Is hip pain getting in the way of living your life? Is osteoarthitis making it difficult to walk or complete daily tasks? Are non-surgical treatments no longer working? If so, a hip replacement surgery might be the right option to get you back on your feet and decrease pain.

Hip replacement surgery replaces damaged or diseased bone with a metal and plastic implant, which is designed to replicate a healthy hip joint. Though this surgery can improve your quality of life, the decision of when, and if, a hip replacement is necessary is a complex decision and should be a coordinated discussion between you, your primary care provider, orthopaedic surgeon and family.

Common Causes of Joint Degeneration

Patients frequently ask when the time is right to get their hip replaced. Before considering surgery for hip arthritis, an orthopaedic surgeon will confirm the presence of joint degeneration. There are several potential causes of joint degeneration including:

• Osteoarthritis (most prevalent), a condition in which the articular cartilage that coats the joint surfaces has thinned or completely worn away. When this occurs, the bony surfaces contact each other, resulting in inflammation and pain. Patients also frequently experience diminished range of motion of the involved joint.
• Inflammatory arthritis, the most common being rheumatoid arthritis.
• And avascular necrosis. In avascular necrosis, the ball of the hip joint (femoral head) suffers a disruption of blood supply, and the ball gradually collapses resulting in an uneven, surface which is painful.

Arthritic Hip Pain Symptoms

Arthritic hip pain typically starts gradually and progresses over time – sometimes years. Patients first notice the pain with increased physical activity, but with time can feel symptoms at rest and even pain that impairs a good night’s sleep.

Common symptoms of arthritis include pain that is localized to the affected joint, stiffness, and a sense of catching or grinding. It is common for arthritic hip pain to localize to the front of the hip and thigh with some patients reporting radiation of the pain to the knee. For others, hip joint pain will feel like buttock, thigh or even knee pain. However, numbness and pain radiating down the entire leg are more commonly associated with other causes of pain such as a pinched nerve or sciatica.

Hip arthritis symptoms can wax and wane. When arthritis flares, symptoms can significantly affect your ability to exercise and sometimes even to perform normal daily activities. It’s important to convey to your physician the degree to which your symptoms are impacting your life. One of the key factors in making the decision for surgery is when your quality of life is negatively impacted by your symptoms and other treatments are providing inadequate relief.

The Orthopaedic Evaluation

The most common test to diagnose degeneration of the hip is an X-ray. Sometimes an MRI or CT scan may show early evidence of joint degeneration that is not evident on X-rays; however, these studies are not typically necessary to make the diagnosis.

X-ray evidence of arthritis alone is never a reason to undergo surgery. In addition to the visual confirmation of arthritis from an X-ray, correlating symptoms with your physical examination and X-ray findings is critical to diagnosis and predicting a good outcome from joint replacement surgery. If your symptoms are well managed without surgery, then it’s probably not time.

It is possible, although less common, that patients with X-ray evidence of significant arthritis feel pain from another source. Prior to proceeding with surgery, it is important to understand what component of your pain is attributed to the arthritis and what portion may be from other sources. This is an important conversation to have with your orthopaedic surgeon. You must understand what level of relief to expect, in addition to a good understanding of the risks involved with surgery.

Conservative Treatments

Initial treatment of mild to moderate symptoms includes activity modification, physical therapy, anti-inflammatory or analgesic medication, and sometimes steroid injections into the affected joint. None of these treatments change or reverse the extent of arthritis in the joint. However, there is frequently a period when they mitigate symptoms adequately to allow normal activities without needing to consider surgery.

At Wake Orthopaedics, we encourage patients to remain active and engage in activities with the assistance of non-surgical treatments as long as they are able. This is, of course, provided these treatments are effective and have no significant side effects.

Is Hip Replacement Surgery for You? Talk to your Doctor.

Unfortunately, no surgery is without risks. Thankfully, hip replacement has a very low risk of major complications. Extensive screening prior to surgery is performed to make sure that your health is optimized for the safest surgery possible. In addition, your orthopaedic surgeon will review the results of your orthopaedic evaluation with you, discuss whether hip replacement surgery is the best option to relieve your pain and improve your mobility, explain the potential risks and set realistic expectations of what the procedure can and cannot do.

Once you’ve decided to proceed with hip replacement surgery, you may learn that there are several different ‘approaches’ your orthopaedic surgeon can use to perform the surgery. An approach is the term surgeons use to identify the path they will take to get into the joint to remove the arthritic portion and insert the replacement. The most common of these are the posterior approach and the direct anterior approach. While both approaches can result in long-term success, the most obvious difference between anterior and posterior hip replacement surgeries is the location of the incisions:

• Posterior approach uses a curved incision on the side and back of the hip. The incision curves just behind the greater trochanter, the knobby bit of bone that sticks out at the side from the top of the femur (thigh bone). Currently, this approach is the most common approach used.
• Direct anterior approach is a muscle-sparing approach that does not require any muscles to be cut. Instead, it uses an incision at the front of the hip that typically starts several inches below the pelvic bone and extends down toward the top of the thigh, allowing the surgeon to work in between muscles supplied by different nerves.

While there is no ‘best’ approach, the ultimate success of the surgery is dependent on proper positioning of the implants and avoidance of complications. In the last 15 years, the direct anterior approach has gained in popularity amongst some surgeons and patients. Proponents of the direct anterior approach cite earlier improvements in functional and clinical outcomes, lower postoperative pain levels, lower dislocation rates, lower postoperative opioid use and earlier discontinuation of assistive devices such as walkers and canes. However, the direct anterior approach can be technically challenging and difficult to learn. This learning curve is associated with a higher risk of complications including fractures, dislocations, and nerve injuries.

The choice of when it’s time for a hip replacement and which approach to use should be a combination of surgeon experience, patient factors and joint decision-making. Your surgeon will discuss the pros and cons of continued conservative management vs. hip replacement. Most surgeons have a preferred approach and can give an informed opinion on the advantages of that approach.

A hip replacement can be life-changing and positive for your well-being. However, you need to be confident that it’s right for you. At Wake Orthopaedics, we’re here to answer questions and help you find ways to recover and enhance your quality of life.

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About Timothy Harris, MD

Dr. Timothy E. Harris is a board-certified, fellowship-trained orthopaedic surgeon. He has expertise in the diagnosis and management of hip and knee arthritis, fractures and adult musculoskeletal deformity. He performs fracture and trauma surgery for the extremities, pelvis and spine and adult reconstructive surgery for post-traumatic and degenerative conditions.

Dr. Harris has received numerous awards for his research and teaching, and his peers have repeatedly selected him as one of ‘North Carolina’s Best Doctors.’ He teaches nationally and internationally and has a special interest in joint replacement surgery, including minimally invasive anterior total hip replacements and total knee replacements.

Dr. Harris was born and raised in Lynchburg, VA. He received his bachelor’s degree in German from Davidson College and attended medical school at the University of Virginia. He completed his orthopaedic surgery residency at the University of Arizona and then continued his postgraduate training with a fellowship in orthopaedic trauma at the R. Adams Cowley Shock Trauma Center in Baltimore, MD.