Hip Replacement Surgery
About Hip Replacement Surgery
Millions of people around the world are affected by arthritis. Osteoarthritis, the most common type, is ranked the fifth among all forms of disability worldwide and the majority suffer from hip and/or knee osteoarthritis. A number of treatments are available to help manage the symptoms of arthritis, but there is no cure.
Hip replacement surgery is a common procedure and is available worldwide. While joint replacement surgery can be a daunting prospect, it offers a welcome relief from pain and, for many, the ability to return to a normal life. This series of short articles provides an overview of arthritis, including how to determine whether or not you have it, what treatment options may be available to you and how to go about getting the right treatment.
What is Arthritis?
Hip Pain and Arthritis
Hip pain or pain around the hip can be short-lived (acute) or persistent (chronic). Joint pain results from tissue damage and when it is persistent, it could be a sign of long-term damage sustained in an injury or by an underlying problem within the joint.
Arthritis, which means ‘inflammation within a joint’, is the most common cause of chronic knee pain. Arthritis can affect people of all ages, sexes and races but occurs more frequently as people get older. Over a third of the population over the age of 50 has arthritis pain that interferes with their normal activities1. Although the word is widely used to describe pain, swelling or stiffness in a joint, there are many types of arthritis which can be caused by inflammatory, mechanical or degenerative conditions.
Osteoarthritis
Osteoarthritis is the most common type of arthritis. It is a condition where the smooth and lubricated cartilage that protects the ends of the bones becomes worn or damaged. Cartilage can become thin and rough and in response to the damage the joint can develop bony spurs. This causes pain, swelling and can restrict movement in the hip (stiffness) or cause problems walking. It is not known what causes osteoarthritis, but several factors are thought to increase the risk of developing it:
- previous injury,
- getting older,
- being overweight (obese),
- certain hereditary factors,
- other health conditions such as rheumatoid arthritis or gout.
Along with knee osteoarthritis, hip osteoarthritis is one of the leading causes of global disability2.
Rheumatoid Arthritis
Rheumatoid arthritis is a disease where the body’s immune system attacks the joints causing pain, swelling and stiffness. In addition to joint problems, rheumatoid arthritis can affect other parts of the body such as the lungs and kidneys and cause symptoms such as:
- tiredness,
- fever,
- weight loss,
- loss of appetite.
Other Types of Arthritis
Chronic hip pain can also be due to:
- haemophilia,
- bone growth disorders (dysplasia),
- blood supply problems (avascular necrosis),
- previous injury,
- gout (less common in the hip than foot and knee joints),
- joint or bone deformities in the knee, hip or spine.
What is Hip Replacement Surgery
Treatments for Arthritis
Unfortunately for many types of arthritis, including the most common types osteoarthritis and rheumatoid arthritis, there is no known cure. However, if you are diagnosed with hip arthritis, there are a number of treatment options depending on its severity, impact and type.
Arthritis differs from person to person but a lot can be done to enable you maintain a normal active life. Depending on your circumstances, the right treatment options may help relieve the symptoms of your arthritis or help minimise its progression. It is common to be prescribed or recommended to follow more than one option.
Drug therapies may be suitable to treat the symptoms of your arthritis such as pain (analgesics or painkillers), to suppress inflammation (anti-inflammatory drugs) or to inhibit some forms of inflammatory arthritis (disease-modifying anti-rheumatic drugs).
Physical therapies may include physiotherapy or light-exercise options such as hydrotherapy to restore or maintain function. Occupational therapy may help you to work with your arthritis and continue to achieve the activities that you need or want to maintain.
You may also be able to discuss lifestyle options including appropriate levels of activity including leisure and work activities, weight loss or even types of food that may trigger increased symptoms or arthritis.
If your arthritis becomes severe enough that despite these treatments it becomes too difficult to get on with everyday life or your pain is no longer sufficiently managed, surgery may be recommended.
What Is A Joint Replacement?
Joint replacement is the term used for surgically removing diseased or worn out bearing material in the body known as cartilage. The purpose of a joint replacement aims to remove the pain and allow a patient to return to their normal active function.
The bearing surface is replaced with a combination of metal, ceramic and/or plastic components. These components form an implant that work with the natural tissue around the joint to hold it together.
An implant is placed within the joint to provide an articulating interface for two bones that rub together, when the two bones rub together this is where a patient will start to feel in pain this can commonly be known as ‘bone on bone’. Over time the pain will worsen which will eventually have an impact on the patients’ health; they will find that everyday tasks such as climbing the stairs will become a painful experience.
Types of Hip Replacement Surgery
A total hip replacement (THR) is where both sides of your hip joint are replaced. Your hip surgeon removes damaged cartilage from the hip socket and replaces it with a new bearing surface. Your surgeon then removes the top portion of the thighbone and replaces it with an artificial hip usually made of a metal stem that is inserted into the cavity in the thighbone and has a peg on which a ball-shaped bearing is placed to articulate with the new socket. All components are made with particular metal alloys, ceramics or high-grade plastics that are proven to work in the human body.
An alternative to standard total hip replacement is hip resurfacing. This operation also replaces both sides of your hip joint; however, much like a knee replacement, only the worn cartilage is removed from both sides of the hip. Instead of removing the top portion of the thighbone and replacing it with a stem, this type of hip replacement uses the existing top (neck) of the healthy thighbone. Although this type of hip surgery removes less bone and does not require a stem to replace the top of the thighbone, it uses a larger bearing (closer to the size of your natural hip bearing) and requires a similar size of incision to a total hip replacement. Hip resurfacing delays and may avoid the need for total hip replacement.
Your hip specialist will help you to decide on which type of knee replacement surgery is right for you.
Implants: What Are They?
The main job of an implant is to provide an articulating surface. They are designed to work with the natural tissue, reproduce a motion that feels normal to the patient, and last for as long as possible. More innovative designs may enable patients to return to a normal level of pain-free activity without their hip joint wearing out too soon.
Implants: What Are They Made From?
Implants are usually two or more components which work together to make an implant. The components are made of implantable grade metal alloys, ceramics or high-density polyethylene.
All materials used to make up a device have been tried and tested, which have been proven to work well in the human body.
Benefits of Hip Replacement Surgery
Living with Arthritis
Common arthritic joint symptoms include swelling, pain, stiffness and decreased range of motion. Symptoms may come and go. They can be mild, moderate or severe. They may stay about the same for years, but may progress or get worse over time. Severe arthritis can result in chronic pain, inability to do daily activities and make it difficult to walk or climb stairs. Arthritis can cause permanent joint changes which may be visible, but often the damage can only be seen on X-ray.
The Burden of Arthritis
Chronic arthritis is life limiting. The majority of people with arthritis experience pain most days, which seriously affects their quality of life. Arthritis limits movement and a quarter of people living with osteoarthritis cannot do normal activities because of their arthritis. This can have an impact on the ability to work, sleep and exercise and increases the risk of depression, cardiovascular disease, diabetes, hypertension and other health conditions.
Statistics available for individual countries all agree that the impact of arthritis costs millions of pounds: to sufferers of arthritis, due to their ability to work or through early retirement; to healthcare systems, including costs of treatment for arthritis and associated co-morbidities (additional conditions associated with symptoms and impact of the arthritis); and to the wider economy, for example costs of reduced work productivity and sickness absence from work.
The Value of Joint Replacement Surgery
Considering the lifetime direct and indirect costs of this chronic disease the true economic burden of chronic arthritis is underestimated, but the benefits of providing joint replacement surgery to the many thousands that require it far outweigh the cost of surgery.
For the individual sufferers of chronic arthritis, successful joint replacement provides a new lease of life. Following a relatively short recovery period and ongoing adherence to physiotherapy, patients can return to normal, pain-free, independent, active life, often including sports. A renewed ability to manage one’s own health and wellbeing brings life-extending benefits. The vast majority of patients do not require further treatment for the condition for many years and many do not require further treatment in their lifetime.
Do I Need A New Hip?
Diagnosing Arthritis
We commonly experience aches and pains in our muscles and joints, but when symptoms persist for more than a few days it is important to consult your doctor soon. In most cases, the sooner a treatment begins the more effective it will be.
Arthritis in the hip can be difficult to diagnose at first because the pain may be difficult to pinpoint and it may be felt in the backside, groin, thigh or even knee, but there are some usual recognisable symptoms. Common symptoms include a stiff hip joint after a period of inactivity, pain, swelling or tenderness in the hip, difficulty in flexing the hip enough to put on your socks for example, or a sound or feeling of grinding or crunching when you move your hip
You should seek advice from a healthcare professional if:
- you experience aches and pains in your joint(s) that are not related to an injury and do not ease after a few days, or aches and pains in your joint(s) that persist long after an injury;
- if a joint becomes swollen and stiff especially if not related to an injury;
- if you are unable to perform daily tasks because of aches and pains in your muscles or joints.
Before diagnosing arthritis, your doctor will ask you about your symptoms and how they developed. They will examine you, and may arrange for tests to be done such as request a blood test or x-rays. Hip arthritis is usually confirmed when an x-ray shows characteristic features of a reduced gap between the hip ball and socket and bony growths around the joint.
When Surgery is Recommended
Many people do not require surgery for many years if at all and not everyone who has hip arthritis needs a hip replacement. For many people the symptoms of arthritis subside or remain sufficiently mild with infrequent flare-ups for periods or many years without severely impacting on quality of life. Many people do not experience arthritis until late in life or can reduce symptoms or slow the disease sufficiently that further treatment options are not required. However hip replacement surgery is an option when alternative treatments have been exhausted.
Hip replacement surgery is likely to be offered to you if:
- you have severe pain, swelling and stiffness in your hip joint and you have reduced mobility,
- pain has reduced your quality of life and affects your sleep,
- everyday tasks have become difficult or impossible,
- you feel depressed because of your pain and lack of mobility,
- your hip means you are unable to work or have a normal social life.
What Are My Options?
There Are Differences in Hip Replacement Designs and Providers
Like all common and familiar product categories, there are different makes and designs of hip implant and there are differences in how well they work. Success can also depend on the quality of service provided and how experienced a surgeon is in using a particular product.
Although the cost of an implant is relatively small compared to the cost of surgery, state funded and private healthcare systems usually select implants based on financial and logistical concerns and implants available from large companies that can offer bundled deals and one-stop supply. Even surgeons have less say in what implants they use than in the past. This makes it quite reasonable to believe that the best implant for you – the one that is most likely to give you what you want – might not be the one offered to you by the first surgeon or hospital that you are sent to.
You Have The Right To Choose
If you are diagnosed with hip arthritis and recommended to have hip replacement surgery, it is important to understand that you have the right to choose your implant, surgeon and hospital – regardless of how your treatment is funded. The implant is going to be yours for what should be a long time, so making good decisions early is important.
How To Choose
You are more likely to make your decision based on how well other patients have returned to normal life, how satisfied they are with their hip replacement and how many have lasted for many years than your surgeon or hospital. So the first thing to decide is what implant you want; then find out the best surgeon or hospital to get it fitted. This does mean doing some research, but with the availability and easy access to good information it can be quite straightforward.
Many countries now have a National Registers of joint replacements. Independent organisations also provide ratings for implants based on the quality and amount of clinical evidence for their performance. These sources usually provide information on how many patients require further treatment in the years after surgery – a fundamental but important measure of performance. National Registers may also report on the performance of individual hospitals or surgeons and may show how experienced they are and how often they perform hip surgery.
Journal articles are often available on the internet free of charge and can provide comparative information including measures for pain, function and activity based on studying groups of patients. Even when not available without charge, synopses (abstracts) are usually provided and results of studies may be referred to in other articles.
Information on manufacturer’s websites can also be evaluated for factual versus marketing content. Do the marketing claims make sense to you? Do they provide evidence? How well do they relate to what you think is important?
Forums, blogs, YouTube videos and social media posts also include feedback from other patients who have received hip replacement or hip resurfacing surgery.
Don’t be put off by the wealth of information available. We discuss how to navigate these sources of information and what they mean in ‘How Success is Measured’ on this website.
What to do next
Once you have decided on your hip implant, you can request to be treated by a knee surgeon of your choice. Most surgeons will only operate at one or two hospitals – many work for the NHS and also have a private practice. When deciding, look at the success rate of the surgeon and the hospital. After all, it is not just about the surgery – aftercare, such as physiotherapy, provided by the hospital is critical in the overall success of the procedure. It’s best to select a specialist who has good experience with your choice of knee implant. An example of how to do this in the UK is to visit the NJR Surgeon and Hospital profile website: http://www.njrsurgeonhospitalprofile.org.uk.
The Power of Informed Choice
The idea of being operated on can be a daunting prospect for most people so it is easy to understand why some people may not want to consider all aspects of it. Having a hip replacement is a major decision and one that you should be fully involved with. Rather like buying a car or phone, you may not fully understand all the technology involved, but you tend to know what you want it to do. It’s the same with new hip implants. The factors that healthcare systems prioritise when deciding what treatment options to offer may not be the same as your priorities. If you leave the decision to others, you might not hear about options that you would think are best for you and you might not even be offered one of the better performing devices – if only you had known beforehand! With some research you may be surprised at what you learn.
With the right information, you can take control of your disease and get the best treatment for you. By fully understanding your options, being able to assess them for yourself and being a part of the decision making process, you are more likely to receive a treatment option consistent with your values. As a result you are more likely to be happy with the outcome of your surgery.
Questions to Ask Your GP
The next step is to talk to your GP. It is important to have a frank and open conversation with them about what you want to achieve with your knee replacement. It may be a good idea to take a short written list of questions with you to your GP consultation.
Ask your GP about their experience with other patients who have had hip implants. They may be able to help guide your research or, if you have done some research already, they may be able to comment on your findings including manufacturer’s marketing claims.
In some countries, you will need to request a referral from your GP before you see a knee specialist. Your GP can also assist you in finding the best available specialist hip surgeon and set up a consultation. Ask your GP which knee surgeon and hospital they would recommend and why. Does the surgeon perform total hip replacement or hip resurfacing surgery regularly? Surgeons may get better results from devices and techniques that they are experienced in using.
Does the surgeon use the device that you would like to receive? Orthopaedic surgeons will usually be more experienced in using one or two devices, a small percentage of what is actively available on the market. By only speaking to one surgeon you are seriously limiting your options over the device you receive. Liken this to going to a Ford car showroom, not realising if you had done some research, you might actually be happier with a Jaguar. The ford dealer won’t offer you that!
You can also talk to your GP about whether to have your hip replacement surgery done privately or within your state healthcare system – for example the NHS.
When you meet the surgeon, tell them what is important to you and what you would like. Are they happy to discuss their results with you? Remember that you do not have to accept what one surgeon tells you and are free to talk to more than one surgeon. It may be that you need to shop around to get the implant you want.