Am I a Candidate for Hip Replacement?

You might be a good candidate for hip replacement if you’re someone who’s quite active but finding that hip pain is now slowing you down. Perhaps you’ve noticed you’re not walking as far as you used to, or your relatives have commented that you’re limping. If your sleep is being disturbed by hip pain, or you find you’re starting to live on painkillers, then you should certainly consider hip replacement surgery.

As this is a major operation, it’s important to be as fit as possible beforehand. I always advise patients to do as much physiotherapy as possible, because the better you are going into surgery, the better you’ll be coming out.

How I Diagnose Hip Arthritis

Clinical assessment is one of the most important parts of diagnosis. Hip pain typically presents in the upper thigh or groin area, though sometimes you may feel it in your buttock.

During examination, I look for specific movements that provoke your pain – usually deep hip flexion with internal rotation. If this reproduces the pain you’re experiencing, particularly pain that wakes you at night, it’s likely due to hip arthritis. 

For investigations, I’ll arrange an X-ray, which you may have on the same day or beforehand. On the X-ray, I look for your joint space and whether there’s a reduction in the gap in your joint itself. This indicates that the cartilage is being eroded away and that hip arthritis is the main cause of your symptoms. If X-rays aren’t entirely conclusive, we can arrange an MRI scan, as there are many other causes of hip pain.

Conditions That Can Mimic Hip Arthritis 

Many conditions can masquerade as hip arthritis, particularly if you’re experiencing buttock pain. Sciatica can easily mimic hip arthritis, as can problems higher up in your sacroiliac joints (the joints that connect your pelvis). I also look for conditions outside your hip, such as psoas tendinitis and greater trochanteric pain syndrome. This is why a detailed clinical history and assessment is crucial for accurate diagnosis.

“Am I Too Young for a Hip Replacement?” 

This is a question I often get asked by patients. There are many causes for arthritis, including a genetic component. But to answer your question: you’re never too young. Take Andy Murray, for example – he was diagnosed with hip dysplasia, developed hip arthritis, and underwent a hip procedure.

Hip replacements are lasting longer and longer. While younger patients do have a higher likelihood of requiring revision surgery in future, you’re never too young to have a hip replacement. It’s important to get you out of pain so your muscles don’t deteriorate or waste away.

This is the link to an article I contributed to in “Good health magazine” about why patients are receiving hip replacements at younger ages:

Understanding the Risks

 Like any operation, hip replacement carries both general and specific risks. You can expect to be sore afterwards, and you’ll have a scar. Sometimes there’s delayed wound healing or a risk of infection. You’ll notice swelling after the operation, particularly around your thigh and knee. If you experience swelling around your calf, this could indicate a blood clot (deep vein thrombosis), which can travel to other parts of your body.

Specific to hip replacement, there’s always a risk of:

• Dislocation
• Leg length discrepancy
• Fracture or break
• Loosening or wearing out of the implant
• Future infection requiring revision

There are also anaesthetic risks, which our anaesthetist will discuss with you. However, in general, it is a safe procedure.

Preventing Dislocation 

Dislocation can be caused by various factors. In private practice, I’m particularly cautious if there’s an underlying neurological condition, in which case I’d use a dual mobility hip replacement to reduce the risk.

The surgical approach makes a significant difference. The traditional posterior approach involves cutting all the muscles and tendons in the back of the hip. However, I use a less invasive approach called the SPAIRE approach, where only one tendon is cut and the others are preserved. The muscles in the back that cloak your hip are all spared, which reduces the risk of dislocation and allows you to mobilise more quickly without hip dislocation precautions.

The National Joint Registry 

The National Joint Registry is one of the largest databases storing anonymised data about joint replacement implants. It covers all types of joint replacements – hips, knees, shoulders, wrists, and foot and ankle replacements. Its purpose is to track the implants we use, follow them up, and ensure we’re using the best-performing implants.

Understanding Implant Failure 

Prosthetic implants are mechanical devices designed to move for a certain number of cycles. Some older implants wear away more quickly depending on their bearing surfaces. For my hip replacements, I use ceramic on polyethylene bearing surfaces, which have some of the lowest wear rates. I also use newer titanium implants that bond to your bone and become a living part of your body, reducing the risk of loosening.

If a hip wears away, there’s a higher risk of erosion, dislocation, and the need for revision surgery.

Preventing Leg Length Discrepancy 

Leg length discrepancy is a commonly quoted risk. When you come to see me, I perform a thorough clinical assessment comparing both legs. Most people naturally have slightly different leg lengths they never notice, so I’ll ask if you’ve noticed any difference.

I obtain an X-ray to visualise the top of your thigh bone, ensuring that when I template and plan the operation, I’m using the right implants at the right depth. During the operation, your leg lengths are checked before and after the implants are positioned.

If there is a discrepancy, up to a centimetre is when you might start experiencing difficulties. If this occurs, I can advise on orthotics, insoles, and physiotherapy gait assessment.

Surgical Approaches Explained 

The SPAIRE approach (which I use when indicated) is a modified posterior approach that avoids cutting through major muscles like the piriformis and obturator internus. If a SPAIRE approach is not appropriate, then I would use a piriformis sparing approach. One of the advantages of these less invasive approaches is that there are no hip precautions postoperatively.

The posterior approach (which is a commonly used traditional approach) gives good exposure to the hip but it involves cutting several of the muscle groups around the back of the hip.

The anterior approach is muscle-sparing approach, but there’s a risk of nerve injury in the thigh, and some surgeons need a special table.

The lateral approach involves cutting through gluteal muscle tendons, which can lead to pelvic weakness.

Your Anaesthetic Options 

After thorough pre-assessment, you’ll meet the anaesthetic team. In most cases, you’ll be offered a spinal anaesthetic, which allows you to breathe on your own and provides excellent pain relief. You can also have sedation during the operation, which allows faster recovery afterwards.

If a spinal anaesthetic isn’t possible, general anaesthetic is the second option. This involves an airway tube, which can be uncomfortable afterwards.

What to Expect After Surgery 

You’ll wake up in the recovery room. Once the sedation has worn off, you’ll see the team – me, the anaesthetist, recovery staff and nurses – who’ll reassure you. Once back on the ward, our team and physiotherapists will get you up and about.

You won’t be in significant pain initially. The spinal anaesthetic lasts several hours, and we pre-empt pain by ensuring you take prescribed medication before it wears off. It’s vital to take painkillers regularly for the first 48 hours, as pain often gets worse before it improves.

My patients are often standing and walking within six hours of surgery. Some who progress well with physiotherapy go home the same day.

Wound Closure 

I use newer knotless sutures that are dissolvable and absorbable – no metal clips need removing. These sutures are coated with antiseptic material to further reduce infection risk.

Recovery Timeline

 For the first week, you’ll feel pain and exhaustion – it is a major operation. It’s important to mobilise gently following the physiotherapists’ advice.

• 2 weeks: Wound check
• 4 weeks: Target to be off crutches
• 4-6 weeks: Return to driving
• 3 months: Most patients “turn the corner”
• 6-9 months: Full recovery

Implant Longevity

 The implants I use (both cemented and uncemented) have a 95% survival rate at 10 years – they’re rated 10A*. This means that of 100 patients I’ve operated on, 95 will still have well-functioning hips at 10 years. At 20 years, 78 out of 100 hips will still be functioning well.

Recognising Problems

 If you develop problems, you might notice a different type of pain – perhaps in your thigh when getting up from a chair, or groin pain. If you experience any concerning signs, contact my team and we’ll arrange an X-ray to check everything is okay.

Understanding Revision Surgery

 Revision surgery encompasses a wide spectrum of procedures to help maintain your mobility, control pain, and keep you functioning. As a revision surgeon, I first need to identify exactly what the problem is and what needs changing. This might involve replacing one or both parts of the implant, depending on the cause – loosening, wear, dislocation, fracture, or infection.

Activity Guidelines

 I don’t have hard and fast rules about what you can and can’t do. My most important advice is to listen to your body. If something hurts, stop and pause before proceeding.

For the first six weeks, I’d discourage running as you’ll find it painful and the implants are still bonding. After that, there are no strict restrictions.

Hip Resurfacing vs Replacement

Hip resurfacing is a procedure that replaces just the surface while maintaining most of the bone. However, we’ve experienced problems with metal particles causing reactions in the body. Current government guidance mandates yearly monitoring with blood tests for metal ions, as there’s evidence these can cause cysts and tumours, and affect the heart and cognition. Resurfaced hips also don’t tend to last as long as hip replacements.

Female patients don’t do as well with hip resurfacing. While it’s something to consider, bear in mind the need for yearly monitoring and the risk of developing problems requiring revision.

Range of Movement 

I use ceramic heads with the largest size possible to maximise your range of movement. You’ll likely have slightly more movement than before surgery, as the operation changes the bone but not the muscles. Your final range depends on the physiotherapy work you do in the early phases, before scar tissue builds up.

Timing Your Surgery

Studies in the Bone and Joint Journal show that after just six months on a waiting list, there’s a significant increase in frailty and reduction in quality of life, along with deterioration in mental and physical wellbeing.

While you can consider delaying, I advise having the operation while you’re as fit as possible.