PROFESSOR MICHAEL R WHITEHOUSE
CONDITIONS & TREATMENT
> What are the common reasons people need treatment for hip problems?
The aim of most treatments for hip problems are to reduce pain, improve function and to return you to the activities that you want to do. This is important to remember as you may be told that you need treatment for a problem that has been picked up when you are not experiencing any pain or problems. It is often reassuring to know that this is very rarely the case, hence it is important to see someone who has a full and in depth understanding of your hip and can accurately and reliably correlate your symptoms with any problems seen. This means the best advice can be offered on what treatment you may need and when it would be best to perform this.
The most common reason that you may need to see a hip surgeon is due to pain. Certain patterns of pain suggest particular diagnoses. For example, hip arthritis typically leads to pain felt in the groin that may radiate down the leg. Labral tears or hip impingement typically cause groin pain as well, but this is particularly bad when the hip is flexed up and turned in such as when sitting in a low chair or car or getting in and out of a low car. Trochanteric or lateral hip pain, as the name suggests, is felt over the side of the hip and you would tend to notice it when you lie on your side.
> Hip arthritis
Hip arthritis occurs when the cartilage and eventually the underlying bone wears away or degrades in the hip. The most common form is osteoarthritis. This is commonly referred to as “wear and tear” arthritis but this is not quite correct. Although it becomes more common as people get older or after they experience an accident where the hip is injured, if it was just wear and tear, most people would present with arthritis which was the same on both sides, which it rarely is. If you need a hip replacement, there is about a one in ten chance that you would need to have the other side replaced in your lifetime. Osteoarthritis is a condition that affects the whole joint, not only the bearing surfaces that rub together. The lining of the joint, or synovium, is part of the process and the thick capsule that surrounds the joint becomes scarred and stiff as well. All of these factors can lead to symptoms that cause pain or otherwise affect you.
Hip arthritis: the effect of pain
Osteoarthritis of the hip most commonly causes pain. This pain means that you may tend to cut back on or stop doing activities that cause you pain which can be very frustrating and lead to other health problems. The scores that are used to assess how badly you are affected by your hip arthritis you are asked a few questions about pain but most of the questions are about particular activities and how easy you find it to perform these activities. You may have been asked to fill in one of these scores by people that you have seen about your hip. The most common one in use in the UK is the Oxford Hip Score (OHS), this consists of 12 different questions. Although more questions are about activities than pain, the majority of the change (around 80%) seen in the score is actually due to pain. So, if we can reduce your pain, you will be able to do more of the activities you want to do.
Hip arthritis: where is the pain felt?
The pain from osteoarthritis of the hip is typically felt in the groin and may be felt in the thigh too. Less frequently, you may feel pain over the buttock or side of the hip. If the pain goes below the knee, it is very important that we rule out back problems that may be contributing to your pain as this may be due to problems such as a nerve being pressed on in the back.
Hip arthritis: when do people feel pain?
The pain is typically associated with activity to start with. You may find that the hip gets painful after sports or walking distances that you used to find no problem. As the osteoarthritis gets worse, you may start to feel pain at rest. You may find that the hip feels like it seizes up if you have been in the same position for a while, such as sat in a chair or when you first get up in the morning. If you are beginning to get pain at rest or that you feel at night in bed, that is a strong indicator that your hip may benefit from treatment. National guidelines say that treatments of hip problems, such as hip replacement, should be considered before you need strong painkillers such as patches or opiates (morphine type painkillers)
Hip arthritis: stiffness
As the arthritis progresses, you may find your hip gets stiff. This can be due to the wear of the cartilage but is also due to spurs of bone forming around the hip and the scarring of the soft tissues that we mentioned earlier. It is rare for patients to experience stiffness with no pain but this can happen and if the stiffness becomes bad enough, this can be an indication that treatment is needed on its own.
Hip arthritis: giving way
True giving way of the hip, such that you fall to the floor, is relatively unusual with hip arthritis. Most of the time when it feels like the hip is giving way, it is due to episodes of pain that come on suddenly, catching you unawares and as your body tries to protect itself, the muscles spasm or you try to take weight off the hip. If there are true “mechanical” symptoms of the hip, where something locks in the joint or it truly gives way, this may be due to loose bodies in the hip or part of the cartilage and/or bone coming away. When it does occur, this is most often part of severe arthritis but may be part of other problems such as avascular necrosis when the blood supply to the bone in the hip joint is damaged or stops working and the hip joint rapidly collapses. In cases such as these, there tends to be severe pain which may require relatively urgent treatment.
Hip arthritis: rheumatoid arthritis
The other main type of arthritis is rheumatoid arthritis. This is a very different kind of hip condition. Rheumatoid arthritis is a type of autoimmune condition where your body’s own immune system attacks the joints causing damage to the cartilage and erosion of bone and soft tissues around the joint. The chances of needing a joint replacement if you have rheumatoid arthritis have decreased a lot over the last few decades as the drug treatments for this condition have improved markedly. If your rheumatoid arthritis has severely affected your hip, or if you have had the condition for a long time, you may end up needing a hip replacement eventually. If you do, it is reassuring to know that despite this being a different condition, excellent results can still be achieved. We may need to alter or temporarily adjust the treatments you take for your rheumatoid arthritis around the time of your surgery. If we do need to alter your medication, we will discuss this with your rheumatologist if needed. Our aim will be to give you the lowest risk of complications such as infection or poor wound healing (which are more common for people with rheumatoid arthritis being treated with medications that affect their immune system) whilst trying to avoid a flare of your rheumatoid arthritis which can be painful and interfere with your rehabilitation.
> Hip cartilage or labral tears
There are two types of cartilage in the hip. The first is the articular cartilage, this is the smooth hard-wearing cartilage that is affected in hip osteoarthritis as we have talked about above. The second is the labrum. This is a different type of cartilage, it is triangular in cross section and attaches to the rim of the acetabulum or cup. It effectively deepens the socket and helps with joint lubrication and stability.
The problem with the location of the labrum is that if the hip is flexed and turned in (internally rotated), then the labrum can be squeezed between the neck of the femur (thigh bone) and the edge of the acetabulum (cup). If this happens suddenly during sports or an accident, it may lead to a large tear or to the labrum being detached from the rim of the cup. This can lead to you feeling a clunking sensation in the hip, instability or more commonly, pain. If the labrum has torn away from the cup, it may need to be reattached. In order to determine if this is the case, you will need to have a special type of scan performed where dye is injected into the hip and an MRI scan is performed.
The other kind of labral teat that can occur, happens when the same kind of problem as above occurs but the labrum is squeezed between the neck of femur and the cup repeatedly. This is termed a degenerative tear. These are more common as you get older and the labrum gets stiffer. The labrum attaches to the articular cartilage in the cup and if it is damaged, can cause the cartilage in the cup to peel away from the bone. It is therefore very important with this kind of problem, to determine if the pain is actually coming from the damage to the labrum or is due to early arthritis. We can find out which is the case by carefully examining your hip and performing the right kind of imaging to determine what is causing your symptoms. If this is not done, there is a high risk that you could undergo treatment but your symptoms not be improved as much as you would have hoped for or that you may need further treatment in the near future.
> Hip impingement
Hip impingement occurs due to a similar mechanism to that described for labral tears above and the two can coexist. The difference in hip impingement is that there is a underlying problem with the shape of the hip joint that leads to the neck of the femur (thigh bone) coming into contact with the edge of the cup.
There are two main reasons this can happen. The first is more often seen in men and is called “Cam” impingement. This is when there is a bump of bone on the top and front of the neck that means that it comes into contact with the labrum and edge of the cup sooner than it normally would. This occurs more commonly in men due to the shape of their hip joint, particularly the head and neck. The other kind of hip impingement occurs when the acetabulum (cup or socket) is deeper than usual. Again, this means that contact occurs between the neck and the labrum or edge of the cup earlier that it otherwise would.
In both of these situations, if this is causing pain and problems, the hip may need treatment which ranges from pain relief and physiotherapy up to surgery.
> Lateral or trochanteric hip pain
If you are experiencing pain or tenderness over the side of the hip, this may be due to problems around the prominent bit of bone you can feel at the side of your hip, roughly at the level of the top of your pocket if you are wearing jeans. This is an important bit of bone and the hip joint as major muscles attach to it that are very important for walking normally and the function of your hip.
If you are experiencing pain over the side of the hip and there is tenderness there, the problem is most likely to be coming from one of two areas. The first is the attachment of the big muscles from the pelvis onto the trochanter at the top of the femur (thigh bone). These tendons can be damaged if your hip is injured and chronic damage can occur as you get older where the tendon is not detached but there are a series of small tears or chronic inflammation in the tendons. This can lead to weakness of the muscles or overlying swelling and inflammation that causes pain. If you actively use the abductor muscles, they lift your leg away from the side of your body. This is not something that you will probably spend much time doing in your normal day, but you do use these muscles every time you take a step. As you take the weight off your opposite leg, these muscles activate to stop your body weight from pulling you down on the opposite side. Effectively they stop you from falling over when you lift the other foot off the ground. If the muscles become weak and you are walking, in order to compensate and prevent yourself from falling over, you will tend to throw your bodyweight back over the bad hip, leading to a typical lurching gait.
The other area where problems typically occur is in the soft tissues overlying the side of the hip. Here there is a thickened band of tissue that muscles attach to. To reduce friction, there is a small fluid filled sack that sits between the thick band of tissue and the side of the bone. Tissue in this area can become irritated, producing more fluid which leads to a vicious circle of injury and irritation. This can sometimes happen at the same time as damage to the muscle tendons as described above, due to prominence of the bone or a band of tissue that is too tight, or it can occur after hip replacement ssurgery.
You may feel that it is tender over the side of your hip. You will probably particularly notice this if you lie on the side of the hip and it often feels like you are lying on something lumpy or irritating. You may also feel an ache over the side of the hip when you have been walking or performing other activity and you may feel that the hip feels weak or tired quite quickly.
> Non-surgical treatments
It is really important to know that not all hip problems will need an operation. If you are experiencing hip pain for the first time, although it is important we determine why the hip is painful, the chances are that once we know the cause, we can treat the hip in ways that do not involve an operation to improve things for you. If these do not work or your symptoms have been present for a while, we may need to consider surgery but part of my aim will be to explain all of the options to you so you can make an informed decision as to which kind of treatment is best for you.
Non-surgical treatments: doing nothing!
The most basic form of non-operative treatment is carrying on as you are! Much as this may sound a bit strange to start with, there are a variety of hip problems that are described as self-limiting. This means that they are problems that you might need to protect for a short while whilst a problem such as a muscle strain improves on its own.
Non-surgical treatments: pain relief medication
During a period of protecting the hip, after a hip injury or in the early phases when a hip begins to become affected by a condition such as arthritis, you may need to take pain relief. Pain relief comes in many forms. The most common type we think of is taking tablets such as paracetamol or anti-inflammatories. Caution should be taken with anti-inflammatories if you suffer from stomach irritation, have a history of bleeding from the stomach or the rest of the bowel, have asthma or problems with your kidneys. If these are not controlling your pain then oral codeine can be added. If this is still not controlling your pain, it is important that other treatments are considered as national treatment guidelines recommend that we do not wait until strong morphine type pain relief is required before considering treatment such as hip replacement.
Anti-inflammatories can also be applied topically, or rubbed into the painful area. These have been shown to be just as effective as taking the tablet varieties but with a lower risk of side effects. This may be in part due to the benefit that comes from massaging the area.
Non-surgical treatments: TENS
Pain is transmitted from painful joints to the brain by nerves. The nerves that carry pain signals have a maximum frequency at which they can transmit signals to the brain. TENS (transcutaneous electrical nerve stimulation) works by applying continuous or pulsed stimulation to the nerves via the skin which reduces the number of pain signals that the nerves transmit. This can be an effective form of treatment and TENS devices are now small, battery powered and can be bought from most pharmacies. They are typically suitable to apply whilst you are at rest but it is difficult to get them to stick or stay in place when you are moving.
Non-surgical treatments: walking aids
You may find that you hip pain is helped by using a walking stick, crutch or other walking aid. If you do use one, then you need to use it in the opposite hand to the side you get pain on, the stick should be used so that it contacts the ground at the same time as the foot of your painful side and the weight shared between the stick and the leg. This leads to less force going through the hip and muscles around the hip, easing the pain experienced. It can also help prevent limping which leads to less load being put through other joints and may help symptoms there too. Even if you would prefer to avoid using a stick, it is worth doing so before going forward for surgery as you will need to use them in the early phases of your recovery so this will be easier if you are already used to them.
Non-surgical treatments: hot and cold packs
You may already have tried applying hot or cold packs to the area and these can often provide some relief. Heat can be particularly effective for the stiffness that develops when the joint remains in the same place for a period of time or is aching. Just be careful to not apply packs or hot water bottles to the area directly to the skin if they are too hot and limit the time the packs are applied for to prevent skin damage. Cold or ice packs can be particularly effective if the joint feels inflamed or sore after activity, Again care should be taken not apply ice directly to the skin, you can wrap it in a towel or similar to prevent this and exposure should be limited to no more than 20 minutes at a time.
Non-surgical treatments: physiotherapy
Physiotherapy is an important part of the treatment of nearly all joint and musculoskeletal problems. The critical factor is the exercises and activity that you perform rather than who supervises the activity. It is perfectly reasonable to perform self-directed exercises in the first instance. Even if you are very active or even usually participate in sports to a high level, physiotherapy can still be of benefit as particular muscle groups may be weak, soft tissues overly tight or joints affected by contractures.
Physiotherapy can help by strengthening muscles that help support and offload joints. It can also help to improve the strength of muscles, such as the abductors of the hip, that help you walk normally and hence decrease the strain on other joints such as the back, other hip and knee. You may find as the muscle strength improves around the joint, that you experience less pain. Although some elements of the stiffness that you may experience can’t be improved with physiotherapy, such as that arising from the bone spurs that form when you have arthritis, tightness of the joint capsule and the muscles around the joint can be improved with exercises and therapy.
Exercises should be commenced even if you think that you will definitely need surgery. The stronger we can make the muscles around the joint, the less likely it is you would need surgery but even if you do end up needing an operation such as hip replacement, it will make your recovery progress more smoothly and rapidly. If you do have an operation, physiotherapy exercises, either self-guided or under the supervision of a physiotherapist, will be a critical part of your treatment and recovery.
Non-surgical treatments: intra-articular injections
We will consider together whether it may be appropriate to consider injections into the affected hip. There are a few different situations where this may be appropriate. If you have problems arising from your back and your hip, they can be a useful way to separate out which is the main cause of your pain or how effective treatment such as joint replacement may be in improving your symptoms given your other problems. There are times when you may have pain due to arthritis in a joint but it may not be the right time for you to consider an operation such as hip replacement to treat this. There may be other important things happening in your life at the same time so that you would prefer to delay definitive treatment or perhaps you are planning on retiring in the next year and are looking for something to tide you over until you do given the recovery period following joint replacement.
Sometimes you may suffer from marked pain, even if there is only early arthritis in the joint. This is because when cartilage breaks down, it causes irritation to the lining of the joint which then becomes inflamed and sore, producing more fluid and leading to a swollen joint. If the arthritis is quite early, it may not be appropriate to have a joint replacement as the symptoms may settle down or the benefits that surgery can offer may not be great enough to make the risks worthwhile. If this is the case for you, an injection can provide relief for a period of time, typically up to 3 months to see if your symptoms will settle. Lastly, you may decide that a hip replacement is too risky for you after we have discussed the benefits and risks of surgery. This may be due to other health problems that you have, making surgery more risky than it would normally be. In such cases, we may be able to improve your pain to a level where the symptoms are acceptable for you with one or more injections.
When injections into the hip are performed, we use local anaesthetic and steroid. This helps reduce the pain and inflammation in the joint. They are considered to be relatively low risk. One of the biggest risks is that they don’t lead to any benefit for you which is the case in about one in three patients. After the injection is performed, the hip may initially feel a bit more sore as additional fluid has been put into the joint and the steroid can be irritant to the joint before its anti-inflammatory effect kicks in. This is one of the reasons that we use local anaesthetic at the same time, to reduce this initial irritation. Any time a joint is penetrated, even when deliberately with an injection such as this, there is a risk of bacteria entering the joint and causing infection. For this reason, we take great care to ensure the injections are done under sterile conditions with the use of ultrasound or x-rays to guide us if needed. The risk of this is very rare and occurs less than one in five thousand cases. There is also a risk of bleeding but we know where the major blood vessels are and avoid these. The risk of bleeding is increased if you take blood thinners and if this is the case, we may need to check your clotting levels before going ahead. If steroid from the injection escapes into the soft tissues just underneath the skin, it can cause a loss of pigment in the skin or dimpling due to atrophy of the fat cells.
It is possible to inject other substances into the joint such as hyaluronic acid, platelet rich plasma or stem cells. All of these are expensive in comparison to local anaesthetic and steroid and have no good evidence of an increased benefit. Indeed, in the case of hyaluronic acid, the risk of adverse effects is higher meaning they should not be considered as a first line injection.
> Hip replacement
Total hip replacement
A hip replacement consists of removing the damaged joint and replacing it with a series of implants that replicate the function of the normal joint. The main aim of a hip replacement is to remove or reduce your pain and to improve your hip function, allowing you to return to the activities your hip has stopped you from carrying out.
In a total hip replacement, the femoral head (the ball of the ball and socket joint) and most of the neck are removed allowing access to the cup. The damaged and abnormal cartilage and bone from the cup is then removed. An implant is then used to replace the cup. The cup can either be uncemented or fixed in place with cement. Which option is most suitable for you depends upon the quality of the bone in your hip, your age and the reasons you are undergoing the operation. We will select the best implants for you with the aim of achieving the most rapid and reliable recovery with the lowest risk of needing redo or revision surgery in the future. My aim is to give you one hip that will do everything you need and last you for as long as you need it to. If the cup is cemented in place, it is all one piece and the inner surface of the cup is made from a very smooth and hard-wearing type of polyethylene. If the cup is uncemented, a press-fit initially holds the cup in place but it is also coated with materials very similar to those that make up your bone so that your bone grows into the cup in the months after the operation, permanently fixing it in place. For this type of cup, a liner is then fixed into place in the cup to make up the bearing surface. This will either be made of highly cross-linked polyethylene or ceramic. Previously metal liners were also used but these had very high failure rates and hence are not used for this kind of hip replacement now.
A cavity is then prepared in the top end if the femur and a stem is fixed into this. Again, the stem can be uncemented or cemented and we will select the stem that has the best chance of leading to excellent hip function and a low risk of revision for you. It is critical that the correct choices are made for the implants that make up your hip replacement as some are associated with higher risks of needing a revision done and certain types can lead to higher risk of problems such as fractures around the stem.
Hip resurfacing is an option that you may have heard about. In this procedure, an uncemented metal one piece cup is fixed into the pelvis and the femoral head reshaped by removing cartilage and bone so that a metal cap can be fitted with a peg that goes down the femoral neck. The head is typically fixed with cement. These were marketed as a hip suitable for young sporty people with the advantage of preserving more bone than total hip replacement. Unfortunately, the data we have available shows that they are associated with higher risks of revision than total hip replacement. There are certain unique circumstances when they may be the most appropriate choice, such as very high risk of dislocation or a very deformed femur that would prevent the insertion of a stem that would normally be used in a total hip replacement, however these are unusual and the increased risks of revision for hip resurfacing need to be carefully balanced against the potential benefits if it is being considered.
There are newer types of hip resurfacing procedure being performed such as ceramic on ceramic and metal on polyethylene resurfacings. The numbers performed to date are very small indeed and I have studied the design philosophies and designs. At the moment, they should still be considered experimental procedures and only performed in well controlled clinical trials in order to prevent the profound and wide spread poor results that were seen with the rapid adoption of metal on metal hip replacement before outcomes were properly known.
> Redo or revision hip replacement
Hip replacements can unfortunately fail. This can lead to pain and other problems with the hip that mean further surgery may be needed. It is very important that we understand the reasons why the hip replacement has failed so that we can plan operations to address these reasons and ensure the best results. My aim is to fully address the problems that you have encountered but not to over complicate the treatment which can lead to a higher risk of problems during or after the operation.
Revision hip replacements are usually bigger procedures than first time hip replacement and there will be more scarring after they are performed. This can mean that recovery will take longer than it did after your first hip replacement. I will always design an operation plan that will get you back to your normal function as soon as possible. In particular, we will try to avoid the need to keep weight off the hip in the recovery period and let you get back to putting full weight on the hip straight away.
What are the benefits and risks of hip replacement?
> Hip replacement - risks/benefits
As described on the hip conditions and hip treatment pages, the intended benefits of surgery and to safely and effectively treat your pain and to restore you back to your normal level of function.
Modern hip implants are made of robust and hard-wearing materials such as ceramic on highly cross-linked polyethylene. This means that will serve you well even under demanding loading conditions such as cycling, running and skiing. It is advised that caution is taken with activities that lead to repetitive forceful unloading (taking the weight off the foot and hip) and loading (putting the body weight forcefully down on the foot) of the hip as these may accelerate the wear of the hip bearing surface. If your preferred activities and sports involved long distance endurance running on hard surfaces (such as tarmac) or competitive mogul skiing, then we can discuss this and select the best option for you.
There are a number of things that will or can happen after your hip replacement that you need to know about before deciding whether surgery is the right thing for you. We will discuss these together when you are deciding whether to have a hip replacement and we will both sign a consent form to say that we have discussed these and that you have had the chance to ask any questions you may have. If we complete the consent form in clinic, we will confirm on the day of surgery that you are happy to proceed and have no further questions.
Scar: you will have a scar over the side of your hip. The length of the scar will depend upon the thickness of the soft tissues and the complexity of your hip replacement. We will use an incision that is long enough to safely perform your operation bit not one that is longer than necessary. The scar may remain tender until the wound and soft tissues are fully healed. If there are any problems with the wound healing (such as fluid discharge from the wound or redness around the wound), it is important that you contact my secretary, or if you are unable to speak to them, the hospital where you had your operation performed so we can review the wound and make sure everything is satisfactory or start any needed treatment.
Bleeding: The risk of injury to a major blood vessel requiring repair during a hip replacement is very small. Most of the bleeding that occurs is from smaller blood vessels and this will be stopped at the time that it occurs during an operation. It is unusual now to need a blood transfusion after a first-time total hip replacement, but your blood levels and symptoms will be checked before your operation and monitored afterwards. If your levels are low before your operation, we may recommend that you have iron supplements or come into hospital to receive an iron transfusion (iron given via a drip) to improve these. You may also need investigations performed to establish why they are low so that this can be treated. We will ensure such factors are optimised before surgery to reduce the risks for you. If the blood levels are a little low after the operation, you may need iron supplements. If they fall further or you develop symptoms related to low blood levels, you may need a blood transfusion. Very rarely, you may need a blood transfusion during your operation, this is more common in revision surgery but still rare. We would only do this if absolutely required. You may develop a haematoma (collection of blood) around the hip or under the skin. If this is large, it may require evacuation although this is rare.
Blood clot formation in the veins or lungs: Blood clots may form in the deep veins at any time but the risk of this happening increase with periods of immobility and when undergoing operations. Your risk will therefore be increased by undergoing hip replacement surgery. We will take steps to reduce the risk of this such as using pumps on your feet and calves during the operation and until you are mobilising, mobilising you as soon as is safe to do so after the operation, by using compression stockings in hospital if these are safe for you (the current national guidance is that these do not need to be continued after you go home), keeping you well hydrated and giving you medication to make blood clots less likely. Medication options include injections of heparin in hospital followed by aspiring after this, tablets such as rivaroxaban or continuing your own medication if you are already on a drug to reduce the risk of clot formation. If a clot does form in the deep veins of the leg, it may go to the lungs and be a serious threat to your health.
Infection: Infection can be a serious complication after joint replacement. Sometimes an infection may only be superficial and relatively simple to treat, requiring antibiotics alone. If the infection is deep and affects the tissues around the joint replacement itself, attempts to treat and cure the infection will involve further surgery. If we catch the infection early, we may be able to treat the infection by removing the infected tissue and replacing the exchangeable parts (such as the head and liner). If the infection is established or has been partially treated for a period of time, surgery usually involves the removal and replacement of all of the implants, a much bigger operation that may need to be done in multiple stages. This is why it is important that you let us know if you have problems with the wound or anyone suggests prescribing antibiotics for infection around the hip. The risk of undergoing revision for deep infection after first time surgery is between 0.4 and 0.7%. It can be higher if you are diabetic, have a high body mass index or other risk factors we will discuss. Following revision surgery, the risk of infection is higher at around 1.6% overall.
Pain: You will have some pain after the operation. Our aim is to keep this to a minimum and certainly to keep it under enough control so that you can mobilise and perform your exercises. It is generally easier to take regular pain relief to try to keep out of pain than it is to get you out of pain so I do recommend taking regular basic pain relief (such as paracetamol, anti-inflammatories and/or codeine) for at least the first couple of weeks after the operation. When you first wake up from the operation, the hip will usually be comfortable as the anaesthetic and local anaesthetic we inject into the wound are still working. If you begin to feel pain and this is increasing, please let the nursing staff know so that your pain relief can be reviewed.
Long-term pain: Around one in ten patients report that they get persistent pain in the longer term after hip replacement. Some of these patients still feel that it was worth having the operation done as the pain is better than it was or because their symptoms have improved in other ways however this is not always the case. Some patients do tell us that they would not have had the operation done if they had known what the result was going to be like. This is why it is critical that we fully explore the nature of your pain and why you are getting it, as well as other potential sources and how much they are contributing to make the risk of this as low as we can.
Dislocation: When we perform your total hip replacement, the head of the implant is smaller than the head it replaces, this is because we also have to fit the cup in. This and the fact that the head and the cup are not attached means that the head can come out of its socket. The risk of this is approximately 2% over the life of the hip replacement. You will be asked to avoid particular positions that increase the risk of this (such as bending you hip up and turning your knee in to get to your foot) and it is important to remove as many trip hazards as you can from your house prior to undergoing surgery as if you fall over before the muscles are healed, the hip may come out of joint. If this does happen, you will need to be seen by a doctor, usually in hospital to have the hip put back in. If this goes on to happen multiple times, revision surgery to stop it happening may be required.
Leg length discrepancy: Nearly all peoples legs are slightly different lengths. If you develop osteoarthritis, it is likely that you will loose length in the affected as the cartilage and bone is worn away. Part of the aim of the operation is to restore your leg lengths, this is achieved by comparing to the other side and checking various landmarks and the soft tissue balance of the hip. It may be necessary to alter your leg length in order to achieve a stable and balanced hip or because you have an issue such as curved spine which can create an apparent difference in the leg lengths. If you have a preference in terms of leg lengths, it is important to tell me about this so we can factor this into the decision-making process. Small differences are generally not noticed but sometimes the difference can be enough that it is noticeable.
Stiffness: Your hip may become stiff after a hip replacement although this is rare. Generally, those at greatest risk are those with a very stiff hip prior to the operation. Hip replacement generally improves range of motion, but this is not guaranteed. Very rarely, patients form bone in the soft tissues and muscles (heterotopic ossification) after surgery or injury and this can occur after hip replacement. If this has happened to you before, there may be steps we need to undertake to reduce the risk. If it does happen to you and it makes the hip very stiff, an operation to excise the bone may be required.
Numbness: Nearly all patients will experience some numbness after a total hip replacement. This will be felt along the scar itself. Initially there may be a patch of numbness around the scar, but this improves over the first few months after the operation and generally fully resolves. There can be numbness caused by bruising to, swelling around, or damage to one of the large nerves that travels past the hip as described below.
Nerve injury: There are large nerves that travel past the hip that are close to where the operation takes place. These include the sciatic, femoral and obturator nerves. If there is an injury to a major nerve, it can cause numbness further down the leg or weakness of muscles (e.g. the muscles that pull up your ankle in the case of the sciatic nerve or the muscles in the front of the thigh in the case of the femoral nerve). If there is bruising or swelling, this normally resolves within a few months of surgery, but you may need to wear a splint for your ankle to stop you tripping. The chances of nerve injury are less than 1% but are increased by factors such as having had previous hip surgery, scarring and severe deformity. Direct injury to the nerve is very rare, if this does occur, surgical exploration or operations to repair the nerve or transplant tendons may be required.
Fracture: When your bones are being prepared during the operation or implants inserted, there is a risk of fracture of the bones. The type of operation that is performed for you will take account of these risks and implants that minimise this risk for you will be selected. If a fracture like this does occur during your operation, it will either be fixed, or we will switch to other implants to bypass the fracture. The aim will be to perform an operation that allows you to fully weightbear straight away. Fractures around hip replacements can also occur in the years after surgery, typically if you have a fall or other form of trauma. If this does occur, revision surgery may be required to address this. The risk of a fracture occurring is less than 1%.
Adverse reaction to debris: All types of joint replacements will produce debris of one kind or another. This can either due to wear of the bearing surfaces themselves or due to corrosion or wear from modular junctions where implants are fixed together. Some of the materials released can cause problems such as soft tissue destruction and may have effects on remote organs, such as was the case with metal debris released from metal on metal hip replacements. If soft tissue damage is severe, this can lead to late problems with dislocation. Reaction to debris can also need to the lead for revision. With the kind of implants that I use, the risks of this are very low.
Wear and loosening: As time goes on, bearing materials will wear and implants that are fixed to bone may become loose. These are the most common reasons for revision of hip replacements in the long term. Over 95% of total hip replacements will last for 10 years or more and 58% will last for 25 years or more.
What will undergoing total hip replacement involve?
> The process
Prior to surgery
We will discuss all aspects of your operation in clinic prior to you deciding whether you want to go ahead with surgery. If any further questions come up, you will be able to contact me via my secretary so these can be addressed and we can always change the treatment plan if you have any doubts.
You will be seen in the preoperative assessment clinic where our nursing staff will carry out a detailed assessment. Any necessary investigations that you need prior to surgery such as blood tests, heart traces and x-rays will be performed. You will be advised which of your medications to take up until the day of surgery, any you need to stop in advance (such as HRT and blood thinners) and which ones if any you should take on the day of surgery. If necessary, you will also see an anaesthetist if there are any elements of your medical history that put you an increased risk of problems at the time of or after surgery.
You will also be assessed by occupational and physiotherapy to commence preparation for your postoperative period and rehabilitation. You may be asked to fill in some forms to aid this process and you may need to take some measurements of furniture in your home to complete these.
My secretary will be in touch to provide you with the details you need to know for admission. You will be told where to report to and what time to be here. On the day of your hip replacement, you will be asked to not eat food or drink anything other than clear fluids for at least 6 hours before your operation. You may carry on drinking clear fluids up until 2 hours before the operation. Avoid using chewing gum for 6 hours before the operation.
From reception, you will be shown up to the ward, admitted to your room and you will meet the nursing staff and physiotherapist who will be caring for you. You will also see both myself and my anaesthetist on the ward. I will confirm your consent with you and answer any further questions you may have. My anaesthetist will describe the anaesthetic options to you and discuss with you which would be the best option for you. Any additional interventions that may be needed, such as a catheter, will also be discussed.
After all of the above has occurred and paperwork been completed, you will be taken down to the anaesthetic room adjacent to the operating theatre. Here you will be met by the anaesthetic team and your anaesthetic performed.
Following your anaesthetic, you will be transferred to the operating theatre. We will then move you across to the operating table and turn you so that you are lying on your side with the affected hip uppermost. We will then prepare you for surgery and perform the operation.
Once the operation has been performed and the wound closed, you will be turned onto your back, transferred across to your bed and your legs supported with a wedge-shaped pillow until your anaesthetic wears off. You will then be taken round to the recovery area where you will be monitored one to one by a member of the nursing staff until you are recovered from surgery and safe to return to the ward.
Once back on the ward, your pain and recovery will be closely monitored by the nursing staff. Please let them know if you feel you are in pain and they will review your pain relief. Once you have recovered from the after-effects of the anaesthetic, you will be mobilised by the ward staff. You can begin performing exercises in bed before you first get up. You can exercise your ankle, knee and hip. Try to avoid twisting the hip at this stage. You will initially learn to transfer to the chair and you will practice walking with a zimmer frame before progressing to walking sticks or crutches. Once you have mastered these, the physiotherapists will teach you how to safely climb and descend stairs.
When you have achieved your rehabilitation targets and medically you are stable with your pain under control, you will be safe to be discharged home or to where you have arranged to go for the postoperative period. You can stop using the compression stockings at this point, unless specifically advised otherwise by myself.
Fit note for work
If you do require a note for your employer, please let us know whilst on the ward prior to discharge so this can be completed for you. If you subsequently find that you need one after discharge, please contact my secretary and one can be completed and posted to you or given to you at your next clinic appointment.
If you have a fit note for work, you do not need to be signed “back on to work” at the end of this. If your employer requests this, please direct them to the advice available from the DWP here: https://www.gov.uk/government/publications/fit-note-guidance-for-employers-and-line-managers
Before leaving the ward you will be given a follow up appointment in the outpatient department at 2 week for a wound check by the nursing staff or advised to contact your practice to arrange a wound review with the practice nurse.
There are no sutures or clips to be removed so at the wound check, the dressing will be removed along with some small steri-strips that will be under the dressing. It is usual to then give you a further temporary dressing for the wound that can stay in place for a couple of days before being removed.
Your first outpatient appointment with me will be at either 6 weeks or 3 months. You will have an x-ray performed and we will check on the progress of your hip.
You will be followed up until at least a year after the operation is done, in accordance with the guidance issued by the national specialist societies.
Return to driving
The DVLA advise that in order to return to driving, you must be confident that you are able to fully control the vehicle.