One of the questions I am often asked in clinic from patients in Leeds and Sheffield is:
“When is the right time to have hip replacement?”
This is a question I have given significant amount of time considering and I have discussed with hundreds of patients. Although my main area of expertise is the surgery itself I would consider myself an expert in guiding patients when is the right time to have the operation, ultimately the decision is the patients and the patients alone.
To manage your expectations I do not give a one word answer to this question. In many situations when to have a hip replacement is not a black or white decision, but an evaluation of many factors. Here I will discuss some of the factors that I regularly discuss with patients with arthritis of the hip and knee, this list is not exhaustive but will give an idea of the decision making process. I will discuss functional considerations, social considerations, and degree of arthritis.
Before I start I want to discuss the disease of arthritis, most specifically osteoarthritis of the hip. This is a condition where the cartilage or joint lining fails which commonly results in stiffness and pain. There is no known cure for osteoarthritis and typically the degree of damage to the joint and the symptoms that this causes will continue to increase. In some situations this deterioration can happen very rapidly rather than gracefully over many years. Treatments such as joint injections will help improve the symptoms of arthritis but generally become less effective as the arthritis progresses. If left untreated the cartilage will disappear the bone underneath the joint surface will start to wear away leading to an increase in deformity and an increase in the surgical challenge of a joint replacement. This is not to suggest a patient should rush to surgery as many people with arthritis never need a joint replacement, however the loss of function and challenges of more severe arthritis should be given consideration.
↑ Before and after total hip replacement for bone on bone arthritis
1. Functional Considerations
Firstly lets talk about function before and after a total hip replacement.
Total hip replacement has been described as the operation of the century, it is a fantastic operation that in the vast majority of patients removes the arthritis pain and improves quality of life. There is an important caveat here, and that is a total hip replacement is not as good as the hip a patient is born with but it is better than a badly arthritic hip.
Although a total hip replacement can allow most activities there are some activities I would not recommend such repetitive impacts like running on a hard surface, this may make a hip replacement not last as long. There are alternatives to hip replacement such as metal on metal hip resurfacing that famously allowed Sir Andrew Murray to return to international level sport however this operation is not suitable for all patients, and comes with additional risks such as damage from metal debris.
On the one hand if a patient has a hip replacement too early they may feel that they have a drop in function compared to how they were before the operation, and not be fully satisfied even if over the course of 20 plus years the function may be tremendously higher than if the arthritis was left untreated.
I have recently treated a 49 year old patient with arthritis bad enough on Xray to warrant a hip replacement, however he is a very competitive marathon runner and although he knows he will need a hip replacement at some point but he wants some more year to achieve his sporting goals before then and he is willing to put up with a significant amount of pain to do this. He chose to have an Xray guided injection into his hip which he knows is temporary but has bought him some time, and has subsequently completed another marathon in a sub 2hour 30 time!
On the other hand if a patient with more severe arthritis has a hip replacement they will have an early improvement to their function and will be very happy from the operation, but may have missed out from several years of benefit.
An example of this group of patients is retired coal miners, I treat a lot of these patients working in Yorkshire and typically they are very stoic, just get on with things, and present very late with completely worn out hips, they are all transformed after hip replacement, I just wish I could have met them and offered the operation a few years earlier so that they did not have to suffer for as long.
With regard to timing a hip replacement based on the patients function, it is easy to argue going early or waiting longer is the right thing to do. As a surgeon I make more money for operating so there is a financial incentive to operate early, conversely if I operate later in the arthritis process I can come across as a ‘magician’ for bringing an immobile patient back to life. My thoughts are that arthritis will never get better on its own and will continue to get worse. Once conservative treatments have failed (such as joint injections and activity modification) and symptoms are limiting the activities a patient wants to do then the time has come to consider a hip replacement. This time point will be different of every patient.
It has also been clear to me after performing 100s of joint replacements that once a patients function has dropped significantly then the rehabilitation after a hip replacement is more challenging. If a patients function has meant they are immobile such as in a wheelchair, and a period of time has passed then the rehabilitation is very challenging and often the arthritis pain is removed but the full functional benefits of a joint replacement cannot be achieved. Having a good amount of strength before surgery is an excellent starting point for a fast rehab, and getting the best functional gain. Sometimes I will arrange for patients to see one of the musculoskeletal physiotherapists I work closely with before the operation for pre-habitation to get them as strong as possible before surgery.
2. Social Considerations
Every patient has different social issues to take into account, whether this be work or family. One of the questions I get asked the most is:
“When can I return to work after my hip replacement?”
Again there is no single answer to this. For me the period immediately after a joint replacement should be dedicated entirely to rehabilitation and returning to work too soon could limit this rehabilitation. For a physically light job such as office based I have had patients return to work in a lighter capacity from 3 weeks. For a more physically demanding job patients often go back to a period of lighter duties, and wait 3 months before doing more physical work would be more appropriate, although many have started physical activates much earlier than this.
Invariably patients with physical jobs, which likely contribute to their arthritis, present in the latter years of their employment. This leads onto the question of what is the right timing and right treatment for a early 60 year old with hip arthritis who is still working. Although a hip replacement can have very fast recovery, with daycase discharge and mini-incisions, it is still classed as major surgery and your body will take time to recover. For a patient within a year or two of retirement from a physical job I would have a realistic discussion of whether returning to a very physical job with a hip replacement is the right thing for them, and support can then be given to planning surgery at that stage, or trying to hold out for another year or two with other treatments. The decision making for self employed patients often has bigger financial considerations.
Another common situation I find is patients that are caring for an older relative and they are worried that a hip replacement will stop them being able to perform this role whilst they are recovering. Invariable these are often caring patients that do not put themselves first and present with advanced hip arthritis, and reducing function. This patient group are often really struggling, hence they have come to see me. In this situation my first responsibility is to my patient and if their symptoms warrant a hip replacement I would discuss rehab in more detail and the likely time this would take. Looking at alternative care and support for relatives can often help in decision making. When a patient is really struggling with mobility then prioritising their own care will actually allow them to be better support for their relative in the longer run.
3. Degree of Arthritis
I have intentionally left the degree of arthritis till later down the list as by far the most important factors in deciding when is the right time to have a hip replacement are patients symptoms and function.
In early arthritis there is still cartilage remaining, in advanced arthritis there is no cartilage, and even loss of bone from wear and tear. There is a correlation with the degree of arthritis, most often shown on an Xray, and a patients symptoms, but this is not absolute. There are patients with bone on bone arthritis who can still walk many miles and enjoy their activities, and likewise there are patients with much less arthritis on an Xray who are really limited with their function. This means that an Xray alone cannot decide when is the right time to have a hip replacement.
As a surgeon I would be delighted if the Xray alone said when a patient was ready for a hip replacement, but this is just not the case. There are certain situations when a patient has severe bone loss or deformity on an Xray that make surgery more challenging and need more robust implants at the time of surgery. This complexity will increase as time goes by, and in a patient with moderate symptoms having a more straightforward operation may be a better operation than waiting and needing a more complex operation with a greater period of rehab. This is a relatively unusual situation as often once a patient is developing bone loss on X-rays they will already have severe symptoms and generally will want to have surgical treatment at that time.
4. Age
Historically a total hip replacement has been an operation reserved for an older patient, and historically patients were told the operation would last ten to fifteen years. That is no longer the case. Modern implants and bearing surfaces mean a total hip replacement lasts much longer than the early designs. One of the implants I use has a survivorship of 97% at 15 years. This means that if you have a hip replacement from fifties to sixties onwards there is a good chance that the replacement will never need to be revised.
For the younger patient a hip replacement still has good outcomes, however there is a higher chance of a patient needing a redo or revision operation within their lifetime. Modern implants and operative techniques have meant a total hip replacement has good outcomes in younger patients with lower risks of problems like dislocation in a more demanding patient, this means getting back to more activities such as swimming, horse-riding, tennis are possible. Techniques such as robotic assisted hip replacement (I use the Stryker MAKO system) increase the accuracy of implant positioning which I feel is even more important in a high demand patient. The youngest patient I have personally performed a hip replacement on was 33 years old, this was done after all conservative options had been exhausted and careful preoperative counselling. As the patient was so physically fit apart from their hip arthritis they recovered very fast and returned to the non competitive sport and activities they had previously enjoyed.
Summary
As we approach the end of this article I want to stress again that the considerations here are not exhaustive, and will not apply to every patient. Every patient with hip arthritis will be in a unique situation with different degrees of arthritis, different activities and social responsibilities, and different goals.
I also want to note that the treatments offered by a specialist may affect the treatment a patient chooses. A patient that sees a specialist that just offers joint injections may not have surgery until late in the disease process. Equally a patient that sees a surgeon that only offers surgery may have surgery earlier. I offer non operative treatments including image guided joint injections, physiotherapy, weight loss referrals, and I also offer surgical treatment in the form a total hip replacement. I feel that this allows me to give patients an opinion with less bias, and more based around a patients wishes, lifestyle, and commitments. If you would like to book an appointment to discuss treatment options for hip arthritis please contact my team below.
I have been fortunate to have patients travel to see me for hip and knee arthritis. Many of my patients with hip arthritis come from Sheffield, Barnsley, Leeds and across South Yorkshire. For patients who are further afield and would like to have a discussion about treatment options, or a second opinion I also offer video consultations to avoid the stress and time of travel. If you would like to book a face to face or video consultation please contact my team below.
Get specialist help today
with hip arthritis
Mr Samir Ali Salih
I am a consultant hip and knee surgeon specialising in joint replacements for arthritis using the Stryker MAKO robotic system
This article was written with human intelligence