When Is It Time to Have a Total Hip Replacement
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Hip replacement, one of the most successful operations of modern medicine, is very effective at relieving pain. In the vast majority of cases, hip replacement is an elective procedure. There is no rush to getting a hip replacement, and it should be done when the patient is physically and emotionally ready for the operation. Below, we present nonoperative treatment of hip arthritis, risks of surgery, and signs that it might be time to consider hip replacement.
Conservative Treatment for Hip Arthritis
For patients who have hip arthritis and are not yet ready to undergo surgery, management of the arthritis consists of physical therapy, corticosteroid injections into the hip, and the use of anti-inflammatory medications.
Physical therapy can help strengthen the weakened hip muscles surrounding an arthritic hip and improve a patient’s ability to manage the pain and dysfunction caused by hip arthritis. Therapy can also sometimes increase the motion surrounding the hip. Many patients who also have hip pain have low back pain. Physical therapy is very good at improving low back pain.
Corticosteroid injection involves a radiologist injecting an anti-inflammatory steroid medication directly into the hip joint to help relieve some of the pain caused by hip arthritis. The shots can be repeated every 3 months to make a patient more comfortable.
Anti-inflammatory medications, such as acetaminophen (e.g., Tylenol) and ibuprofen (e.g., Advil), are also very effective at relieving pain. For acetaminophen to be effective, patients should take it three times a day. For example, patients without liver problems can take two Extra-Strength Tylenol (1000 mg acetaminophen) three times a day to maximize the results. Ibuprofen can also be used for pain relief as long as patients do not experience stomach problems, such as ulcers or bleeding. Excessive doses of ibuprofen can harm the kidneys, so follow the instructions on the bottle.
Do These Nonoperative Treatments Work?
These nonoperative treatments do not treat the underlying problem but rather treat the inflammation and side effects of the arthritis. Their purpose is to limit the patient’s symptoms, not cure the underlying arthritis. Unfortunately, conservative treatments for hip arthritis are not nearly as effective as for knee arthritis and patients who have groin pain and radiographic evidence of arthritis can expect their condition to worsen over time.
Risks Associated with Hip Replacement Surgery
Hip replacement surgery is commonly performed. Overall, it is extremely safe. However, in a small number of patients, unwanted complications can occur. Below is a description of some of the complications that can occur.
Before and during hip surgery, we take a number of steps to limit infection. The University of Maryland is a leader in the prevention and treatment of joint replacement infection. Overall, infection associated with hip replacement is uncommon.
However, infections do occur, and when they occur, their treatment is disruptive for the patient and the surgeon. If an infection occurs around the hip replacement, the hip replacement parts usually have to be removed. After the parts are removed, a temporary antibiotic hip is placed for 3 months and then the hip surgery is redone (three total operations). Although infection infrequently occurs around a hip replacement, patients should be aware that it is an associated risk.
Hip replacements are not as stable as native hips, and dislocation where the head ball pops out of socket is a possible risk associated with hip replacement. At the University of Maryland, we use specific techniques to prevent dislocation and have achieved an extremely low dislocation rate. For most patients, we do not impose specific long-term limitations on hip movement. However, the hip replacement is always going to be slightly more prone to dislocation than the native hip joint.
Differences in Leg Length
Most patients with hip arthritis have one leg that is shorter than the other. The shorter leg usually is the one with the hip arthritis. During hip replacement, we use multiple techniques to equalize leg lengths to the extent possible. It is not possible to get them exactly laser-line equal, but in the vast majority of cases, it is possible to get the leg lengths close enough that the patient does not notice any difference in between the two legs.
The one exception to this is if the hip with the arthritis seems longer than the other hip before surgery. In general, it is very difficult to make a hip shorter at the time of hip replacement because the hip would no longer be stable. If the leg on the side with the hip that has the arthritis feels longer than the other leg, this will be the case after surgery as well.
The main goals of hip replacement are as follows: 1) stable hip implants, and 2) pain relief. Leg-length equality is a priority only after the first two goals are established. It therefore is not always possible to make patients’ legs equal in length after hip replacement.
Fracture around the Hip Implants
Hip replacement parts in the United States are most often press-fit into the bone at the time of surgery. During or after surgery, it is possible to develop cracks in the bones where the implants are pressed into place. If the cracks are observed at the time of surgery, they can be addressed at that time. However, sometimes cracks develop after surgery.
To limit these problems, we use special implants and techniques to avoid fractures. In addition, we ask that patients use some form of assistive device¾a walker, crutch, or cane¾for 6 weeks after hip replacement surgery to provide additional support to prevent twisting or falling that could produce a fracture around the hip implant.
Hip replacement can temporarily worsen any particular medical condition that a patient has. The most frequent medical complications associated with hip replacement are blood clots. We take specific steps to prevent blood clots during and after hospitalization, but clots can occur and do require treatment. In addition, patients who have heart or lung disease might note worsening of these conditions, such as heart attacks, problems with breathing, or stroke, after joint replacement.
All these complications are very rare. However, they can occur and it is important to work with your primary care physician to optimize your health before undergoing hip replacement.
Time for Hip Replacement?
With the above risks in mind, when is it time to consider hip replacement? If patients have tried the nonoperative treatments and are still suffering, below are some indications that it might be time for hip replacement.
Most of the time, patients with substantial hip arthritis have pain deep down in the groin and this is the pain that is effectively relieved by hip replacement. In addition, many patients with hip arthritis also have knee pain because the nerves that supply the knee run by the hip and are affected by the inflammation. Hip arthritis can cause a patient knee pain when there is nothing wrong with the knee! Most of the time, both the groin pain and the knee pain associated with hip arthritis are dramatically improved with a hip replacement.
Buttock pain might be coming from the hip but can also result from the back. Pain that is being caused by low back problems can persist after hip replacement. Therefore, patients who have primarily buttock pain should maximize nonoperative treatment by allowing us to evaluate their back before they consider hip replacement.
In general, it is best to wait until the arthritis progresses until the bones are touching, as shown on x-rays. Groin pain in a patient with bone touching bone is reliably relieved by hip replacement.
Some patients with the ball part of the ball and socket (femoral head) no longer round benefit from hip replacement, but this is on a case-by-case basis. Patients who have hip pain from arthritis but do not have bone touching bone shown on x-rays should maximize all nonoperative treatments before considering hip replacement.
Marked Interference with Daily Activities
Before proceeding with hip replacement, the hip arthritis should markedly impact your activities of daily living. Patients who have an inability to climb stairs, an inability to put on shoes and socks, or the need to use a cane should consider hip replacement. Patients who markedly change their activities or avoid social outings because of hip pain also should consider hip replacement.
Interference with Sleep
Patients who have hip pain at the end of the day that keeps them from sleeping despite the use of anti-inflammatory medications should consider hip replacement.
Hip replacement is an extremely successful operation. In the vast majority of cases, patients do not experience any complications. In deciding whether hip replacement is right for you, it is important to know the complications that can occur and the alternatives for treatment. We are more than happy to discuss these with you. Most of the time, hip replacement is an entirely elective operation and can be done in the patient’s time frame. Knowing the risks, benefits, and options will help you to be included as part of the care team and will help you to get the most out of your hips.
Ted Manson, MD