of advice and a program of strengthening exercises aimed at giving the patient a stronger leg and core that can better control their hip. For many patients this is highly successful and they improve and are able to manage their hip for a long time.
6. Pain Has Not Improved: not everyone improves with physio and some do but then their pain returns. If physiotherapy has not been successful and the patient is struggling a referral will be made to orthopaedics for a consultation with a surgeon.
7. Orthopaedics: here for the first time the patient will meet an orthopaedic consultant who will look at their x-ray and conduct an assessment. At this point many people will be offered a steroid injection to see if this will help manage things. However, if things are too severe or if the injection does not work then the surgeon will discuss a hip replacement.
8. Pre-Operative Assessment/ Hip School: before having your hip replacement you will need to attend a pre-op assessment which sometimes is called hip school. Here you will have an assessment by the doctors but you will also get vital information either in a booklet or sometimes in person from a physiotherapist. It is important that you read the booklet thoroughly or pay close attention what you are told by the physio because this will give you a large amount of key information about your hip replacement and recovery afterwards.
9. Operation Takes Place: at this point you come into hospital and undergo the procedure. Whether or not this takes place under full anaesthetic or just under a spinal block depends on your anaesthetist, your past medical history and at least to some extent your own preferences.

 

What Happens After My Hip Replacement Operation?

An obvious and pretty reasonable question that many people have is: what will happen immediately after my hip replacement? Well this depends upon a few factors such as your age, past medical history, how well you come out of anaesthetic and whether or not you have any complications but below is a reasonably standard process for someone without too many complicating factors:

1. You wake up in a hospital bed: at some point after having your hip replacement you will wake up in bed feeling pretty sore and fatigued. The nurses and healthcare assistants will come round to check you are okay and will take some observations such as oxygen saturation and blood pressure. You will also very likely be given some food and drink for the first time in a while. At this point pain may well not be too bad as you will still have some of the effects of the anaesthetic lingering in your system.
2. Pain Relief: fairly quickly once the anaesthetic has worn off your hip will start hurting and it is important that you get pain relief. Don’t think that you should be brave at this point. It is absolutely normal to need pain killers as you have just had a major operation.
3. The physios arrive: getting up and weightbearing as soon as possible is a key part of the process. Ideally the physiotherapists will come around on the first day after you operation and try to get you standing and taking steps with either crutches or more likely a zimmer frame. This improves recovery time and reduces the likelihood of complications such as a chest infection.
4. Discharge home is discussed: the physios and occupational therapists will come around and discuss with you what you need to do to get home. If you have stairs, then it is likely that before going home you will need to be able to go up and down a set of stairs.
5. Stairs: if you need to use stairs at home the physios will come around in the hospital and practice the stairs with you. Once you have successfully completed these and you are medically stable, the hospital staff will start preparing you for going home.
6. Home: all of your medicines should be packaged up and preparations are made for discharging you off the ward. This is usually done within 3 days after your hip surgery but sometimes can be quicker or take longer.

 

Recovering At Home

The next step of your recovery from your hip replacement is by far the longest and in many ways the most important. Once the doctors have determined that you are medically safe for discharge home after your hip replacement you will then be sent home. If you have someone who can pick you up then this is ideal otherwise it may be by ambulance or taxi. If a relative or loved one is driving you home then you need to consider the angle that your hip will reach when getting in and out of your car. Most hospitals will have hip precautions for about 6 weeks and you are not allowed to move your hip past 90 degrees. Once at home, resting and letting things settle down for at least a few days is the key. You need to do your exercises that you will have been given and you need to try and mobilise around your home a bit but you should not do too much and you need to accept you have just had a hip replacement which is major surgery! From this point timeframes of recovery and how well you progress after your hip replacement are very individual and hard to describe as it depends very much on your age and previous levels of fitness. In general, the younger and stronger you are the quicker and better you will recover from your hip replacement. Before looking at stages of recovery and key things to do at home it is important to discuss hip precautions.

Hip Precautions

Whether or not you have precautions on what you can do after your hip replacement depends upon your surgeon and what he/she has decided. It used to be the case that all hospitals had a list of “hip precautions” (things you are not meant to do) for after a hip replacement with the idea being that by avoiding these actions and positions you would reduce the likelihood of a dislocation post surgery. However, research now suggests that your chance of dislocation is unlikely to be significantly affected by following hip precautions and now the use of hip precautions is much less common and depends upon the exact surgical technique your surgeon has used. The most common precautions are as follows:

1. No flexing your hip past 90 degrees, by this we mean that your knee must not come above your hip and also that the angle between your pelvis and your hip does not go over 90 degrees. This means you need a raised chair and need to think about how you get into a car and out of a chair after your hip replacement.
2. No crossing the midline with your leg: simply you can’t allow your leg to go over and past your other leg. The most common place this might happen is when sleeping on your side and in this situation you need a pillow between your legs.
3. No twisting: you aren’t allowed to twist or swivel on your leg and instead you need to step around.

As mentioned, many hospitals will not insist upon hip precautions or they will only have them for a few weeks. After your hip replacement you need to check whether you have hip precautions to follow or not.

So, now you are home and have had a few days rest what should you be expecting after your hip replacement? Well, as explained this very much depends upon your age, previous level of fitness and if you have fallen and broken your hip or if you have had elective surgery. Below we will look at a few different categories of patient and their likely recovery process:

Elective Surgery, 50yrs Old and Previously Very Fit:

This person will almost certainly recover very quickly from their hip replacement and if you are older or less fit then you will take much longer. In this case, you will return home on two elbow crutches after a maximum of 2 days in hospital and pain will be immediately well managed. Within a week you will find that your pain has subsided greatly and often you will have less need for analgesia. Within a couple of weeks you will most likely be able to walk without crutches and although your hip may still feel very stiff in the morning you will begin to feel much better. You will be doing exercises daily and feeling stronger each day. After 6 weeks you will see your surgeon again and he/she will be very happy with your progress and will very likely discharge you as you are doing so well. You will now be able to drive again, you will find most daily activities completely pain free and you will be considering trying to return to previous sports and activities. There will still be positions that cause pain and your leg will still be weaker but overall you will be doing very well. This progress will continue over the next 3 to 6 months until eventually you will have made a full recovery.

Anyone reading this should bear in mind that this is the absolute quickest anyone can recover from a total hip replacement. Everyone else will be slower, much slower! Age will increase recovery time significantly and both previous fitness and other illnesses will also increase it. Most people will need at least 12 months to make a full recovery.

Elective Surgery, 80yrs Old and Walking with a Stick

This is a very common category of patient, here we have someone who has had groin and hip pain for a while and has been struggling with things. They have been using a stick for a while and have generally experienced a drop in strength and mobility over the last 18months whilst waiting for an operation. They have a few other medical conditions but nothing significant. This person will probably be out of hospital in under a week but will be sent home with a zimmer frame as they couldn’t cope with crutches. Over the next month they will eventually be able to move to using two crutches but many movements will be very painful and they will feel very unsteady at times. By the time they see their consultant at 6 to 8 weeks they will be on two crutches but the consultant will want to see them again. Over the next couple of months they will wean off their crutches down to just using a stick but they may still use crutches outdoors. It will likely take them 4 months or more to stop using a stick indoors but it will likely be 6 months before they are happy walking with no support outdoors. It will take a further 3 to 6 months for them to build up their walking outdoors to a point that they can walk an hour without significant discomfort.

Here, it is clear that there is a massive difference in time of recovery for two people with 30 years between them, they still both make a good recovery but the older person takes a lot more time.

Broken Hip, 85yrs, Relatively Good Health, Previously Independently Mobile

Another common category of patient: here we have someone who has had a fall and broken their hip and then had it replaced. They will say that they were fully, independently mobile before but on closer discussion it will transpire that they have had other falls and they have generally been losing fitness and strength. Most likely they will spend a week in hospital and then be discharged home with a zimmer frame, it will take them a while to get down to crutches but by the time they see their consultant for a review into their hip they will be using 2 crutches. It will likely take them at least a couple of months to slowly wean off their crutches and get down to using a stick indoors and outdoors. Over the following months and maybe taking up to 6 more months they will build up their outdoor stamina and be able to walk a fair distance (up to an hour) but here there is a difference between this patient and our previous case. There is a reasonable likelihood that even with a lot of work, this patient may never feel confident enough to walk outdoors without a stick. This is because often a fall is the tip of the iceberg and actually this person has been losing strength, balance and fitness over many years and will never be able to fully regain it.

Broken Hip, 80yrs, Some Health Conditions, Previously Mobile with a Stick

Here we have another very common category of person who has had a fall, broken their hip and needed a total hip replacement. This person likely has quite a few other health issues, they have had a few hospital admissions for infections, UTIs and chest infections over the last 3 to 5 years and they have in general experienced a decline in fitness and mobility. They have been walking with a stick for a while and now they are really only mobile indoors and they have had quite a few falls. This person will almost certainly spend a couple of weeks in hospital recovering as often the fall was caused by a chest infection or water infection. By the time they leave they may have progressed to mobilising short distances with a zimmer frame with supervision or they may still be using a hoist or stand aid such as a mo-lift. Once home if they are transferring with a zimmer frame they will almost certainly need carers to go in and help with safely getting out of bed and into a chair. It will take this person a very long time to recover to their previous level of using a stick indoors and if they have been discharged with a hoist transfer it may be the case that the best they can hope for is being mobile indoors with a zimmer frame.

Again, here we can see the impact that both age and most importantly previous physical strength and heal have on recovery and prognosis. In this case, a poor previous level of mobility and some significant health issues have made it very hard for this person to recover after a hip replacement. Hopefully by looking at these various scenarios of types of patients having a hip replacement you will now have a better understanding of the time frames involved for a recovery from a hip replacement.

 

Physiotherapy After A Hip Replacement

A key part of the recovery for anyone after a hip replacement will be physiotherapy. How much physiotherapy you need and how often after your hip replacement will depend upon a number of factors such as age, previous fitness levels and how easily you can do exercises yourself. In general though all patients will benefit from an early assessment by a physiotherapist with experience of helping patients with hip replacements. Having an assessment early on in the process will give you the information you need to make the best possible recovery after your hip replacement. Below is a general process covering physiotherapy after a hip replacement with a few scenarios and options:

The Initial Assessment:

Once home and you have had a day or two to recover from effects of being in hospital for your hip replacement it is important to have an initial assessment with a physiotherapist. This will involve taking a past medical history, discussing your current symptoms and understanding of the hip replacement. There will be a physical assessment that looks at how much you can do and how strong you are. After this the physiotherapist will give you an exercise program and discuss a management plan plus they should talk through time frames and key stages post hip replacement. This is probably the most important physiotherapy session post hip replacement for most patients as it gives them the information they need to manage their recovery themselves and maximise their chances of returning to previous levels of mobility.

Follow Up Physiotherapy Sessions:

How many sessions of physiotherapy you need and how often after your hip replacement very much depends upon how much you are able to do independently or with family help. If you are able to do all of your exercises yourself, are currently walking (with a couple of crutches) and are highly motivated then you will clearly need to only see a physio a few times. Possibly, you will see the physio once for the initial assessment, once a few weeks later and then a couple of times over the next few months until you feel happy to continue independently. However, if you have been discharged with a hoist for transferring then you will most likely be needing several sessions per week for at least a month or two in order to get off the hoist and begin attempting to mobilise with a frame.

 

How Can ThreeSpires Physiotherapy Help with My Hip Replacement?

Here at ThreeSpires Physiotherapy we help a large number of patients with their recovery after a hip replacement. Our physiotherapists are experienced in helping all categories of patients recover after a hip replacement. Our physiotherapists will visit you as soon as possible at your home after your hip replacement and will help you on the road to recovery. Below I have tried to detail this process:

1. Assessment: this is a vital part of recovery after your hip replacement and the sooner you have an assessment with one of our physios the sooner you will know what you need to be doing to maximise your recovery.
2. Management Plan: once you have had an initial assessment our physiotherapist will discuss a clear and comprehensive plan to begin managing your recovery.
3. Exercises: your physiotherapist will be able to determine which are the most appropriate exercises for your hip replacement and will be able to prescribe the optimum number and frequency to promote recovery.

Okay, I hope that you have found this article about hip replacements helpful and it is part of a series of articles that we are completing about issues around the hip. Should you or anyone you know need help with recovery after a hip replacement please get in touch and one of our physios would be happy to help. Just to remind you we are a home visit physiotherapy service and our physios are mobile and will come out to you at home.