Hip Replacement
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Hip replacement surgery, also known as total hip arthroplasty, is a common surgical procedure used to replace a damaged or diseased hip joint with an artificial joint, also called a prosthesis. The procedure is usually recommended for people who have severe arthritis, arthrosis, a hip fracture, or other hip conditions that cause significant pain and difficulty in daily activities. Partial hip prostheses, also called endoprostheses, are most frequently used in cases of femur fracture and consist of replacing the entire head of the femur with a prosthesis.Â
Both interventions aim to recover maximum functionality of the damaged joint by removing the risk of other complications. The hip replacement is performed very frequently and has seen significant progress over time regarding the techniques and materials used, improving recovery and reducing pain in the immediate post-operative period.
Indications
Types
Procedure
Recovery
Complications
Indications
Hip replacement is an effective and successful surgical procedure for end stage osteoarthritis of the hip when conservative treatment has failed. The implantation of a hip prosthesis can also be an indicated solution for numerous hip pathologies, such as:
- primary arthrosis (i.e. without an identifiable cause) and secondary arthrosis (i.e. caused by other hip pathologies)
- rheumatoid arthritis
- aseptic osteonecrosis of the femoral head
- hip dysplasia
- ankylosing spondylitis
- psoriatic arthritis
- medial femoral neck fracture in patients over 60 years old
- secondary tumor lesions
Types
The damaged components of the hip can be different, so the prosthesis can replace:
- the femoral head alone: endoprosthesis or partial prosthesis;
- the head of the femur and the acetabular cavity: arthroplasty or total prosthesis.
The total hip prosthesis is basically made up of two components: the femoral component or stem of the prosthesis, which is inserted into the medullary canal and the cotyloid component fixed to the iliac bone of the pelvis or cotyle of the prosthesis.
Endoprosthesis replaces only the femoral part which will articulate with the patient’s cup. It is used only in very elderly patients who have suffered a fracture of the femoral neck; in such patients, with serious functional limitations and/or with significant general diseases, the choice to apply an endoprosthesis reduces surgical times and therefore operating risks and allows a rapid recovery of verticality and walking.
There are also various types of prostheses, both in terms of materials and models, among which the surgeon can choose.
Standard total hip replacement implants are typically made up of approximately four individual components: titanium and cobalt-chromium implants, that are considered highly biocompatible; ceramic and Cobalt-chromium, that present a very hard surface and are extremely resistant to scratching or other damage, and Polyethylene, a plastic material commonly used for hip replacement liners. This material has provided good to excellent results when paired with ceramic or cobalt-chromium balls.Â
Procedure
Before carrying out any intervention, an accurate diagnosis by a specialist is essential. Usually an x-ray is necessary to confirm the diagnosis and a possible (and not always necessary) magnetic resonance imaging, as well as an always recommended study of the patient’s soft tissues.
The operation for the implantation of the hip prosthesis is performed under general or epidural anesthesia with sedation.
In most cases it is possible to carry out this with minimally invasive procedures with a significant reduction in recovery times after the operation, guaranteeing early mobilization. Using the minimally invasive technique for implanting the prosthesis, the periarticular soft tissues are safeguarded, the joint capsule is reconstructed and the skin incision is reduced to 7-8 cm. Today modern hospitals follow Fast Track protocols, according to the principles of Tissue Sparing Surgery (TSS), which involves a rather short stay in hospital, a very rapid and effective intervention with a significantly reduced administration of opiates compared to standards.
The average duration of hip replacement surgery is 60 minutes.
Already on the first day after surgery the patient will be able to sit up and begin to bend the knee and extend the hip. Once the first 48 hours have passed after hip replacement surgery (sometimes even earlier), the patient will be able to start walking with the help of the physiotherapist and the aid of two Canadian canes (crutches). Discharge from hospital occurs after an average of 4 or 5 days.
Recovery
There are many variables in the speed of the operation, mainly linked to the age of the patients and general health conditions, but in the vast majority of cases recovery times are very short.
Following the procedure, a brief post-operative rehabilitation process becomes necessary to acclimate to the prosthetic and help the body adjust to its presence. The duration of recovery is influenced not only by the patient’s health but also by their dedication to the rehabilitation process. Some patients may recover in a few weeks, while others may require a bit more time.
The primary and significant benefit is the relief of pain, with nearly all patients experiencing substantial alleviation from arthritic hip pain. Following pain reduction, improved mobility is a key advantage, allowing individuals to resume walking without constraints. Enhanced hip function also aids in tackling common challenges associated with hip arthritis, such as climbing stairs, putting on socks, and rising from a chair. Notably, the positive effects are long-lasting, with current evidence indicating that 80-85% of hip replacements still function well even 20 years after the procedure.
Complications
The complication rate following total hip replacement is low. Serious complications, such as hip infection, occur in less than 1% of patients. Chronic diseases can increase the risk of complications. Patients with diabetes or obesity (BMI >30 kg/m²) have a higher complication rate and might benefit less from the total hip arthroplasty. Implant survival may be diminished in patients with a history of malignancy and in patients with diabetes or obesity.
Some possible complications include:
- It is the difference in length that may remain between the two lower limbs at the end of the operation; it may depend on intraoperative mechanical factors or on pre-existing local situations relating to the pathology in question (for example in hip dysplasia).
- Dislocation (risk less than 1%). It represents the disassembly with separation of the prosthetic components. It is statistically more frequent in the first two months following surgery and can be directly caused by incorrect postural attitudes and careless joint movements.
- Intraoperative fractures (risk less than 1%). It represents a rather rare complication, mostly linked to fragility of the femoral bone tissue due to osteoporotic causes.
- Allergies to metal components (previously unknown to the patient).
- Deep vein thrombosis and pulmonary embolism.
- Vascular and nervous complications. Intraoperative lesions of important vascular structures are quite rare; while the possibility of damage mainly due to stretching of the sciatic nerve and/or the femoral nerve should be noted, for which the risk can be quantified in the literature at approximately 2-3%.
Prof. Raul Zini
30 years of experience. 12.000 procedures performed. Has operated multiple Olympic athletes and medalists with great success.
Hip Surgery Treatment Costs
A hip replacement is often the only solution for those patients in excessive pain from osteoarthritis in the hip joint. The Covid pandemic has placed a huge strain on many national health services, with the result that the waiting lists for elective surgery like hip replacements are exceptionally long. The only way to reduce this excessive waiting time is to consider private treatment which, without medical insurance, will cost around £15,000 depending on the UK area.
Prices for private treatment abroad can reduce the costs considerably, being up to 50% cheaper in some very reputable countries. Due to the increase in the risk of blood clots after major surgery, like a hip replacement, it is best to keep the flight time short and some countries in Europe offer good value surgery. The countries listed below make excellent choices with their well-appointed modern hospitals/clinics and well-trained surgeons. Our medical consultants will be happy to advise you on the best choice for your hip replacement.
Hip Arthritis
The primary reason people opt for hip replacement surgery is often hip arthritis. Also known as coxarthrosis, this condition involves a gradual breakdown of the cartilage in the hip joint. While it’s more prevalent in individuals over 60, attributed to the rise in average life expectancy, it can also manifest at a younger age due to factors like engaging in specific sports or experiencing joint trauma. Since it’s a degenerative condition, the symptoms, initially mild, progressively intensify over time, potentially severely limiting one’s ability to walk.
Symptoms
Causes
Diagnosis
Complications
Treatment
Symptoms
The main symptom of hip osteoarthritis is pain during movement, which subsides at rest. In the early stages, it is mainly felt in the groin area and radiates to the front and inner thigh, sometimes reaching the knee. It occurs only during the loading phase, becoming more persistent in advanced stages and manifesting even at night and at rest. Other observed symptoms include back pain, often confused with simple sciatica, difficulty in walking, and instability (a sensation that the leg is giving way). The pain experienced during simple daily actions is the first warning sign of hip osteoarthritis, so it is recommended to undergo a specialist examination, especially if it is felt frequently and the patient is over 50 years old.
Causes
The main cause of hip osteoarthritis is aging. In this case, it is referred to as idiopathic osteoarthritis, where the condition is a result of advancing age. Other factors that can promote its early onset include dislocations, fractures, inflammatory processes, congenital malformations such as congenital hip dysplasia, adolescent pathologies, engaging in high-impact sports for extended periods, and avascular necrosis.
Some factors also contribute to the development of early osteoarthritis, such as obesity, individual anatomical predisposition, and immuno-rheumatological diseases. It is estimated that hip osteoarthritis has an incidence of approximately 470 cases per 100,000 people per year, with slightly higher numbers (495) for women aged 70 to 79. It is also the most common chronic disease in the elderly.
Diagnosis
Various diagnostic tools may be employed to diagnose hip arthritis. This includes a thorough examination of your medical history and a physical examination. Blood tests may be conducted to check for genetic markers and rheumatoid arthritis (RA) antibodies. X-rays are commonly used to assess cartilage loss, even though cartilage itself is not visible on X-rays. Instead, the space between the bones in the hip joint is examined, and a narrowing of this space may indicate cartilage loss. X-rays also reveal bone spurs and cysts associated with osteoarthritis. In general, an MRI of the hip is not typically necessary for arthritis diagnosis.
Complications
Potential complications of osteoarthritis encompass various issues, including the swift and complete breakdown of cartilage, which can result in loose tissue material within the joint known as chondrolysis. Additionally, complications may involve bone death (osteonecrosis), stress fractures, which are hairline cracks in the bone that develop gradually due to repeated injury or stress, and bleeding inside the joint. Other complications consist of joint infections, deterioration or rupture of tendons and ligaments around the joint, leading to a loss of stability, and the possibility of a pinched nerve, particularly in cases of osteoarthritis affecting the spine.
Treatment
We can divide therapies for hip arthrosis based on the severity of the pathology:
- 1st stage, mild coxarthrosis with mild cartilaginous degeneration;
- 2nd stage, moderate coxarthrosis with significant wear of the cartilage and presence of cracks;
- 3rd stage, severe coxarthrosis in which the cartilage is completely deteriorated, with significant cracks.
As regards severe coxarthrosis, the solution that is generally adopted is the implantation of a hip prosthesis: in the other two stages, the therapies can be pharmacological or regenerative medicine, generally associated with physiotherapy courses.
The procedure requires a rehabilitation period to regain optimal walking abilities, as the surgery alone doesn’t fully restore maximum functionality. Instead, it demands commitment and consistency during the post-operative phase. Achieving the highest level of autonomy is facilitated through a personalized rehabilitation plan.
REHABILITATION PHASES:
- Joint mobilization, muscle strengthening, and progressively challenging exercises;
- Active exercises and walking with aids;
- Independent walking;
- Advice to minimize the risk of further falls;
- Guidance on the best habits to safeguard the joints;
- Information on the importance of proper nutrition;
- Maintenance of results once back home, aiming for the maximum possible autonomy.
Rehabilitation serves as a key component in expediting the return to a normal, independent lifestyle over the long term. By three months, most people have regained much of the endurance and strength lost before or around surgery and can participate in daily activities without restriction.
