Total Hip Replacement

Indications

• Hip arthritis (osteoarthritis, inflammatory arthritis) causing severe pain and loss of function despite nonoperative care.
• Femoral head osteonecrosis (avascular necrosis) with collapse or advanced secondary arthritis.
• Certain hip fractures or deformities where reconstruction is unlikely to restore function.
• Major limitations in walking, stairs, sleep, and daily activities due to hip pain and stiffness.

Reasons to delay or avoid surgery

• Absolute: active infection (skin, urinary, dental, or systemic), uncontrolled sepsis.
• Relative: poorly controlled diabetes, active nicotine use, severe anemia/malnutrition, untreated dental infection, uncontrolled cardiopulmonary disease, high fall risk, or inability to participate in rehabilitation.

Benefits and alternatives

Benefits

• Substantial pain reduction and improved walking and daily function.
• Improved hip motion (often limited by preoperative stiffness and muscle weakness).
• Improved sleep and quality of life.
• Correction of deformity and improved limb mechanics in many patients.

Alternatives

• Activity modification, cane/walker, weight management.
• Physical therapy: strengthening, gait training, flexibility.
• Medications: acetaminophen, NSAIDs (if safe), topical agents.
• Image-guided intra-articular injection (temporary relief; not permanent).
• Surgical alternatives (selected cases): hip resurfacing, osteotomy, core decompression (early osteonecrosis).

Surgical procedure

• An incision is made to access the hip joint (approach may be anterior, posterior, or lateral).
• The damaged femoral head is removed.
• The acetabulum (socket) is prepared and a metal cup is placed.
• A liner (usually highly cross-linked polyethylene; sometimes ceramic) is inserted in the cup.
• The femur is prepared and a stem is inserted (cementless press-fit or cemented fixation, depending on bone quality and surgeon preference).
• A femoral head (ceramic or metal) is placed on the stem and the hip is reduced.
• Leg length, stability, and range of motion are checked before closure.

Key variants: surgical approach and implant choices (fixation method, bearing surface, and in some cases dual-mobility constructs for stability).

Implant specifics and MRI considerations

• Most modern hip implants are designed for long-term implantation and are not routinely removed.
• Fixation may be cementless or cemented; bearing surfaces commonly include ceramic-on-polyethylene or metal-on-polyethylene.
• Some patients receive larger femoral heads or dual-mobility designs to reduce instability risk (case-dependent).
• MRI is generally possible, but images near the hip can be distorted by metal artifact; tell the MRI facility you have a hip implant.

Typical anesthesia

• Common options: spinal anesthesia with sedation or general anesthesia.
• Many patients also receive periarticular local anesthetic injection; some centers use regional blocks.
• Many patients go home the same day or after a 1-night stay, depending on medical risk, pain control, and home support.

Recovery timeline

Risks and complications

Common

• Pain, stiffness, temporary limp, muscle weakness, scar sensitivity.
• Leg length perception differences (sometimes improves as muscles adapt).
• Blood loss, transient nausea, constipation from medications.

Less common

• Dislocation/instability (overall pooled estimates around 2% in large studies; risk varies by approach, head size, diagnosis, and patient factors).³
• Infection (often reported around 0.5% to 1.0% within 1 year in large registry-linked cohorts; surveillance definitions can yield higher estimates).^4,5
• Blood clots (DVT/PE), delayed wound healing, nerve irritation, heterotopic ossification.

Rare but serious

• Periprosthetic fracture, implant loosening or failure, major nerve injury, major medical events (cardiac, stroke), deep infection requiring additional surgery.

Patient-specific risk modifiers

• Higher complication risk with active nicotine use, poorly controlled diabetes, obesity, immunosuppression, chronic kidney disease, and poor nutrition.
• Fall risk, severe spine disease, and neuromuscular conditions can increase instability risk.

Durability and revision risk

• Registry-based long-term survival estimates vary by implant, patient age, diagnosis, and activity.
• Large registry data suggest approximately 89% of primary total hip replacements remain unrevised at 15 years, about 70% at 20 years, and about 58% at 25 years; these estimates are historical and may not exactly match modern implants or individual risk.^1,2
• Common reasons for revision include loosening/wear, infection, instability, and periprosthetic fracture.
• Younger age, high-impact activity, higher BMI, and certain diagnoses (e.g., osteonecrosis) can increase lifetime revision risk.

Practical instructions

• Pain control: use a multimodal plan (scheduled acetaminophen; NSAID if allowed; short-term opioid only as needed). Avoid alcohol and driving while using opioids.
• Constipation prevention if using opioids: hydration, fiber, stool softener, and laxative as needed.
• Ice and elevation: ice 15-20 minutes at a time; elevate to reduce swelling (avoid direct ice-to-skin contact).
• Wound care: keep dressing as instructed; showering timing depends on dressing type; avoid soaking (bath/pool/ocean) until fully sealed and cleared.
• Blood clot prevention: take prescribed medication exactly as directed and walk frequently; consider compression stockings if recommended.
• Sleep: pillow between knees if side-sleeping; avoid twisting the operated leg.
• Driving: only when off opioids, alert, and able to brake safely with normal reaction time (often 2-6 weeks; may be longer for right-sided surgery).
• Return to work (typical ranges): desk work 2-4 weeks; standing/light duty 4-8+ weeks; heavy labor often 3-6 months (job and recovery dependent).
• Travel/flying: discuss timing with your surgeon; use frequent walking, calf pumps, hydration, and compression if advised, especially on flights or car rides.
• Call urgently for: fever with worsening wound pain, drainage or spreading redness, calf swelling/pain, shortness of breath or chest pain, sudden hip deformity or inability to bear weight, new numbness/weakness.

FAQ

1. How long will pain last? Most pain improves substantially over 2-6 weeks; soreness with activity can persist for months.
2. Is swelling normal? Yes; swelling and bruising can last several weeks. Walking and elevation help.
3. When can I shower? Often within a few days, depending on dressing and incision type; avoid soaking until cleared.
4. When can I drive? When off opioids and you can safely control the vehicle; commonly 2-6 weeks.
5. Will airport metal detectors go off? Sometimes. Carrying an implant card can help, but policies vary.
6. Can I have an MRI later? Usually yes; tell the facility you have a hip implant because it can create artifact near the hip.
7. Do I need PT? Most patients benefit; the focus is walking mechanics, hip strength (especially abductors), and safe progression.
8. What infection or clot symptoms matter most? Worsening drainage/redness/fever, calf swelling/pain, chest pain, or shortness of breath require urgent evaluation.

Disclaimer: This handout is educational and not individualized medical advice. Follow your surgeon and therapy team instructions, which may differ based on approach, implant type, and your medical risk.

Bibliography

1. Evans JT, Evans JP, Walker RW, Blom AW, Whitehouse MR, Sayers A. How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet. 2019;393:647-654.
2. NIHR Evidence. More than 50% of hip replacements appear to last 25 years. 2019 Jun 18.
3. Kunutsor SK, Barrett MC, Beswick AD, et al. Risk factors for dislocation after primary total hip replacement: meta-analysis of 125 studies involving approximately five million hip replacements. Lancet Rheumatol. 2019;1(2):e111-e121.
4. Gundtoft PH, Pedersen AB, Schonheyder HC, Moller JK, Overgaard S. One-year incidence of prosthetic joint infection in total hip arthroplasty: a cohort study with linkage of the Danish Hip Arthroplasty Register and Danish Microbiology Databases. Osteoarthritis Cartilage. 2017;25(5):685-693.
5. Muscatelli S, Zheng H, Muralidharan A, et al. Limiting the surveillance period to 90 days misses a large portion of infections in the first year after total hip and knee arthroplasty. Arthroplast Today. 2022;16:90-95.
6. American Academy of Orthopaedic Surgeons. Total Hip Replacement (OrthoInfo).
7. American Academy of Orthopaedic Surgeons. Activities After Total Hip Replacement (OrthoInfo).
8. Hannon CP, Goodman SM, Austin MS, et al. 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty. Arthritis Care Res (Hoboken). 2023;75(11):2227-2238.
9. National Joint Registry. National Joint Registry 22nd Annual Report 2025 (webpage).
10. Australian Orthopaedic Association National Joint Replacement Registry. AOANJRR 2025 Annual Report announcement (webpage).