A hip replacement, or hip arthroplasty, is surgery to replace a diseased or injured hip joint with an artificial joint or implant. Arthritis-related pain and inflammation, hip fracture and natural wear-and-tear are common reasons for hip replacement surgery.
What Are the Risks and Benefits of Hip Replacement?
Risks include infection, device failure and surgical complications, but for many, the benefits for many people include eliminated pain and increased mobility. While common, it is major surgery that requires months of recovery.
The American Academy of Orthopaedic Surgeons recently released their 2022 Annual Report. It notes that between 2012 and 2022 there were 821,640 elective primary total hip arthroplasty procedures and a total of 1,064,750 hip arthroplasty procedures performed.
Some hip replacements require revision surgery to replace worn parts or address complications. According to the report, however, the revision surgery rate has been declining since 2011.
Candidates for Hip Replacement
The most likely candidates for surgery are those in good overall health but experience pain that disrupts regular activities. Doctors may recommend hip replacement for people with osteoarthritis, hip injuries, rheumatoid arthritis, osteonecrosis, bone tumors and limited mobility to help improve overall quality of life.
Be sure to tell your doctor if your consistent pain or lack of mobility causes depression or other changes in your mental health. Talk to your doctor if you experience the following symptoms:
- Consistent pain in your hip even when not moving or standing
- Pain that prevents walking, bending, climbing stairs or daily activities
- Stiffness in your hip that prevents lifting your leg
- Failure of non-surgical treatments to provide relief
Your doctor will rule out other health problems that may cause your pain and mobility issues. Your risk for complications will also be weighed.
Calculating Complication Risks
Dr. H. John Cooper, a board-certified orthopedic surgeon, tells Drugwatch that each individual patient’s age, weight and medical conditions such as diabetes can affect a patient’s risk for complications following hip replacement.
The risk of a specific complication “can be somewhere between 0% and 3% for somebody who’s healthy and in good shape,” Cooper explained. “There are risk factors that are greater than 20% in patients with the wrong sort of combination of risk factors.”
Hip replacement patients are typically between the ages of 50 and 80 years old. Young teenagers with juvenile arthritis and some people over the age of 80 have successfully undergone hip replacements.
To avoid complications, doctors may advise avoiding jogging, running or participating in high-impact sports following surgery. They may be able to swim, bike or perform other low-impact activities. Talk to your doctor about their specific recommendations for you.
Alternatives to Hip Replacement
Subchondroplasty is an alternative treatment that attempts to promote natural bone growth to repair damaged hips. Doctors inject a bone substitute into the hip joint. The material fills gaps, voids and lesions in the bone. Over time, the body begins replacing the material with natural bone, which can sometimes lead to permanent repairs.
Additional alternative treatments often tried before hip replacement include:
- Exercises that increase muscle around the hip
- Canes, walkers and other walking aids
- Over-the-counter medication for pain without inflammation
- Nonsteroidal anti-inflammatory drugs for pain with inflammation
- Osteotomy of the femur, a procedure that involves cutting and realigning the bone
If alternative treatments don’t improve your mobility or quality of life, doctors may recommend a hip replacement procedure. Your medical history, X-rays and physical exams will be reviewed. MRIs or CT scans may also be taken.
Types of Hip Replacement Surgery
Surgeons use a posterior approach or an anterior approach when performing hip replacement surgery. With a posterior hip replacement, the incision is made at the side or back of the hip. During anterior hip replacement, the surgeon makes the incision at the front of the hip.
The posterior approach, which allows better visibility of the hip joint, is more common, but the anterior approach is becoming more prevalent. There’s no significant difference as far as recovery, but the anterior procedure may pose a higher risk of nerve damage that could cause numbness in the outer thigh.
Patients younger than 50 who are in good health may be candidates for minimally-invasive surgery. The incision is smaller and recovery time after the surgery is shorter for this procedure.
Special bone cement is commonly used to hold hip implants in place, but some surgeons use a cementless fixation technique. Its textured surface allows the bone to grow onto the implant and secure it. A hybrid total hip replacement involves implanting the cup without cement and setting the ball in place with cement.
Total Hip Replacement
Total hip replacement is the most common hip surgery. It uses artificial components to replace the entire hip structure. During the procedure, surgeons insert a stem into the patient’s femur, or thighbone, for stability. They replace the head of the femur with a ball and replace the natural socket in the hip joint with an artificial cup.
Partial Hip Replacement
Partial hip replacement removes and replaces the patient’s femoral head, which is the ball at the top of the femur, or thighbone. It does not replace the socket. A ceramic or metal ball is attached to the top of a stem that’s inserted into the hollow center of the femur. Surgeons typically perform this surgery to repair certain types of hip fractures.
Hip resurfacing helps relieve pain from cartilage loss. A surgeon trims damage from the natural bone ball at the top of the thigh bone. He or she then resurfaces it with a smooth metal covering. The surgeon also lines the natural bone socket of the hip with a metal lining or shell.
Bilateral Hip Replacement vs. Staged Hip Replacements
Staged hip replacement involves replacing both hips one at a time in two separate surgeries. A bilateral hip replacement involves replacing both hips during one surgery.
A staged hip replacement affords the patient recovery time between the two hip replacements. A bilateral hip replacement means a single trip to the operating room, but isn’t recommended for all patients.
Because the risk of blood loss during surgery is greater and patients are under anesthesia for twice as long (up to four hours), bilateral hip replacement is typically recommended for younger patients. Patients are also more likely to require longer hospitalization or inpatient rehab, as well as more rigorous physical therapy and exercise.
Types of Implants
The primary differences between implants are their size and the material of the components. Hip implant components are made of polyethylene (plastic), metal, ceramic or a combination of the materials. All are designed to replicate the body’s natural movements as much as possible.
Metal-on-polyethylene has been used commonly since the 1960s. The ball is made of metal and the socket either has a plastic lining or is made entirely of polyethylene.
Plastic has a smooth surface that causes little friction while the ball moves within the socket. However, MoP implants can produce plastic debris that can eventually cause implant failure and a condition called osteolysis, which occurs when inflammation destroys the bone and the implant in the bone loosens.
Metal-on-metal hip devices are no longer available in the U. S. These hip implants were made from MoM components, meaning the ball, stem and socket were all made out of metal.
The shedding of metal particles could cause a number of serious health issues, including a type of metal poisoning called metallosis. Several models of MoM hips were recalled or taken off the market.
Ceramic-on-polyethylene devices couple a ceramic ball with a socket made from plastic. They may also substitute the plastic socket for a polyethylene lining in the natural socket. With plastic parts, there is still a risk of wear and debris that can cause osteolysis.
Ceramic-on-ceramic devices combine a ceramic head with a ceramic lining in the hip socket. Studies indicate statistically high success rates of CoC implants. The most common failures have been loosening of the lining and component fractures.
The U.S. Food and Drug Administration approved the first ceramic-on-metal hip device in 2011. The ball is made of ceramic and the socket has a metal lining.
Hip Replacement Risks and Complications
Most people who have hip replacement surgery don’t experience major complications. Dislocation and loosening are the most common complications of hip replacement, according to the National Institute of Arthritis and Musculoskeletal and Skin Disease.
Hip surgery complications can include:
- Loosening of implant
- Blood clots
- Bone growth beyond normal edges of the bone
Dr. Cooper told Drugwatch that he categorizes device-specific concerns into two major groups: MoM complications and MoP complications. MoM bearings are associated with a higher risk for failure and metal release from the bearing’s surface. MoP bearings release metal debris where the pieces of the stem or head come together.
“The reactions are similar: inflammation around the joints, fluid collections, and in more advanced cases, tissues damage, bone loss or some of the more rare but serious complications like blood vessel constriction or compressions,” Cooper said.
Most hip implants can last for 10 – 15 years, but can wear out more quickly with an active lifestyle. An estimated 21.2% of all hip replacements that require revision surgery between 2011 and 2021 were because of infection and inflammatory reactions according to AAOS’s 2022 report.
Hip Implant Recalls
Hip replacement recalls have been issued when implant-caused complications impacted significant numbers of people. Several leading device makers have issued large recalls related to hip complications.
- U.K.-based Smith & Nephew recalled all 6,266 lots of its Modular Redapt Hip Systems in 2016 because of “a higher than anticipated complaint and adverse event trend.”
- Wright Medical recalled shells for its Conserve and Dynasty hip replacement lines in 2016 because of metal debris leading to revision surgeries.
- Smith & Nephew recalled almost 6,000 Birmingham Hip Resurfacing, or BHR, components in 2015 because of “revision rates which were higher than established benchmarks.”
- Stryker recalled 9,003 ABG II Modular hip stems in April 2012 after reports of fretting and corrosion. The junction where the device’s angled necks connect shed particles.
- Johnson & Johnson subsidiary DePuy Orthopaedics issued a global recall for its ASR and ASR XL Acetabular Cups in 2010.
- Zimmer recalled 19,000 Durom cup components in 2008 because of false and misleading labeling.
Some of these recalls are also associated with legal action. More than 20,000 lawsuits over DePuy’s ASR and Pinnacle MoM implants were filed.
What to Know About Metal-on-Metal Implants
“Metal-on-metal implants were commonly used up to a third of the time in hip replacement in the early and mid-2000s,” Cooper told Drugwatch.
The devices had higher than expected failure rates. Today, there are no FDA-approved MoM hip implants available in the U.S. and there are only two FDA-approved MoM resurfacing systems available.
“Often in these patients when inflammation around the joints and local tissue damage develop, if caught early, the bearing surface can be changed so permanent damage is not typically done,” Cooper explained.
In rare cases, if unaddressed, patients can experience serious irreversible, permanent tissue damage or bone loss. In the most extreme cases, patients may experience nerve compression, compression of blood vessels and even side effects related to the heart, vision or hearing.
“The patients with these more problematic or riskier implants need regular follow-up with an orthopedic surgeon familiar with hip or knee replacements,” Cooper said. “If they haven’t been within the past year, I would recommend making an appointment with their surgeon who put the device in.”
Some patients filed lawsuits against hip implant manufacturers, claiming the companies knew their hip systems were defective.
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