HIP REPLACEMENT XRAY

Please click on the sections links below for detail

TYPE OF OPERATION AND INDICATION (REASONS FOR HAVING THE OPERATION)

Joint Replacement is a moderately large operation. It can be considered in situations in which pain and disability from arthritis have reached a significant level and there is no alternative. As with any operation, it carries risks of complications and adverse outcomes. The surgery should only be carried out if the necessity for the operation is sufficient to outweigh the risks. This usually means severe pain and applies to patients who are fit and well enough to potentially have the surgery.

If you are seen in clinic to discuss potential suitability for a hip replacement, Mr Sehat will help with reaching a decision on whether hip replacement is an appropriate option in your particular case, given the specific balance of risks and benefits.

As a basic rule if pain from the hip is sufficiently severe to disturb sleep or prevents being able to walk far enough to attend to essential activities, one may reasonably consider having a hip replacement.

The Oxford Hip Score can help you to decide if your hip symptoms have reached a level at which a hip replacement should be considered. It should only be used as a guide. (click here to calculate your score).

Approximately 80,000 hip replacements are carried out each year in England and Wales. It is therefore a commonly performed and routine operation for treating severe arthritis and is considered a relatively successful operation. Nevertheless, as with any operation, it should only be carried out when absolutely necessary to maintain or improve quality of life.

The operation involves removing the diseased and painful surface cartilage and bone of the worn hip joint and replacing it with an artificial implant. This means that hip movement and weight bearing will then occur through the artificial surfaces rather than the painful cartilage, reducing pain and improving function. However, hip replacements may initially feel stiff but reproduce almost normal hip function by about one year after surgery. There can be mild persisting pain. More detail on the outcomes that can be expected are given below under ‘outcomes’.

Any joint replacement will eventually wear out, become loose or otherwise fail and need to be revised (replaced again). At least 90% are expected to last more than 10 years and 80% are expected to last more than 15 years. However, this means that some may fail earlier and need to revised sooner. Having a joint replacement operation means potentially committing to more operations later on in life. The later in life that one has a joint replacement, the less likely it is that further surgery may be required.

Hip Replacement involves a four day stay in hospital, 6 weeks of recovery at home and at least 6 months to the end result, with a gradual improvement during that time.

If you are very overweight, this type of surgery carries a greater risk of complications, a poorer result and is generally not recommended. You should make attempts to bring your weight down to an acceptable level before considering surgery. You should discuss this with your GP. A Body Mass Index (BMI) of 35 (moderately overweight) is the threshold for relatively safe surgery. To calculate your BMI, you need to know your height and weight. Please click here to calculate.

Please also see the section on ‘Hip Disorders in adults’ for further information on hip arthritis, the options for treatment and when surgery may be helpful.

TYPES OF HIP REPLACEMENT

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Total Hip Replacement:

Also known as Total Hip Arthroplasty, THR or THA.

Most patients will require this type. The whole of the main weight-bearing cartilage surface of the hip joint socket and the ball of the hip joint (femoral head)  are replaced with artificial implants. Mr Sehat will routinely use the hardest wearing available bearing material including ceramics to optimise the longevity of the hips replacement.

Hip Resurfacing:

This is a variant of hip replacement which is suitable for a small number of patients and can be discussed in clinic.

Type of fixation:

The implants may be attached to the bone either with cement or with a biological process of bone growth onto the implant. The differences are not of practical significance or noticeable to the patient. Mr Sehat will advise if from a technical perspective there should be a preference.

Type of Bearing:

The actual articulation in the ball and socket joint of the hip replacement is the key component of the prosthesis. There is a choice of material. Most hip replacements use a combination of polished metal on the ball and polyethylene (plastic) on the socket. Ceramic bearing components which are harder wearing are available and are used in preference by Mr Sehat whenever possible.

More details on the functional outcomes and life expectancy of hip replacements are provided under ‘outcomes of hip and knee replacements’.

ARRANGEMENTS FOR THE SURGERY

Full details will be provided if you are booked in for surgery. The following is a brief summary of what you can generally expect.

Before surgery you will be seen in a “pre-operative assessment clinic”. This is a medical check of general fitness and if any further tests or changes to medication, etc… can be carried out to optimise your condition, prior to surgery. Blood tests, heart tracing (ECG) and blood pressure checks are routine.

On the day of the operation, you will be asked to attend hospital, having fasted that day. Several patients may be having surgery on the same day and you may be waiting before the operation, potentially for a few hours altogether, so please bring reading material.

The anaesthetic is usually a spinal anaesthetic. This is an injection to the lower spine which numbs the nerves that provide sensation below the waist. The numbness from a spinal anaesthetic is sufficient to be able to carry out the operation. Patients may choose to either be awake and aware or to receive sedation and be asleep and unaware through the operation. A spinal anaesthetic is a good option because it provides pain relief for a few hours after the operation also, meaning that less painkillers need to be given and fewer side effects of strong pain killers are therefore experienced. Sometimes a general anaesthetic (fully unconscious) may be necessary or requested by a patient who wishes to be entirely unaware of the operation. The anaesthetist will see patients on the day of surgery before the operation and discuss further.

A Hip Replacement operation will take approximately two hours but the duration is very variable for many reasons and if it takes longer, that does not mean that any difficulties were necessarily encountered.

Following the operation, patients rest in bed for the first few hours or overnight and receive observation, monitoring and pain relief as required. At the earliest opportunity, later that day or usually the next day, it is beneficial to commence exercises. A physiotherapist will visit and instruct and assist. The sooner that the hip movements and standing up can be commenced, the quicker the overall pace of recovery will be. It is preferable to ask for more painkillers as required in order to be able to perform the exercises. The physiotherapists and nursing staff will guide and assist with this process.

The usual stay in hospital is around four days for patients returning home with family support. Some patients may be ready for discharge earlier than this or the stay may be prolonged if there are particular circumstances or other medical conditions to take into account.

A blood transfusion may need to be given if required but this is uncommon.

POST-OPERATIVE ARRANGEMENTS

shutterstock_126963317By the time of discharge patients will be walking with two crutches. A few older patients may prefer a frame. It is possible to use stairs with crutches, slowly but safely. Physiotherapy exercises will be instructed and should be continued at home.

We will ask your practice nurse to inspect the scar at 10-12 days after surgery but the suture that is usually used is dissolvable and will not require removal.

You will be sent an appointment to return to clinic approximately 6 weeks after surgery for a review but please contact us to expedite the appointment if you or your GP have any concerns.

RECOVERY

shutterstock_161045939The pace of recovery varies greatly between patients and situations. The following is a brief guide to what one can generally expect. Sometimes it is possible to return to function much sooner but similarly recovery can also take longer on occasions and it is advisable to allow for this.

Patients will ordinarily spend about 1 month mostly at home and carrying out physiotherapy exercises. During this period help will be needed with personal tasks such as washing and dressing and ideally a stay with family or close friends is advised. Patients returning home to an independent existence will need to stay in hospital for longer until they can be sufficiently independent (about 10 days).

Walking will be with two crutches for the first one to two months then one crutch or a stick for 3 to 6 months. Patients are encouraged to walk outside the house by two weeks and can usually return to driving by 6 to 8 weeks. To be able to walk around a supermarket or carry shopping will also take about 8 weeks.

As long as steady improvement is taking place, the pace of recovery is not important and will vary greatly between patients.

OUTCOMES

The outcome of THR is not absolutely consistent in all situations and may vary even between the same patients two hips. It depends on the pre-operative condition of the joint and the general fitness of the patient. If you are having a hip replacement, Mr Sehat will discuss with you in clinic before the operation if there are any specific reasons for you to expect a different outcome to the usual.

About 90% of patients are pleased with their hip replacement and find it has improved their pain and walking ability sufficiently to have been worthwhile.

Most patients will find that the new hip feels rather different at first. There will often be some slight aching and tenderness on the scar that takes several months to resolve and occasionally persists long term. Some patients aim to return to strenuous activity such as hill walking. This is usually possible as far as the hip joint is concerned but also relies on sufficient general fitness to be able to rehabilitate well enough from the operation and adapt to the new hip.

A peculiarity of hip replacement is that the leg may be made slightly longer or shorter at surgery. The intention is to restore normal length that matches the opposite side but a greater priority is to ensure good stability of the hip and minimise the chances of dislocation. Thus the length of the leg at the hip is adjusted to conform to the tension in the ligaments and if the ligaments are soft, which is sometimes the case, Mr Sehat prefers to slightly lengthen the leg and ensure good stability. The lengthening will only be less than 10 mm (1/4 inch) and although it may feel slightly odd at first, the pelvis adjusts and comfortable walking is restored within a few months.

Walking distance varies greatly and assuming there is no other impediment can be up to 2 hours comfortably for most patients, by one year after surgery. Pain at night should resolve by 6 months.

Swimming, cycling, recreational walking and gentle sports such as golf and bowling are usually possible and perfectly safe. Running and racquet sports are usually possible at a gente pace but not necessarily recommended if the durability of the hip replacement is to be maximised.

The functional outcome will be significantly better if the physiotherapy exercises are carried out with eagerness after the operation.

The functional outcomes of knee replacements are monitored nationally by the HSCIC (Health and Social Care Information Centre – www.hscic.gov.uk/proms). Patients report their knee function before and six months after having a knee replacement.

The main measure used is the Oxford Knee Score. This score is a number from 12 to 48. A score of 0 is the lowest score and would represent a totally non-functional knee. A score of 48 represents normal function with everyday activities.

Graph showing functional “Oxford Hip Score” for patients having hip replacement surgery

Graph showing functional “Oxford Hip Score” for patients having hip replacement surgery

For more detailed information on the outcomes of hip replacements, please see section on ‘Outcomes of knee and hip replacements’.

A summary of the outcomes of hip replacement is shown in this table:

Hip Replacements
Primary Hip ReplacementAverage improvement in Oxford score (unadjusted) in first 6 months (a)Risk of mortality within 90 days (b)Risk of requiring revision within 3 years (c)
National average (England)21SMR 1 (0.6%)1.6%
Nottingham University Hospitals average21SMR 1.2 (0.7%)1.9%
Mr Sehat’s patients average21SMR 1 (0.6%)0.8%

Notes:

(a) The figures are the average for the period April 2012 to March 2014

(b) SMR is the standardized Mortality ratio. It takes into account the patients other long term medical complications. The national average is a ratio of 1. A higher risk of mortality is an SMR greater than 1 and a lower risk is a number less than 1. Source: www.njrsurgeonhospitalprofile.org.uk

(c) This is the overall revision rate. Nationally, many hospitals will only offer a revision procedure if it is necessary due to failure of the joint replacement. In Nottingham and in Mr Sehat’s practice, approximately half of the revisions are necessary due to early failure (eg: due to infection) and approximately half are carried out optionally to improve the outcome further.

Please note that in Mr Sehat’s practice, unlike most centres, we offer revision surgery when it may help to improve and optimise the outcome, even though it was not strictly necessary.  The rate of actual failed joint replacements is lower than the overall revision rate stated by the NJR.  Leading hospitals such as Nottingham University Hospital that treat complex cases also tend to have higher revision rates because of the nature of the cases and despite their expertise.

COMPLICATIONS

Hip replacement is a moderately big operation and carries a small but significant risk of complications. Therefore the operation should only be carried out if the symptoms are sufficiently troublesome in the first place to justify the risks. You can reach a sensible decision on the requirement for surgery following a discussion in clinic.

Being very overweight (BMI greater than 35) increases the risks of complications. Patients who are very overweight should endeavour to lose weight before considering hip replacement surgery.

The common complications which are not serious but can delay recovery include:

  • Discharge or fluid leak from the scar in the first few days. This may require re-dressing.
  • Excessive swelling of the hip and/or leg. This can delay progress but not necessarily alter the eventual outcome.
  • Persisting pain or slow recovery is common but most patients will reach a satisfactory result by 6 months to one year following surgery .

Uncommon complications include:

  • superficial scar inflammation or minor infection: If this is suspected please contact the relevant secretary and we will arrange a prompt review. If confirmed, would respond to simple antibiotics.
  • A ‘Deep Vein Thrombosis’ (DVT) or blood clot in the deep veins of the leg: This can occur in approximately 5% of cases and causes tight swelling, redness, discomfort and tenderness of the calf. If suspected, please seek a same day appointment with your GP to be assessed. Simple swelling that goes down with lying down at night and elevation is not a sign of DVT. Most legs will swell after surgery- this is normal and does not require a review.
  • A disappointing functional outcome: This is reported by about 10% of patients initially, usually because of some persisting pain or weakness. We would try to improve the outcome as much as possible, including with extended physiotherapy or occasionally further surgery. The risk of a longterm poor outcome is less than 10% and the risk of being worse off than before surgery is less than 5%.
  • General Medical complications of surgery: These include heart attacks, strokes, chest infections and kidney failure. These complications are possible despite the preparation and care at anaesthesia and surgery. They occur in up to about 5% of cases. They are more likely if the patient has a history of such conditions already and will be discussed before surgery. We would carry out a medical assessment and only proceed with surgery if the risks of such complications can be reduced to an acceptable level or if the pain in the hip is sufficiently severe for the patient to wish to proceed despite the risks.

Rare complications include:

  • Dislocation: A hip replacement can come out of joint or dislocate. This is rare with normal hip movements but can occur accidentally or if there is a fall. 1% of hip replacements may dislocate in the first 5 years after the hip replacement. If a dislocation occurs, the patient would have sudden pain and be unable to walk. An ambulance would be required to bring them to hospital for the hip to be relocated under anaesthetic. If dislocation occurs more than once or twice, further surgery may be required to stabilise the hip.
  • Internal infection in the hip itself: This occurs in less than 1% of cases and requires further treatment with surgery and lengthy courses of antibiotics. Infection may develop at any time in the lifetime of the hip replacement. The hip would become strikingly painful and the scar may be very red or leak fluid. If suspected, you should seek a a review with your GP who may carry out a blood test to check or arrange for us to review you in clinic. Mild pain soon after the operation is common, does not indicate infection and is of no concern.
  • Pulmonary Embolus (blood clot extension to the lungs): This is rare but can occur after any operation, including hip replacement. Symptoms typically include feeling breathless, pain in the chest with breathing and sometimes coughing with some blood. If suspected, please attend A&E immediately for assessment.
  • Damage to nerves or blood vessels or uncontrollable infection leading to long term disability. These are very rare (less than 0.5%) but potential complications of this type of surgery.
  • Death from medical complications of hip replacement surgery is nationally recorded to occur in about 0.6% of cases.

There are many other potential complications and adverse outcomes of any operation but which are uncommon. If you have any particular concerns, please discuss with Mr Sehat in clinic.

Any joint replacement will eventually wear out, become loose or otherwise fail and need to be revised (replaced again). At least 90% are expected to last more than 10 years and 80% are expected to last more than 15 years. However, this means that some may fail earlier and need to revised sooner. Having a joint replacement operation means potentially committing to more operations later on in life. The later in life that one has a joint replacement, the less likely it is that further surgery may be required. 

Complications of surgery are kept to the minimum that the present knowledge and technology allows, nevertheless can still occur. This means that surgery should only be considered in situations in which the actual condition being treated is sufficiently problematic to justify the risks of adverse outcomes and complications. This is ultimately a decision for each patient to make, having been informed of the options for treatment and the potential risks. Mr Sehat will help you to reach a reasonable decision on whether surgery is the right course of action in any particular situation and if you would like to discuss further, please request an appointment.