Arthritis of the Hip - Total Hip Replacement (Arthroplasty) and Other Treatments at HSS


Edwin P. Su, MD

Assistant Attending Orthopedic Surgeon, Hospital for Special Surgery

  1. Hip/Knee and Surgical Arthritis Services
  2. The Hip Joint
  3. Arthritis of the Hip
  4. Treatment
  5. Total Hip Replacement
  6. Frequently Asked Questions

Hip/Knee and Surgical Arthritis Services

The Hip/Knee and Surgical Arthritis Services are teams of orthopaedic surgeons, nurses, and physiotherapists dedicated to the treatment of adult patients with disorders of the hip and knee. Such conditions include cartilage damage, meniscal tears, ligament injuries, bursitis, and arthritis.

Each of the orthopaedic surgeons on the Hip/Knee and Surgical Arthritis Services has undergone extensive specialty training in this field. They utilize years of experience, cutting edge technology and proven surgical techniques to maximize patient results.

Over 4000 procedures are performed yearly at the Hospital for Special Surgery by the surgeons of the Hip and Knee service. Their familiarity with all types of disorders of the hip and knee allows them to effectively treat problems with fewer complications.

If you have a problem pertaining to the hip or knee, make an appointment to see one of our hip and knee physicians. They will formulate an individualized plan combining physical therapy, medications, and/or surgical treatment to remedy your problem.

The Hip Joint

The hip joint is a ball and socket joint made up of the femur (ball) and the acetabulum (socket).


Illustration of hip joint

The ends of the bone are covered with a smooth, glistening layer called articular cartilage. The articular cartilage is what allows the bones to glide smoothly with less resistance than ice sliding on ice. The articular cartilage can be seen on x-ray as the space in between the ball and the socket.


X-ray of hip joint

The geometry of the hip joint allows for a large range of motion, and the hip is by nature a very stable joint because of the large contact area between the femur and acetabulum. In addition, there is a special cartilage surrounding the hip joint called the labrum, which also contributes to stability.

Arthritis of the Hip

Arthritis of the hip is a condition in which there is loss of the articular cartilage of the femoral head and acetabulum. This can be seen on x-ray as a loss of the space between the two ends of bone.


X-Ray of Arthrtic Hip

Because of the loss of the gliding surfaces of the bone, people with arthritis may feel as though their hip is stiff and their motion is limited. Sometimes people actually feel a catching or clicking within the hip. Generally, loading the hip joint with activities such as walking long distances, standing for long periods of time, or climbing stairs makes arthritis pain worse. The pain is usually felt in the groin, but also may be felt on the side of the hip, the buttock, and occasionally into the knee.

Arthritis of the hip usually occurs in people as they enter their 60ís-70ís, but this is variable depending upon factors such as weight, activity level, and hip anatomy. Arthritis may be caused by a variety of factors, including simple wear and tear, inflammatory disorders such as lupus or rheumatoid arthritis, infections, and trauma. The end result of all these processes is a loss of the cartilage of the hip joint, leading to bone rubbing against bone.

Another cause of hip arthritis in younger patients is femoroacetabular impingement, in which abnormal anatomy leads to premature cartilage deterioration.

Treatment

Depending upon the severity of arthritis and the patientís age, hip arthritis may be managed in a number of different ways. Treatment may consist of non-operative or operative methods, or a combination of both.

Non-operative

The first line of treatment of hip arthritis includes activity modification, anti-inflammatory medication, hip injections, and weight loss. Giving up activities that make the pain worse may make this condition bearable for some people. Anti-inflammatory medications such as ibuprofen,naprosyn and the newer Cox-2 inhibitors help alleviate the inflammation that may be contributing to the pain. Furthermore, studies have shown that walking with a cane in your opposite hand significantly decreases the forces across the hip joint. Finally, weight loss helps decrease the force that goes across the hip joint.

A combination of these non-operative measures may help ease the pain and disability caused by hip arthritis.

Operative

If the non-operative methods have failed to make your condition bearable, surgery may be the best option to treat hip arthritis. The exact type of surgery depends upon your age, anatomy, and underlying condition. Some examples of surgical options to treat arthritis include an osteotomy, which consists of cutting the bone to realign the joint; total hip replacement, and hip resurfacing.


X-Ray of THA

An osteotomy is a good alternative if the patient is young and the arthritis is limited to a small area of the hip joint. It allows the surgeon to rotate the arthritic bone away from the hip joint, placing weightbearing on relatively uninvolved portions of the ball and socket. The advantage of this type of surgery is that the patientís own hip joint is retained and could potentially provide many years of pain relief without the disadvantages of a prosthetic hip. The disadvantages include a longer course of rehabilitation and the possibility that arthritis could develop in the newly aligned hip.


Hip implant

Hip replacement surgery involves cutting away the arthritic bone and inserting a prosthetic joint. Both the arthritic ball and socket are replaced, usually with a metal ball and a plastic socket. The ball is placed upon a stem that is implanted within the femur (thigh bone), with or without cement. The socket is inserted within the native acetabulum after removing the arthritic surface.


Implant in hip

Total Hip Replacement

History

Total hip replacement surgery has evolved over the years into a reliable and effective way to relieve disabling pain and allow patients to resume their active lives. Many of the advances in total hip replacement surgery were pioneered by Sir John Charnley, a British orthopaedist, in the early 1960ís.

Dr. Charnleyís great contributions to this procedure include creating the first low-friction total hip arthroplasty by replacing the arthritic hip joint with a metal ball and polyethylene plastic socket. He fixed the prosthesis to the bone with polymethylmethacralate cement, which acted as a grouting to bond the implant to the native bone. Today, many of his principles form the foundation of modern total hip replacement surgery. Many patients who have had their hip replaced using Dr. Charnleyís technique still have a functioning prosthesis after over 30 years. The surgeons of the Hip and Knee service utilize the surgical techniques of Sir John Charnley as the foundation of modern total hip replacement surgery, along with modern modifications designed to make the implants last longer. Today, approximately 150,000 total hip replacements are performed annually in the United States.

Decision to have surgery

People often wonder when and why they should have their hip replaced. This is an individualized question that depends upon a personís activity level and functional needs. Many people with arthritis live with pain that prevents them from participating in activities that they love, or pain that interferes with their sleep; others are so debilitated that they have difficult putting on their shoes and socks. Total hip replacement offers a solution to the problem of arthritis and is performed with the goal of pain relief and resumption of activity. A consensus statement by the National Institutes of Health stated "total hip replacement (THR) is one of the most successful surgical procedures and provides immediate and substantial improvement in a patient's pain, mobility, and quality of life. Compared to treatments for other chronic debilitating diseases, THR is highly cost effective" (1994).

A total hip replacement is considered a major operation, and the decision to undergo total hip replacement is not a trivial one. People usually decide to undergo surgery when they feel they can no longer live with the pain of their arthritis.

The prosthetic implant

The implant for a total hip replacement is composed of 3 parts: the stem, the ball, and the socket. The stem is made out of metal, usually cobalt-chrome or titanium, and is placed within the native thighbone. The ball is usually made out of polished metal or ceramic, and fits on top of the stem. The socket is usually a combination of a plastic liner and a cobalt-chrome or titanium backing. All together, the components weigh about 1 to 2 lbs. They are fixed to the bone either with bone-ingrowth surfaces or with cement.

There are alternative materials to metal and plastic, namely ceramic-on-ceramic, and metal-on-metal. Each of these material combinations has advantages and disadvantages; learn more about each of these bearing materials by reading our piece on implant bearing surface materials.

The procedure

The total hip replacement is performed in an operating room with a special laminar airflow system, which helps reduce the chance of infection. Your surgeon will be wearing a "spacesuit", also designed to reduce the chance of infection. The entire surgical team will consist of your surgeon, two to three assistants, and a scrub nurse.

The anesthesia for a total hip replacement is given through an epidural catheter, which is a small tube inserted into the back. This is the same type of anesthesia given to women in labor. You will be made numb from the waist down so that you will not feel anything. The catheter stays in for 1-2 days after the surgery to help with your post-operative pain control. During the course of the operation, you can be as awake or as sleepy as you want to be. For more information regarding anesthesia for hip surgery, read our article entitled Your Total Hip Replacement at HSS: What to Expect.

After the epidural block is administered, you will be placed on your side. The incision for a total hip replacement is made along the side of your hip. The incision will measure anywhere from 4 to 10 inches, depending upon your anatomy. It is well-covered by undergarments and is usually not visible when wearing clothes.

The arthritic ball and socket are exposed and removed with power instruments. The bone is prepared to receive the artificial hip joint, and then the prosthesis is inserted. During the closure, two drains may be inserted around the operated area to assist with the evacuation of blood. A combination of staples and/or sutures are used to close the skin.

The entire operation will take from 1 to 2 hours. Afterwards, you will be brought to the recovery room, where your blood work will be checked, and an x-ray of your new hip will be taken. Most patients can be brought to a regular room within a few hours; others will need to stay overnight in the recovery room, as determined by your surgeon and anesthesiologist. Patients generally stay in the hospital for 3 to 4 days following total hip replacement surgery. Younger, more fit patients may be able to leave within 48 hours of surgery if deemed safe by our doctors and therapists. 

Learn more about our Fast Track program here.

Risks

Some of the risks of the surgical procedure include the loss of blood, formation of a clot in your leg, and the chance of infection. The overall incidence of these risks is very small. They should be discussed with your surgeon prior to proceeding with the operation.

Some of the risks of having a prosthetic hip include:

  • The chance that the ball will dislocate (come out of the socket)
  • The parts may loosen or wear out over time
  • The prosthesis may become infected

Again, these issues will be discussed with you by your surgeon.

Longevity

A total hip replacement has a lifespan much like anything with mechanical parts. Its longevity depends upon a variety of factors, including:

  • Patient weight
  • Patient activity
  • The mechanical properties of the prosthesis

The question of how long a prosthesis will last has been studied in detail over the years. Current studies indicated that about 80% of prostheses will function well for 20 years.

New developments

Many new developments are occurring in the area of hip surgery. The Hip and Knee service is comprised of world-renowned surgeons who have made countless contributions to the advancement of the field. A few of the areas of interest include:

  • The use of a special radiographic technique to assess stability and wear of the prosthesis
  • Examining the soft tissue structures after surgery with ultrasound to assess healing
  • Prevention of deep vein thrombosis after hip replacement surgery

The Hip/Knee and Surgical Arthritis services have numerous physicians who specialize in total hip replacement. For more information, click on the links to their biographical sketches.

Pre-operative orientation

Some patients will be asked to donate a pint of their own blood in the weeks preceding hip replacement surgery. This helps reduce the need for a blood transfusion from our blood bank. Almost all of the patients will receive the donated blood as a transfusion after surgery. Rarely, an additional transfusion is necessary from our blood bank. The blood from the blood bank is carefully screened to the best of our ability to detect any infectious diseases.

You will be asked to see a medical doctor at HSS prior to your surgery. This is a precaution to make certain that you are healthy enough to undergo hip replacement surgery. In the course of this workup, you may be asked to have additional testing to examine your heart and lung function. After your surgery, this medical doctor will see you in the hospital.

Post-operative course

Immediately after total hip replacement surgery, you will be in the recovery room. Most patients are able to go to a regular room after a few hours, when the sensation returns in your legs. You will be given a pain pump connected to your epidural catheter which will allow you to control when you are given pain medicine. Most people are quite comfortable with the pain pump in place.

On the day of surgery, you may do some of the exercises as instructed by your physical therapist, including buttock clenches and moving the feet up and down. You will be allowed to take some ice chips after surgery to wet your mouth, but drinking liquids or eating may cause you to become nauseated. You will have a catheter in your bladder so that you do not have to worry about urinating. Once you regain the movement in your feet, you may be allowed to sit up, stand, and take a few steps with the assistance of a walker and a therapist.

The first day after surgery will be an active one, designed to help you get more mobile. You will meet our physiotherapists, who will instruct you in more exercises to perform while in bed. In addition, they will help you stand and take a few steps with a walker. You will be taught the positions to avoid with a hip replacement, as well as the safe positions. Generally, you will be allowed to drink clear liquids.

In the next few days, you will find it easier and easier to move about. You will be freed up from the pain and urinary catheters. Pain medication will be given in the form of tablets. Eventually you will progress to walking with a cane or crutches. On the second day after surgery, if your bowels have shown evidence of recovery, you will be allowed to eat regular food.

Depending upon your age, pre-operative physical condition, and insurance coverage, you may be a candidate for short-term placement in a rehabilitation facility. Otherwise, you will be discharged home and a physiotherapist will come to your house to continue rehabilitation. A case manager will discuss these options with you and help you plan for your eventual return home.

Your return to activity will be guided by your surgeon and therapists. Generally, patients are able to walk as much as they want by six weeks post-operatively. Patients are able to resume driving at six weeks. At eight weeks, patients are able to resume playing golf and swimming; at 12 weeks, they may play tennis. Your surgeon will help you decide what activities you may resume.

Frequently Asked Questions

Q: What is arthritis and what causes it?

A: Arthritis is an umbrella term for a number of disease entities in which the joints become inflamed and the cartilage that lines the bones deteriorates. Eventually, bone on bone wear occurs. As the disease progresses, patients often experience pain, stiffness, and disability. The vast majority of people diagnosed have osteoarthritis and in most cases the cause of their condition cannot be identified. One or more joints may be affected. Rheumatoid arthritis (and other forms of inflammatory arthritis) is a disease that affects the entire system and multiple joints. This type of arthritis is an autoimmune disorder in which the body perceives the cartilage to be a foreign substance and attacks it.

Q: If I have arthritis in one hip, will I get it in the other?

A: If you have been diagnosed with osteoarthritis, having an affected hip does not mean that you will develop arthritis in the opposite hip. In contrast, patients with rheumatoid arthritis often develop problems in both hips.

Q: Can I have joint replacement on both hips at the same time?

A: Yes, healthy patients younger than 75 years old, with no cardiopulmonary disease, may be candidates for such surgery. Your orthopaedist can tell you more about what is involved.

Q: What is a prosthetic hip made of?

A: The implant for a total hip replacement is composed of 3 parts: the stem, the ball, and the socket. The stem is made out of metal, usually cobalt-chrome or titanium, and is placed within the native thighbone. The ball is usually made out of polished metal or ceramic, and fits on top of the stem. The socket is usually a combination of a plastic liner and a cobalt-chrome or titanium backing. A more detailed discussion of materials can be found by reading our piece on implant bearing surface materials.

Q: Will my new hip set off the metal detector at the airport?

A: While hip implants generally do not set off metal detectors, more sensitive machines may register the presence of the implant. Some physicians give their patients cards to show at the airport that explain that the bearer has received a hip implant containing metal.

Q: How soon after surgery can I resume driving?

A: Most patients can resume driving at six weeks after surgery.

Q: How long will the replacement last?

A: Current studies indicated that about 80% of prostheses will function well for 20 years. If your prosthesis wears out you may be a candidate for a second hip replacement.

Diagnostic imaging examinations provided by HSS Radiologists Images © Zimmer, Inc. Used by permission only.

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