Hips FAQs

Arthritis literally means inflammation of a joint. However, it is used as a general term to describe any issue with joints.

The commonest form of arthritis is osteoarthritis. This condition is often referred to as “wear and tear”, and can affect any adult over the age of 40.

Inflammatory disorders, such as rheumatoid disease, can result in arthritis due to damage from the inflammation.

Arthritis may also occur as a consequence of injury, such as a hip fracture or dislocation.

The end result, though, is the same. That is, the joint becomes arthritic. This is a medical term simply meaning that the cartilage surface of the joint is damaged, no matter what the cause. The body is unable to repair or replace damaged cartilage.

The consequences of this for the patient are depend on the joint involved.

Hip joint arthritis predominantly causes pain but may also result in joint stiffness with restricted motion, shortening of the leg, and development of a limp.

These symptoms may affect your quality of life and activities of daily living to a greater or lesser degree.

Treatment for an arthritic hip starts with non-surgical measures. These are referred to medically as conservative treatments.

Conservative treatments for hip arthritis are:

• Activity modification - slowing down, changing the way you do things and avoiding activities that precipitate the pain
• Walking aids - a stick, cane, crutches or a walking frame can be useful, but have a varying degree of acceptability and effectiveness
• Medication - simple pain killers such as paracetamol products, anti-inflammatory medications, and ultimately strong morphine-type painkillers can be considered

When the symptoms reach a level where the above measures are no longer effective or acceptable, this is generally the time that it is appropriate to consider hip joint replacement surgery. That is, the place for surgery is when all non-surgical measures have been taken and are no longer satisfactory.

Hip replacement surgery is performed for irreversible damage to the hip joint, or "arthritis".
(See: What is arthritis?)

Hip replacement surgery is appropriate to consider when non-surgical measures have failed
(See: What are the Treatment options for an arthritis hip?)

The consequences of hip joint arthritis are predominantly hip pain, but also joint stiffness with restricted motion, shortening of the leg, and development of a limp.

Hip replacement surgery aims to relieve the disability caused by pain, stiffness, shortening and limping.

What Are the Benefits of a Hip Replacement?

The vast majority, if not all, of the pain that arises from inside the hip joint will predictably be relieved with a hip replacement.

Because the hip replacement literally renews the ball and socket surfaces of the hip, it will relieve pain that is generated by the damaged cartilage surfaces.

However, a proportion of pain may come from structures around the hip joint and won’t be relieved by simply replacing the ball and socket. Before committing to surgery, the predominant cause of the pain needs to be determined. Scans or diagnostic injections may be required.

It is not possible to categorically rule out all possible additional causes of pain from surrounding tissues prior to surgery. Rest assured, the surgery would not be being offered if it was not thought to be highly likely to relieve the vast majority of your discomfort.

Even if associated structures are contributing to the discomfort, the overall result of surgery is still generally of substantial improvement.

Learn more: see What Can Go Wrong- Unrelieved pain

Relief of Stiffness

Stiffness of the arthritic hip is generally completely relieved with a hip replacement.

A hip replacement actually has a much greater range of motion than a natural hip.

Paradoxically, this is one of the potential disadvantages of hip replacement, as in extreme positions, the ball may dislocate from the socket, and the hip replacement may “pop out”.

Learn more: see What Can Go Wrong-Dislocation

Correction of a Short Leg

Often arthritis causes a flattening or even a collapse of the ball part of the hip joint.

This results in shortening of the leg.

This can be addressed by careful planning beforehand and correction at the time of surgery.

Getting the leg lengths exactly equal is very technical and demanding for the surgeon. A residual difference in the lengths between the two legs is uncommon but is one of the risks of surgery.

Learn more: see What Can Go Wrong-Leg length inequality

Improvement in Limp

A limp can be caused by several reasons.

If it is a painful limp as a consequence of hip joint arthritis, then this has a very high probability of being relieved with the surgery.

If the limp is due to shortening of the leg caused by the arthritis, and this is able to be corrected at the time of surgery, then this type of limp will also improve with surgery.

A limp may also be due to muscle weakness from disuse. That is, the hip is too painful to use normally, and the muscles get weak. As long as the muscles themselves are OK, then this type of limp will also improve after hip replacement surgery.

However, a limp that is caused by a problem with the muscles themselves, the muscle attachment to the hip, or a neurological disorder is unlikely to recover.

Summary

Ideally, of course, all of the symptoms that are experienced prior to hip joint replacement surgery would be completely relieved after the operation. Often this is achieved, with a very satisfying result for both patient and surgeon.

However, not all aspects of the hip disorder can be guaranteed to be addressed completely or predictably with surgery.

Often people are told that they are “too young” to have a hip replacement. It is borne out of the concern that just like any moving part, it can eventually wear out (think car parts).

Generally, the younger you are, the more stress and wear you will place on a hip replacement compared to an older person.

Together with a longer life expectancy, in the fullness of time there is a possibility that the replacement will wear or loosen and may require replacing within your lifetime.

This is why careful consideration of the timing of surgery needs to be given and any decision for surgery is not undertaken lightly.

However, if it reaches a point where all other treatment options have been tried and exhausted, then it is appropriate to consider total hip joint replacement when balanced against having to live with significant pain and disability on a daily basis.
Learn more: see What are the Treatment options for an arthritic hip?

The main issue is that historically, the techniques and replacement parts available to re-do surgery were very limited. This no longer is the case. Our techniques now and the orthopaedic implants available to deal with complex problems are readily available and so this in itself is not a restricting factor in the way it once was.

Other measures that can prevent complicated future surgery are as simple as regular surveillance of your hip replacement, even when it is well functioning. Think of this as a “warrant of fitness” or regular service, just as you would on your car. We recommend and arrange X-rays every 5 years for you.
Learn more: see Do I need to check on my hip replacement in the future?

So, in summary, if you have a hip condition and feel that there may be no other treatment options, it is always worth a review with your surgeon and discussing what other alternative options there may be, and the appropriate timing and place of a hip joint replacement, knowing that age itself is not a barrier in the 21st century to undergo a hip joint replacement.

The question that is often asked is am I too old to have a hip replacement?

The short answer to this is no, there is no top limit as to what age you will benefit from having hip replacement surgery.

As always, it comes down to whether your pain and disability is severe enough to warrant the surgery, and secondly, whether you are medically fit enough to withstand the surgery.

We often have patients with fewer medical problems in their 80s, than others in their 50s. For this reason the decision to have a hip replacement is always undertaken based on every individual’s needs and risk factors.

If you are in any doubt, in the first instance, please have an assessment with your surgeon to determine whether a hip replacement is firstly appropriate to consider, and then secondly whether it could be undertaken safely.

If there is any doubt, an opinion for the anaesthetist is also arranged, and involving your cardiologist or other specialists is routinely undertaken.

A common question quite reasonably is how long will a joint replacement last?

Historically, people were told to expect 10-15 years as an outside timeframe. This came from the original joint replacements done in the 1970’s and 1980’s, and was accurate for that era.

Pleasingly, our modern replacements will generally much longer than 10-15 years. We know this because even the surgery that was done 20 years ago in the 1990’s, 90% of replacements are still in and working after 20 years!

And what we are using today is much better technology than the 1990’s, and has the potential to last 2-3 decades, or even longer. Only time will tell us conclusively, though.

“How long does it last?” refers to the fact that, like any mechanical parts, the joint replacement can wear out or loosen its hold from the bone to which it is fixed. There are, however, other ways that hip replacements can fail, and these also need to be taken into consideration as a reason for “failure” of the replacement, and the possible need for further surgery.

Other reasons for “failure” or repeat operations may be required include fracture (broken bone), infection, multiple dislocations, or some other issue with the device itself.

Generally speaking, whatever the reason a hip replacement runs into trouble, we are able to fix this now and very few situations would be inoperable or unable to be remedied.
Learn more: Can a Hip Replacement be redone?

In general terms, yes.

Whatever causes a hip replacement to fail, it can generally be remedied with further surgery if necessary.

It depends on how the replacement has failed, and identifying what has gone wrong is a key part of the planning for any re-do surgery.

The commonest reason for re-do surgery is eventual wear or loosening of the implant after many years of successful usage. Like any moving part, there will eventually be wear, and this may simply be the end of its useful life span.

Other reasons that a joint replacement may require repeat surgery is if the bone around the hip replacement is broken for whatever reason, such as in a fall. This may affect both the socket site with a pelvic fracture, or the thigh bone site with a fractured femur. This presents a different set of issues for the surgeon and the patient but again generally speaking they can be addressed.

Another reason peculiar to hip replacements, is if the hip replacement was repeatedly unstable. This means that it dislocates or “pops out of joint” time and time again and presents a major impediment to patient’s lifestyle as well as comfort and function. This can happen as a consequence of wear or loosening, but can also be an issue in the first few years after surgery if the particular set-up of the hip replacement doesn’t suit the patient’s individual circumstances.

Infection around joint replacements is a devastating consequence. Eradicating the infection if it has seeded to and around the joint replacement itself, often means removing the joint replacement in its entirety and leaving a temporary joint replacement in place whilst the infection is well and truly eradicated. At a later stage a further operation can reinsert the new hip replacement. Obviously this is as protracted and devastating as it sounds but nevertheless it can be attended to should it occur.

Rest assured, however, that for most patients who undergo a hip joint replacement, the first operation is their only operation.

For peace of mind, we recommend regular checks on your replacement.
Learn more: see Do I need to check on my hip replacement in the future?

We recommend a check at five-yearly intervals after your surgery- at 5, 10, 15, 20 years etc.

Even if you feel 100%, X-rays can sometimes show a potential problem that you might not yet be aware of.

It is a “stitch in time saves nine” approach.

The aim is certainly not to pursue any unnecessary surgery- in fact, is the opposite- it is peace of mind to know that all continues to go well and that there are no impending problems.

Equally, if a problem was evolving on your X-rays, then planning a prudent smaller surgery to replace a worn part might be something that is best undertaken earlier in life, rather than a much greater operation very late in life when you may be less medically well to undergo such a procedure.

Obesity can be an issue, just like it is for most health-related concerns.

With hip replacement surgery, there are issues with the hip itself, with regard to the risks of surgery and with the anaesthetic.

The issue with the technical side of hip replacement is that if you carry a lot of excess weight around your hips in particular, often there is a substantial fat layer between the skin and the muscles and other soft tissues around the hip. This can make access difficult for the surgeon to reach the hip joint which is quite deep down within the operative site. Special retractors and a longer incision can usually accommodate for this but creating a larger “surgical exposure”, but the greater the surgical exposure the greater the potential for higher blood loss, and the increased risk of infection.

Because of the difficult access to the hip joint for then surgeon, the risk of causing a fracture during surgery, or damaging muscles, nerves or blood vessels is potentially higher.

Technically seating and fixing the joint replacement implants in an ideal position is also made more difficult for the surgeon. Depending on the access the surgeon can get to the hip joint, it may have a bearing on the accuracy of the placement of the hip replacement components. Sometimes this is very difficult to judge for the surgeon at the time of surgery. This may result in an increased risk of dislocation.

Obesity itself can affect wound healing, and in itself can be a risk factor for infection.

Historically excess weight has been an issue with the longevity of the hip replacement, with fears that the excess weight the patient carries may result in premature failure of the hip replacement. This is certainly a consideration, but needs to be taken into account with your activity level as well.

Other issues that obesity presents can be the risk of venous thromboembolism (DVTs and PEs), chest infection, urinary infection after catheterisation, pressure areas and skin sores if there is protracted immobility, and technical issues administering the anaesthetic.

Carrying too much weight in itself doesn’t preclude having hip joint surgery but the increased risks do need to be taken into account when planning for and committing to hip replacement, both by the surgeon and the patient.

If you have agreed with your surgeon that a hip replacement is the right option for you, but there is a reason to delay the surgery, often due to circumstances beyond your control, there are several factors that might be of help.

1. Pain Relief
   The first is ensuring you have adequate pain relief. No doubt you have already tried various pain relievers and anti-inflammatory tablets. It is always worth talking with your GP to optimise this and to perhaps try other options that you might not have tried yet to obtain better comfort both in the day and during the night whilst you are awaiting surgery.
2. Hip Injection
   Another option that may not have been tried to date, is an injection into the hip joint itself. This often gets called a “cortisone” injection. It is actually a mixture of local anaesthetic and a modern form of cortisone, usually Kenacort/triamcinolone, which is a pure synthetic steroid anti-inflammatory liquid. (Please note it is not an anabolic or body-building type of steroid). It works by decreasing the inflammation within your hip joint with the aim of obtaining longer lasting relief for weeks or even months at a time. This is an option if you have to delay surgery. Note that it is not recommended to have an injection within three months of the surgery itself, as there is a small but real increased risk of infection around the hip replacement if injections are done close to the time of surgery.
3. The hip joint injection needs to be done in a very precise manner and is normally done with ultrasound guidance (and sometimes with X-ray guidance). The specialist will guide a very fine needle accurately down into the hip joint, numbing the area along the way with local anaesthetic. The local anaesthetic and Kenacort are then injected into the hip joint. The procedure takes about half an hour. It is done in an X-ray suite. It does not require admission into hospital. You can weight bear and walk on the leg straight away. It is recommended to have a friend or family member drive you home. Occasionally the local anaesthetic can temporarily weaken the thigh muscle, making walking or driving for a few hours potentially difficult or unsafe. Nevertheless it is a very easy and cost-effective way of buying time until hip replacement can be undertaken.
   Learn more: see YPO Ultrasound guided hip injection
4. Stick, cane, crutches
   Although you may not wish to have to rely on walking aids, they definitely have a role to play- there’s a reason why so many people use them after all!

Will I do any harm by waiting?

People often worry they will do further harm to the hip joint whilst waiting for surgery. Generally speaking the answer to this is no. The surgeon can generally address any issues that are present within the hip joint at the time of surgery without further consideration. If the delay is greater than 6 months, an up to date X-ray is usually taken to ensure there has been no major structural damage within the hip joint since last X-rayed. The only exception to this would be a condition called avascular necrosis (or osteonecrosis of the femoral head). This would normally be identified on initial X-ray. In this situation surgery is best undertaken within six weeks as there can be significant bone loss as a consequence to the underlying condition. The surgeon will tell you this at the outset if this is the case.

What exercises can I do whilst waiting?

Generally general fitness exercises and walking within your comfort range is recommended. Often non-weight bearing exercises such as cycling or swimming are better tolerated. With swimming, normally kicking in a straight line such as freestyle, using a kickboard or backstroke kick are well tolerated. Because of the action on the hip joints of breast stroke or butterfly this is usually less well tolerated. Your comfort however is the overall guide and generally speaking if it is comfortable and you are managing, then the exercise is appropriate.

Whilst it is the right idea to stay as fit and active as you can prior to surgery, there are limits brought on by the hip joint itself. It is generally stiff as well as painful and this limits the amount of exercise and strengthening that you can actually achieve. Often it is better to wait until the hip replacement is done, and then focus on strengthening and fitness thereafter. So don’t be too worried if you can’t get as fit or exercise as much as you would like prior to surgery.

Other considerations whilst you are waiting for surgery would be to optimise your general health. This would mean having a regular check with your family doctor (if you haven’t already). Identifying issues that may affect surgery such as anaemia, iron deficiency, vitamin deficiency can be useful. If you have any outstanding dental issues, particularly root canals or reconstructions as a result of dental abscess for example, these are best dealt with prior to surgery.

Other issues that would need to be considered on a case by case basis would be prostate issues for men, and uterine issues for women, before considering joint replacement surgery.

You may also take the opportunity to consider your home environment. This would have to be done anyway, but thinking ahead with how you would manage stairs, possibly changing bedroom to minimise…

Firstly, thank you for attending the consultation and I hope I was able to answer all of your questions and give you a clear direction on what your options might be.

I appreciate that normally we cover a lot of information in a short space of time.

It is important to be clear on what your options are and that you make any decisions in the cold light of day, rather than a snap decision. This is particularly easy to do if you are in a lot of discomfort presently.

Hopefully the associated information on the website covers∑ everything you will need to know regarding hip joint replacement surgery and will complement what we have discussed today.

If you simply need to talk through things again, perhaps after a period of trial of non-operative management, or a period of contemplation, please let me know and I am very happy to see you for a follow-up appointment.

I’ve Decided- How do i proceed?

Once you’ve decided that you wish to proceed with hip joint replacement surgery, please contact my practice manager directly.

If you would like to discuss things further prior to surgery then please advise the practice manager and we will arrange a follow-up appointment for this purpose. At this point, the logistical side of arranging surgery can be commenced.

If your consultation has been within the last 6 months, and you are happy that you have all the information that you need to proceed, and are happy to proceed directly to surgery, then please advise the practice manager, who will make arrangements accordingly.

If you have not been reviewed (or X-rayed) within the last 6 months, then a follow-up appointment will be required.

The arrangements vary depending on how the surgery is being funded.

If your surgery is being funded by health insurance, the insurer requires 5 pieces of information that we will help provide for you. These are the date of surgery, the name of the operation, the surgeon, the facility, and an estimate of costs.

As we are a Southern Cross Affiliated Provider for primary hip joint replacement surgery, the application for surgery and approval is done via the practice manager at the rooms. The Southern Cross healthcare portal will then advise if there is a shortfall on your coverage. If so, this needs to be paid directly to Grace Hospital prior to the surgery.

Other insurance companies will advise you on their payment and reimbursement arrangements. This normally requires submitting a series of invoices to the insurer, either prepaid for reimbursement or direct reimbursement by the insurer. In this case, there are likely to be invoices for the surgeon’s fee, the implant fee, the anaesthetic fee, the hospital charges and physiotherapist services. You may also be required to pay for equipment hireage such as crutches, raised toilet seat etc.

If your surgery is to be covered by ACC, an Application for Treatment needs to be submitted by Mr Lamberton’s rooms to gain approval to proceed with surgery. Surgery cannot be scheduled until the ACC approval is given. The time between submission of the application and approval can vary between 3 weeks and 3 months. Generally speaking, all costs are covered by ACC. It is always worth confirming your entitlements with ACC regarding any expenses that might not be covered. Separately, it is always worth clarifying your entitlements to earnings-related compensation. Medical certificates will be provided by Mr Lamberton after surgery if required.

Can I Go Public?

As a New Zealand citizen, you are entitled to treatment through the public healthcare system. This of course is free of charge, but does require assessment and placement on a surgical waiting list.

Currently this is a two-part procedure.

The first step in the process is a “first specialist assessment”. This has to be offered within 4 months of referral. Note that referrals are all graded and not all referrals are judged of sufficient severity to receive an appointment.

If at the first specialist assessment you are judged appropriate for surgery, and your priority score is above the treatment threshold, you will be added to the waiting list for surgery. This is the second part of the procedure where treatment is undertaken within 4 months of being placed on the waiting list.

If your condition is judged not severe enough for surgery or not severe enough for assessment, your referral will be returned to your GP, who is then entitled to refer you for reassessment if and when your condition deteriorates.

For further information please visit the Ministry of Health website at www.health.govt.nz and search “elective services” or press the following link:
http://www.health.govt.nz/our-work/hospitals-and-specialist-care/elective-services/questions-and-answers-elective-services#3