Hip Replacement Surgery Is Safer and Easier Than Ever

By Marianne Wait

If your hip is kaput and you need a new one, your timing couldn’t be better.

Just a few years ago, you’d probably spend up to a week in the hospital, then more time in an inpatient rehab center. It could take months to get off the walker and crutches, and the first few days of recovery could be downright awful.

Today, many patients spend only one or two nights in the hospital — or even go home the same day. Some skip the walker entirely after they leave the hospital and toss the crutches after a week.

“Joint replacements certainly have come a long way since they were first started,” says Michael B. Cross, MD, assistant professor of orthopedic surgery at Weill Cornell Medical College and an orthopedic surgeon at Hospital for Special Surgery.

Close to 400,000 total hip replacements are done each year in the United States, and the numbers keep growing. “These procedures transform people’s lives,” says Joshua J. Jacobs, MD, a past president of the American Academy of Orthopaedic Surgeons and chair of orthopedic surgery at Rush University Medical Center in Chicago. “They take [people] from being in chronic pain and having functional disability — sometimes being unable to work, unable to care for their families — to, nearly overnight or at least a few days or weeks, dramatically reduced pain and restored function.”

Still, joint replacement is major surgery, and patients should be informed and have realistic expectations. Most doctors wouldn’t recommend it for a patient who has only moderate pain, and some people take longer to recover.

Here’s a look at some of the advances that can make hip replacements easier and safer than before. Find out if they’re right for you.

Better Pain Control
In the past, most joint replacement patients underwent general anesthesia.

Now, “We use epidural or spinal anesthesia and rarely if ever general anesthesia,” says Thomas Sculco, MD, surgeon in chief emeritus at Hospital for Special Surgery and professor of orthopedic surgery at Weill Cornell Medical College. “This makes a huge difference in patient rapid recovery.”

Patients also may get an injection into the tissues around the joint. These are often a combination of several pain meds, steroids and a blood pressure drug. The use of regional and local anesthesia decreases the need for pain medications post-surgery, and skipping general anesthesia lowers the risk of serious complications, such as heart attack and stroke. With better pain control, patients can have a good physical therapy (PT) session the same day as surgery. This “rapidly speeds your recovery,” says Dr. Cross.

“Thirty years ago surgeons would start with a big incision,” says Russell Cecil, MD, founder of Mohawk Valley Orthopedics in Amsterdam, New York. “Today we start with a tiny incision and only enlarge it a bit at a time as needed to complete the procedure.”

Smaller incisions avoid damaging muscle, so patients can recover more quickly, says Dr. Cross. And more surgeons have been using an anterior (in front of the hip) approach instead of posterior (back), which requires less cutting and reattaching muscle and tendon, and can reduce recovery time, although the posterior approach is still more common and works well.

“It’s not the approach that leads to the rapid recovery,” says Dr. Cross, “it’s the surgeon, the pain control, the implant choices.”

“Efficient surgery” minimizes the impact on the patient, says Kenneth Kress, MD, of the Atlanta-area Arthritis & Total Joint Specialists. If surgery takes too long, “they’re going to be too sore, they’re going to be beat up, they’re going to have blood loss and then they’re not going to feel good,” so they’re less likely to get up and move.

An experienced surgeon and facility that handle a large volume of joint replacements offer the best chance of a good outcome. “Surgeons who do this all the time … can do these surgeries in a short, efficient manner with very little tissue damage,” says Dr. Kress.

“The surgeon who does maybe 10, 20, 30 of these a year just doesn’t have the repetition to get really good at it.”

Blood Loss Management
About a decade ago, it wasn’t uncommon for 25% to 50% of joint replacement patients to need a blood transfusion during surgery, which would keep them in the hospital longer. Today fewer than 5% to 10% need a transfusion thanks to smaller incisions and a new medication called tranexamic acid (TXA), which reduces bleeding. Less blood loss typically means less swelling or post-surgical pain.

“Many people regard TXA to be the biggest advance in orthopedics in the last decade,” says Dr. Cecil.

Better Implant Materials
Better plastics have made implants last longer. For hip replacements, most surgeons today are using a ceramic head with a liner made of highly crosslinked polyethylene.

“We’ve looked at wear profile at around 10 to 15 years on new polyethylene, and it’s way outperforming the previous generation, especially [in hips],” says Dr. Cross.

“We know that at 10 years, 97% still have the original implant in place that’s well functioning,” says Dr. Jacobs, and those numbers continue improving with time. Coatings that help fix implants into place also have improved. The porous surface of “non-cemented” implants allow bone to grow onto it.

“These new coatings encourage bone to integrate with the implant surface and improve fixation of the implants,” says Dr. Sculco. These are less likely to loosen, a common cause of revision surgery, and less motion in the implant means less pain.

If a patient has poor bone quality (osteoporosis), bone cement is used to fix the implant to the bone. Although cemented implants have about 90% success rate at 15 to 20 years, Dr. Sculco says, “Cement can be the weakest link in the system and break down with time, so most implants in the U.S. are non-cemented today.”

Home Sooner
Joint replacement patients now typically spend little time in a hospital or rehab facility, where they may be exposed to infection. “You’re not sick; you have a mechanical problem,” says Dr. Kress. “We don’t want you in the hospital around sick people.”

Plus, says Dr. Cross, “Being in your own environment helps you recover quicker.”

Most patients go home after surgery and get physical therapy from a visiting therapist or on their own.

Hip replacement patients typically are “a little stiff, a little slow” in the first three weeks, says Dr. Kress. “By about week three or four, it really turns the corner,” and they’re about 90% recovered after 12 weeks.

The best candidates to go home within 24 hours of surgery are those who are healthy, active and will do the necessary post-op physical therapy.

“Patients who are older and have many medical issues generally stay in the hospital for two days — still much less than the three and four days previously,” says Dr. Sculco. “Patients who are very disabled, live alone, have very little support at home and [are] older generally benefit from a rehabilitation center.” Going home too soon carries risks.

“Major surgery creates stress associated with a risk of medical complications,” Dr. Cecil adds. “If a complication occurs at home, it is less likely to be recognized and treated than if it happened in the hospital. Studies have shown, however, that in properly screened patients, the risk is low.”

Combined, these advances have created a better overall experience for people undergoing joint replacement, making it less daunting so more people can get back to living their lives with less pain.

Originally appeared in Arthritis Today, October 2017. Posted 4/21/2021