Do I really need a hip replacement? What are the alternatives?

Please see 'Treatment of arthritis of the hip FAQs' at www.asiamedicalspecialists.hk.

When should I consider hip replacement?

We believe that modern hip replacements will last for many years, so there is little advantage in delaying the procedure if pain is affecting sleep or daily life despite optimal non-operative treatment. Usually the pain and disability from hip arthritis gradually gets worse, until is it is 'worse than death' [1]. The commonest complaint of patients after hip replacement is 'I wish I had done the operation earlier....'

What Kind of Hip Replacements Are Available?

There is a variety of modern total hip replacements, most of which give very good results. There are three major types of hip replacement:

• Conventional — for the majority of people;
• Resurfacing — for active young people;
• Dual Mobility — for people with special risks of instability of the joint.

Major Modern Bearing Combinations

• Polyethylene with metal or ceramic or ceramicised metal — conventional only;
• Ceramic-on-Ceramic — conventional and resurfacing;
• Metal-on-Metal — resurfacing types only.

What About Activity and Recovery Speed?

Resurfacings offer the best chance of the highest possible functional recovery, with many patients returning to impact sport, including professional sport. Tennis Player Andy Murray returned to top-level competition with a Birmingham Hip Resurfacing.

I believe the benefits of activity outweigh the potential risks to the hip replacement, and I encourage my patients with both resurfacing and conventional hip replacements to be active, and I have many patients with both resurfacing and conventional hip replacements playing impact sports and in other ways using their hips to their fullest ability without problems, including returning to running, skiing, professional dance and acrobatics.

What Gives the Quickest Recovery?

Conventional total hip replacement, using a minimally invasive SPAIRE approach [9], gives a very quick recovery, with only a few activity restrictions until 6 weeks and none after 6 weeks.

Hip resurfacing, because it is a bigger operation, requiring release of more muscles, has a slower recovery, and it's necessary to take it very easy for 6 weeks to allow the soft tissues to heal, and then to limit walking for another 6 weeks to reduce the risk of a fracture of the neck of the femur, giving a total of 3 months of activity restrictions.

What About Other Factors (Instability)?

For most people, the most important issues are longevity and activity, and then speed of recovery. People with unusual anatomy — for example after an injury or spinal problems — or weakness of muscles around their hips — may be at increased risk of instability (dislocation) and may benefit from a special 'dual mobility' implants which have improved stability, though at the potential risk of more early complications and, possibly, shorter overall life of the implant.

What Gives Better Function? Hip Resurfacing or Conventional THR?

As with most things in medicine, there is much debate, but much recent evidence supports the position that hip resurfacings give better function [23-26]. However there are at least two papers which report no difference [27, 28]. One of these papers [28] was criticized [29] for reporting a difference of 10% in walking speed as 'no different' when many would argue that the ability to walk 10% faster is very significant, and the authors are wrong in concluding there is 'no difference'.

The other paper [27] describes a well-designed trial, so there is at least one study reporting no difference in function. In a private discussion, one of the authors of this trial expressed surprise at the outcome, and suggested that, because the trial involved many surgeons, most of whom were not hip specialists, and some were in training, that the resurfacing operations were not done as well as the conventional THRs (because resurfacing is a more complex operation) and thus, on average, the resurfacings were not performing at their theoretical maximum potential. However the trial was not designed to look at this, and, though he theorised that a well-performed hip resurfacing should provide a higher level of function than a well-performed conventional THR, his trial did not demonstrate this.

As far as I am aware, there are no reports of worse functional outcomes in hip resurfacing compared to conventional THR.

What gives better function? Hip resurfacing or conventional THR?

As with most things in medicine, there is much debate, but much recent evidence supports the position that hip resurfacing gives better function [23-26].

However, there are at least two papers which report no difference [27, 28]. One of these papers [28] was criticised [29] for reporting a difference of 10% in walking speed as ‘no different’ when many would argue that the ability to walk 10% faster is very significant, and the authors are wrong in concluding there is ‘no difference’.

The other paper [27] describes a well-designed trial, so there is at least one study reporting no difference in function. In a private discussion, one of the authors of this trial expressed surprise at the outcome, and suggested that, because the trial involved many surgeons, most of whom were not hip specialists, and some were in training, the resurfacing operations were not done as well as the conventional THRs (because resurfacing is a more complex operation) and thus, on average, the resurfacings were not performing at their theoretical maximum potential. However, the trial was not designed to look at this, and, though he theorised that a well-performed hip resurfacing should provide a higher level of function than a well-performed conventional THR, his trial did not demonstrate this.

As far as I am aware, there are no reports of worse functional outcomes in hip resurfacing compared to conventional THR.

Special Considerations: Metal Allergy, Pregnancy, Osteoporosis, and Fracture

I'm Allergic to Metal — Is This a Problem?

Currently the question of metal sensitivity or allergy is controversial. We don't believe anyone is allergic to the Titanium widely used in conventional hip replacement. Metal-on-metal resurfacings, some conventional hip replacements, and many other types of orthopaedic implants are made of an alloy of Cobalt and Chromium.

Although both of these metals are normally used in human biology (Cobalt in Vitamin B and Chromium in the liver enzyme Cytochrome p450) it is thought that some people are sensitive to higher levels of these metals. A test for sensitivity to the Cobalt and Chromium used in resurfacings (and other implants) has recently been reported, and will most likely become widely available [17]. Some older women may be sensitised to metal owing to wearing nickel-containing jewellery. A few men seem to be allergic to metal, developing inflammation and fluid collections around their metal-on-metal hip resurfacings.

Can I Have a Baby After a Hip Replacement?

There is no definite risk to having a baby after having a hip replacement, however, if one has the luxury of being able to schedule both the hip replacement and the pregnancy, it is recommended to either have the baby first, or to delay becoming pregnant until about one year after the hip replacement [18] because of the theoretical risk of birth defects from chemicals leaking out of the implants. I say 'theoretical' risk because, so far, no birth defects have been tied to hip replacements, and most mothers with hip replacements have had healthy babies.

The placenta reduces the levels of many chemicals reaching the baby including metal ions from metal hip replacement bearings [19]. Often the pain of arthritis is less in early pregnancy because of the increase in steroid hormones in the mother's circulation. In later pregnancy increased weight and altered posture may make pain worse. It is safe to take paracetamol and/or to have a steroid injection into the hip joint whilst pregnant.

For women who already have hip replacements, some have increased pain during pregnancy, and many of those who have continuing pain after delivery require revision of their hip replacement, however, compared to age-matched hip replacement patients who do not have babies, there is no difference in revision rate — suggesting that pregnancy does not affect the life of the hip replacement [20, 21]. Most likely the pain is owing to changes in posture associated with pregnancy.

Hip replacement has no effect on childbirth, it does not affect the safety or practicality of either a natural or Caesarian section delivery [18]. It is safe to breast feed with a hip replacement [22].

What If I Have Osteoporosis?

In general, osteoporosis is not a problem. In individuals with osteopaenia or osteoporosis of the neck of the femur (thigh bone), the bone density recovers after hip resurfacing [30-33], but it is necessary to take things easy for about 3 months after the operation. In conventional THR the neck of the femur is removed and replaced with metal, so bone strength is not an issue and one does not need to restrict activity, but there is a greater risk of fracture during the operation in osteoporotic bone. In very soft bone, it's probably best to have a cemented rather than cementless femoral stem.

What If I 'Break My Hip'?

The term 'broken hip' usually applies to older people breaking the upper end of their femur as a result of a fall. Young people can break their hips, but, as the bone becomes weaker because of age-related decreases in bone density, this injury is more common in older people. It is a serious injury.

If one has a hip replacement of some sort, one can still break one's hip — but the bone breaks around the hip replacement. If one has a hip resurfacing the broken hip follows the same pattern as in a natural hip, and is treated in the same way [34]. If one has a total hip replacement the bone breaks around the femoral stem, and is often more difficult to treat [35].

Is there anything else I should consider? There are two papers suggesting that overall mortality is lower over several years in resurfacings versus conventional total hip replacement [36, 37]. This is presently unexplained, though it caused a deal of controversy.

Surgeon's Recommendations and Why These Particular Implants

Although every type of hip replacement represents a compromise, and we do not have the data on which to base a truly informed decision, I recommend either:

1. Ceramic on ceramic resurfacing. I specifically recommend the ReCerf system manufactured by MatOrtho. This is probably the best choice for active young people.
2. Ceramicised-metal on plastic. For older people or those whose anatomy is not suitable for resurfacing. I recommend an Oxinium femoral head on cross-linked polyethylene from the Smith & Nephew company — specifically the R3 acetabular shell and the Polarstem femoral stem (non-cemented for younger people, cemented in selected cases for older people). This is a reliable and proven system — however many other orthopaedic companies make similar systems with similarly good results — but the Polar 3 with an Oxinium on cross-linked polyethylene bearing is one of the best-performing total hip replacements in the National Joint Registry for England & Wales.
3. Ceramic on ceramic. Mostly in revisions where there may be debris that could cause damage to polyethylene. I recommend a ceramic-on-ceramic bearing with the R3 acetabular shell and the Polarstem femoral stem from the Smith & Nephew company.
4. Dual Mobility. For people with unusual anatomy or other problems requiring extra stability. I recommend the OR3O from the Smith & Nephew company.

Why These Particular Implants?

• The MatOrtho ReCerf is a new ceramic-on-ceramic resurfacing hip replacement. It has been in experimental use since 2018 and was CE approved in 2025. Short-term results are excellent [8]. It is a ceramic version of the very successful MatOrtho Adept metal-on-metal hip resurfacing, which is itself very similar to the very successful Smith & Nephew Birmingham Hip Resurfacing. The Adept and the Birmingham hips were originally manufactured by the same company.
• The Smith & Nephew Polar 3 THR, with a proprietary ceramicised metal (called 'Oxinium') on cross-linked polyethylene bearing (known as 'Verilast'), is one of the best-performing total hip replacement in the National Joint Registry for England & Wales and performs very well in my hands. It has a useful design feature in the Polarstem trial implant which allows accurate estimation of leg length.
• For patients with unusual femoral version (twist of the thigh bone), I use the Zimmer Wagner Cone titanium femoral stem, as this allows correction of the abnormal twist. It's a well-proven device, in use since 1990 [38].
• For patients with unusual anatomy requiring a dual mobility implant, I use the Smith & Nephew OR3O system, which works with the Polarstem and Wagner Cone femoral stems and Smith & Nephew R3 (and Smith & Nephew Redapt revision) acetabular shells, and uses an Oxinium on cross-linked polyethylene bearing.

Frequently Asked Questions (FAQ)

References

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