Everything you need to know about hip replacements

So effective is hip replacement surgery that more than 100,000 operations are carried out in England and Wales each year.

“Along with cataract and cardiac stent surgery, hip replacements are probably the most impactful procedure we can do for patients,” says Hugh Apthorp, an orthopaedic surgeon who has performed 10,000 operations. “It’s mainly because the effects of having an arthritic hip are so pervasive on people’s lives, that the difference afterwards is very dramatic,” he says. 

In 2018, 109,600 hip replacement surgeries were performed, 85 per cent of which were funded by the NHS. And patients are happy with the results too: 97 per cent of patients receiving an NHS-funded hip replacement in 2018-19 reported an improvement in hip function.

“With conditions such as heart disease or diabetes you can only help people live with their conditions, whereas a hip replacement is a cure. It can give you back a normal life and the failure rate is very low,” continues Apthorp. “Outcomes have improved considerably since a decade ago. Patients are usually home the day after surgery and very quickly regain their movement.”

• Who is most at risk of needing a hip replacement?
• What happens during a hip replacement procedure?
• What to expect post-surgery
• What is the recovery period for a hip replacement?
• What are the risks with a hip replacement?
• Why are more people having hip replacements?
• Lifestyle factors
• Travelling abroad for surgery

Who is most at risk of needing a hip replacement?

Most hip replacements are performed on people between 60 and 80 years old. Patients aged 50 to 69 accounted for nearly 42 per cent of NHS surgeries carried out in 2018 to 2019, compared to nearly 52 per cent for those over 70. 

The most common reason for surgery is osteoarthritis, which affects around eight million people in the UK and usually develops in the late 40s or older. The condition breaks down cartilage (the cushion between the bones), leaving the bones to rub against each other, often causing severe pain.

Other conditions that can cause hip joint damage include the autoimmune disease rheumatoid arthritis, injuries and birth abnormalities.

“The vast majority of people who need a hip replacement have wear-and-tear arthritis,” says Apthorp, who practises at London Bridge Hospital. “Occasionally you get people with abnormally shaped hips and they tend to present younger. Sometimes they’ve had a traumatic event, such as a sports injury, or they may have a tendency to get inflammation in their joints, often caused by rheumatoid arthritis. The modern management of rheumatoid arthritis is much improved, which means we’re seeing fewer patients with this condition coming for hip replacements.”

Nearly 60 per cent of hip replacements are carried out on women. Apthorp says: “Women tend to live longer and so are more likely to develop arthritis. They’re also more prone to be affected by abnormally shaped hips. This is because of the presence in the womb of oestrogen, which has a big effect on how the hips develop. Female babies are exposed to more oestrogen in the womb.”

What happens during a hip replacement procedure?

The hip joint is made up of a ball and socket – the ball, also known as the femoral head, is at the top of the thigh bone and the socket is made of bone and cartilage.

During hip replacement surgery, the surgeon makes one or more incisions into the hip, removes the damaged ball and socket and replaces them with synthetic parts made of plastic, metal, ceramic or a combination. The surgery usually takes between one and two hours and may be performed under a general anaesthetic or a spinal anaesthetic, such as an epidural, to make everything below your waist numb.

“The muscles around the hip are cut during surgery to allow access to the hip socket,” says Apthorp. “Surgeons like me have developed minimally invasive methods where we make smaller incisions, moving the muscles aside so we don’t have to cut them as we used to in the past. This means patients recover much faster.”

Patients can have their replacement cemented into place or uncemented, in which case the bone heals directly onto the replacement. Both methods are long-lasting but the uncemented method is often used on younger patients.

“Most older patients have cemented replacements and they’re likely to last a lifetime, more than 25 years,” says Apthorp. “Younger patients tend to have their replacement uncemented because it allows for greater accuracy and reduces the risk of complications. I prefer not to use cement on my patients, but the results are broadly similar so you shouldn’t feel one method is superior to another. It comes down to the surgeon’s skill.” 

What to expect post-surgery

You may be on your feet and able to move around on the day of surgery and should be able to leave hospital within a few days. Recovery time can vary depending on the state of your hip pre-surgery, your age and physical fitness. The National Institute for Health and Care Excellence (Nice) recommends hip replacement patients undergo rehab on the same day as surgery.

“Physiotherapy provision after a total hip replacement varies around the UK,” says Lucie Gosling, a consultant physiotherapist at the Royal Orthopaedic Hospital, Birmingham. “It can depend on the services available and patients’ needs and preferences.

“Many patients recover well and continue with their own rehabilitation at home with advice and exercises provided. If patients are having difficulties with daily activities or have specific impairments and are struggling to reach their goals, then one-to-one physiotherapy or physiotherapy classes can be recommended.”

What is the recovery period for a hip replacement?

It can take up to 12 months to fully recover from total hip replacement surgery, although some patients recover much more quickly, Gosling advises.

“Being overweight or obese can increase the load on your joints and it can have other negative effects on your general health, including an increase in systemic low-grade inflammation,” she says. “Being a healthy weight is recommended when managing hip osteoarthritis and when having surgery.

“Age is not always a great predictor of how someone will recover. There are many fit, active and healthy older patients who recover more quickly and return to a higher level of activity than some younger patients.”

What are the risks with a hip replacement?

Although very rare, there’s a small chance of developing a blood clot in the leg, which could travel to the lungs and can prove fatal. Other risks, also very rare, include dislocation after the surgery and infections.

“The risk of something going wrong is now very rare,” says Apthorp. “Getting patients up and moving quickly has greatly reduced the risk of blood clots in the leg. Dislocations are also very rare and occur when surgeons get the alignment of the implants wrong, so it’s important to find a surgeon who has performed lots of hip replacements and has good results. It’s always a good idea to ask how many hip surgeries the surgeon has performed and how many revisions. 

“A good surgeon will also use good surgical techniques and protocols that should avoid common infections and complications.”

Why are more people having hip replacements?

This could be due to changing societal norms, suggests Apthorp. “The main reason for the increase in uptake is probably because of the successful long-lasting results and people’s unwillingness to accept anything other than perfection.

“These days if you can’t walk to the shops, you wouldn’t say, ‘This is what I have to put up with now I’m older.’ People have to work until they’re in their late 60s and they want to live long and productive lives.

“If someone’s 80 and still playing tennis, which plenty are these days, then they find they can’t do it any more because they need a hip replacement, I think we should get them sorted out and back playing tennis. It’s about giving people back their quality of life whatever their age. People don’t want to stop living their lives just because they’ve got a bad hip.”

Lifestyle factors

Could our lifestyles be contributing to the need for hip replacements?  

“Some of the younger people I treat, particularly men under 50, have led very athletic lives and this is fine as long as you don’t do things to the extreme,” advises Apthorp. “For example, running has proven health benefits, it gets you out and exercising and will help your long-term health. 

“But if you run lots of marathons, you start to push through the pain to get to the end. Ignoring pain is when joints can be damaged. We’re not really designed to run lots of 26-mile marathons. The gentle stretching of yoga can be very beneficial, but if you take it to the extreme, you can start to injure your joints.”

There are steps we can all take to protect our hip health, says Gosling: “Maintain a healthy weight, eat a balanced diet, don’t smoke and make sure you do regular exercise to maintain hip movement and keep the muscles strong.”

Travelling abroad for surgery

More than 60,000 NHS patients were waiting more than a year for elective trauma and orthopaedic surgery from December 2021, compared to 436 in January 2020, according to the British Orthopaedic Association. So it’s not surprising that many choose to travel abroad for treatment, although they do so at their own risk. Along with knee surgery, hip replacements are the most popular reason for travelling abroad for healthcare. Clinics in Lithuania, Poland and Hungary are popular destinations. Many offer packages with aftercare and physio from between £5,000 and £9,000. Georgia is the cheapest country, offering hip replacements for under £2,500.

Prices for private replacements in the UK vary, but can top £15,000. According to the National Joint Registry, despite the cost of living crisis, there are now more hip replacements performed privately than within the NHS, with the number paid for privately almost doubling since 2019.

Apthorp advises checking that the surgeon is a specialist in hip operations. “As with any surgeon, it’s important that they’re willing to share their outcomes with you,” he says. “All surgeons need to be honest about how many operations they do and how many revisions so that patients can make an informed choice about whether to use them.”

‘Within a year of the surgery I cycled hundreds of kilometres from Toulouse to Barcelona without any hip pain at all’

It was something of a shock for keen sportsman Joe Haile when he was told he needed a full hip replacement at the age of 39. The consultant engineer from London had led an active life since childhood, participating in sports such as football, skiing and swimming.

But in his mid-30s he noticed stiffness in his hip area that developed into a jarring pain when he ran. A visit to his GP led to an X-ray, but he was told that no problem could be identified so he struggled on for another eight months. During this time, the pain worsened and he had to give up his beloved football. Soon even walking became so uncomfortable he developed a limp.

“Walking downhill or down stairs was when I felt the most pain, but even simple movements like bending down or putting on shoes and socks made me wince,” says Joe, now 50. “I was limping quite badly and felt in pain most of the time.”

“When I got private insurance and had my first appointment with a specialist, he was shocked by the state of my hip. He said the joint was badly damaged and must have been for quite some time. He was surprised I could walk at all. 

“The consultant said I needed an immediate hip replacement. It was a shock but it was reassuring to know that undergoing the operation was likely to mean I could get back to normal life with no more pain.” Within days, Joe had undergone a complete hip replacement under an epidural, a spine-blocking local anaesthetic where you’re awake but can’t feel any pain. He spent five days in hospital and was able to walk with the help of crutches within two days.

“I had an epidural rather than a general anaesthetic because I’m asthmatic. It was weird hearing all the noises of the operation without feeling any pain.” With the help of physio, Joe made a rapid recovery, aided by his relatively young age and physical fitness. 

“There was quite a lot of bruising on my thigh and buttock area which lasted around a week. I had physio twice a week for two weeks, then weekly for four weeks. Within six weeks I was fully mobile.” 

The success of the surgery meant that Joe was able to go back to his active, sporting life.  

“Within a year of the surgery I cycled hundreds of kilometres from Toulouse to Barcelona without any hip pain at all. I now go to the gym three times a week and regularly swim and cycle. And I’m back throwing some moves on the dancefloor now, which is also good for the soul. 

“I was told that there wasn’t much cartilage in my joints, which caused the hip joint to wear away more quickly than it would for many people. I was warned the same would happen to my other hip and it’s actually becoming quite stiff and painful now, so I’m expected to have replacement surgery in around a year’s time. I won’t be concerned though because I know what to expect and I know how effective the surgery is.”