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Hip replacement and hip revision

A hip replacement operation involves replacing your hip joint if it has been damaged or worn away – this is usually caused by arthritis, but is sometimes the result of an injury. Hip revision (or repeat hip replacement) involves replacing your artificial hip joint if it has become loose, infected or worn out.

You will meet the surgeon carrying out your particular procedure to discuss your care. It may differ from what is described here as it will be designed to meet your individual needs.

Your hip is a ball and socket joint. Usually the ‘ball’ at the top of your thigh bone (femur) moves smoothly in the ‘socket’ of your pelvis, which has a lining of shiny cartilage. The cartilage stops your bones from rubbing together and has no feeling (like fingernails). If your cartilage is worn away, the underlying bone is exposed and your joint becomes painful and stiff, which makes walking and moving around painful. A new hip joint can help to improve your mobility and reduce pain.

If you have a hip replacement, the parts of your bones that are rubbing together will be removed and replacement pieces made from artificial materials are put in their place.

Artificial hip parts can be made of metal, ceramic or plastic – the most common combination is a metal head and a plastic cup. Metal and ceramic parts tend to be more hard-wearing, but they may have other disadvantages. Hip joints can be fixed (‘cemented’) or pressed into place (‘uncemented’). If the hip is uncemented, the metal surfaces are often treated with a substance that will encourage your own bone to grow into the artificial joint and fix it in place. You may also have a hybrid replacement where only one piece is cemented in place.

Metal on metal hip replacements, where both artificial pieces are made from metal, are no longer being routinely used. This type of joint was mainly used for younger, more active people because it was thought that it would be more hard-wearing and last longer. However, there is now some evidence that when the metal parts move against each other, very small particles of metal may rub off, and some of these may get into your blood. Over time, these particles may also damage the surrounding tissues, leading to pain and the replacement joint becoming loose. There is also some evidence to suggest that this type of replacement joint may increase your risk of cancer – some scientists dispute this however, and more research is needed to confirm it.

About hip revision

If you have had a hip replacement, it will usually last from 10 to 20 years, after which you may need to have it replaced.

Renewing an artificial hip joint is more complicated than the original operation because you will first need to have the existing artificial hip joint taken out. If your artificial hip has worn loose, this may not be too difficult, but if it’s still bonded to your bone, the operation will almost certainly take longer.

You may find that your new joint, although a big improvement on your old one, may not improve your life as much as your original hip operation. This may be because your muscles take longer to recover from the build-up of scar tissue and repeat surgery. See our frequently asked questions for more information.

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Hip replacement
How the procedure is carried out
An image showing a hip with arthritis and a hip with a replaced joint

Details

  • Preparation Preparing for hip replacement

    Your surgeon will explain how to prepare for your operation. For example, if you smoke you will be asked to stop, as smoking increases your risk of getting a chest and wound infection, which can slow your recovery. If you’re overweight, your surgeon may recommend you try to lose excess weight. This will help to reduce the strain on your new hip and may also mean you’re less at risk from the possible complications of any surgery.

    The operation is usually done under general anaesthesia. This means you will be asleep during the operation. Alternatively, you may have the surgery under spinal or epidural anaesthesia. This completely blocks feeling from below your waist and you will stay awake during the operation. Your surgeon will advise you which type of anaesthesia is most suitable for you.

    If you're having a general anaesthetic, you will be asked to follow fasting instructions. This means not eating or drinking, typically for about six hours beforehand. However, it's important to follow your anaesthetist's advice.

    Your surgeon will discuss with you what will happen before, during and after your procedure, and any pain you might have. This is your opportunity to understand what will happen, and you can help yourself by preparing questions to ask about the risks, benefits and any alternatives to the procedure. This will help you to be informed, so you can give your consent for the procedure to go ahead, which you may be asked to do by signing a consent form.

    You may be asked to give your consent to have your name on the National Joint Register, which is used to follow up the safety, durability and effectiveness of joint replacements and implants.

    You may be asked to wear compression stockings to help prevent blood clots forming in the veins in your legs (deep vein thrombosis, DVT).

    Bupa On Demand: Hip replacement surgery

    Want to talk to a Bupa consultant about hip surgery? We’ll aim to get you seen the next day. Prices from £250.

  • Alternatives What are the alternatives to hip replacement?

    You will usually only be recommended surgery if non-surgical treatments, such as taking over-the-counter painkillers (eg paracetamol) or anti-inflammatory medicines (eg ibuprofen), or using physical aids like a walking stick, no longer help to reduce your pain or improve mobility.

    It’s possible that you may be able to have a hip resurfacing operation rather than a full hip replacement. This involves removing the damaged bone and covering the surfaces of the ball and socket with metal caps. This surgery is only suitable for a small number of people – whether or not you’re able to have it will depend on a number of factors, including your age and how strong your bones are.

  • The procedure What happens during hip replacement?

    A hip replacement operation usually takes around two hours.

    Your surgeon will make a cut (20 to 30cm long) over your hip and thigh. He or she will then divide the hip muscles and separate (dislocate) your ball and socket joint.

    The ball at the top end of your thigh bone will be removed and a replacement ball on a stem is inserted into your thigh bone. Your hip socket will be hollowed out to make a shallow cup and an artificial socket placed into it. The hip joint is then put back together (the ball is put into the socket).

    Your surgeon will close the cut in your skin with stitches or clips and cover it with a dressing.

    Alternatively, it may be possible for you to have the operation done making one or two smaller cuts (about 10cm) over your hip and thigh. This means that there may be less damage to your hip muscles. This type of operation (minimally invasive hip replacement) is carried out using specially designed surgical instruments. It isn't suitable for everyone and you may be at a higher risk of complications.

  • Hip replacement on demand

    You can access a range of our health and wellbeing services on a pay-as-you-go basis, including hip replacements.

  • Aftercare What to expect afterwards

    You will need to rest until the effects of the anaesthetic have passed. You may not be able to feel or move your legs for several hours after a spinal or epidural anaesthetic. You may need pain relief to help with any discomfort as the anaesthetic wears off.

    A special pillow may be placed between your legs to hold your hip joint still and stop it from dislocating.

    You may be given medicine to prevent DVT, such as rivaroxaban or dabigatran. You will be given this shortly after your surgery and you may need to carry on taking it for a few weeks.

    A physiotherapist (a health professional who specialises in movement and mobility) will usually visit you the day after your operation and at regular intervals afterwards. He or she will give you physiotherapy exercises to do and it’s important that you do these as often as your physiotherapist tells you, probably at least once a day. These are designed to help your recovery by restoring movement and strength in your hip.

    You will stay in hospital until you're able to walk safely with the aid of walking sticks or crutches. This is usually about five days after your operation. When you're ready to go home, you will need to arrange for someone to drive you. Your nurse will give you some advice about caring for your hip and a date for a follow-up appointment.

    Most skin stitches or clips will need to be removed after 12 to 14 days. Dissolvable stitches don't need to be removed.

  • Recovery Recovering from hip replacement

    If you need pain relief, you can take over-the-counter painkillers (eg paracetamol). Always read the patient information that comes with your medicine and if you have any questions, ask your pharmacist for advice.

    The exercises recommended by your physiotherapist are a crucial part of your recovery, so it's essential that you continue to do them.

    There are certain movements that you shouldn't do in the first six weeks. For example, don't cross your legs or twist your hip inwards and outwards. This is to reduce strain on your scar and also the risk of a dislocation. See our frequently asked questions for more information.

    You should be able to move around your home and manage stairs. You may find some routine activities, such as shopping, difficult for a few weeks and need to ask for help. You will need to use crutches for about four to six weeks.

    You can usually return to light work after about six weeks. If your work involves a lot of standing or lifting, you may need to stay off for longer.

    Follow your surgeon's advice about driving as the length of time before you're fit to drive will depend on several factors, including which leg has been operated on and whether your car is manual or automatic.

    See our frequently asked questions for more information about your recovery.

  • Risks What are the risks?

    As with every procedure, there are some risks associated with hip replacement or hip revision surgery. We have not included the chance of these happening as they are specific to you and differ for every person. Ask your surgeon to explain how these risks apply to you.

    Side-effects

    Side-effects are the unwanted but mostly temporary effects you may get after having the procedure.

    Your hip will feel sore for several weeks and you may have some temporary pain and swelling, both in your thigh and also in your ankle. This is normal and may last for several months.

    Complications

    Complications are when problems occur during or after the operation. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or DVT.

    Specific complications of hip replacement are uncommon, but can include the following.

    • Infection – you will be given antibiotics during and after surgery to help prevent this.
    • Joint dislocation – this is most likely to happen in the early weeks and months after your surgery and you may need another operation to treat it. See our frequently asked questions for more information.
    • Difference in leg length – your leg may be slightly shorter or longer and you may need to wear a raised shoe to correct your balance.
    • Hip fracture – tiny cracks can occur in your bone while fitting the new joint. These usually heal, but sometimes your bone can fracture and require further surgery.
    • Unstable joint – the hip joint may become loose and you may need further surgery to correct this.
    • Nerve damage – this can result in numbness around your scar, but rarely the sciatic nerve may be stretched and this can lead to loss of movement and sensation in your foot (this is usually temporary).
  • FAQs FAQs

    Are there any sports or activities I shouldn't do after my hip replacement?

    Answer

    It's important to stay active after you have fully recovered from your operation. However, don't do any high-impact sports that puts a lot of pressure on your hips, such as running, squash or tennis.

    Explanation

    During your recovery your physiotherapist will recommend exercises for you that will improve your strength and range of motion.

    As you recover, you can start swimming (but don't do breaststroke as the sideways kicking can cause a dislocation) and do more walking to strengthen your muscles around the joint.

    When you have made a full recovery, you can have a more active lifestyle. However, try not to run on hard surfaces or take part in sports that could cause injury, such as football or rugby, or activities that put a lot of pressure on your hip such as squash or tennis. It's best not to do any sports with a high risk of falling such as skiing or snowboarding.

    Regular exercise will help to improve and maintain your mobility. When returning to any sport, it's important to take your time to rebuild your strength, co-ordination and reflexes. For example, if you play golf, work on chipping and putting before attempting longer distance shots.

    Your doctor, surgeon or physiotherapist will be able to give you more information about what activities are suitable for you.

    What can I do to make my recovery easier?

    Answer

    It’s important that you try to be as fit and healthy as possible before your operation. You can also prepare your home for when you return from hospital.

    Explanation

    If you're having a hip replacement, it's a good idea to try and be as fit and healthy as possible before your operation to speed up your recovery.

    Your surgeon will explain how to prepare for your operation. For example, if you smoke you will be asked to stop, as smoking increases your risk of getting a chest infection, wound infection or blood clot (deep vein thrombosis, DVT), which can slow your recovery.

    If you're overweight, your doctor may recommend a weight-loss programme. You can also exercise to strengthen your upper body. This will help you to get around after the surgery when using walking aids, such as crutches. If it's possible, try to strengthen your leg muscles. Strengthening the muscles in your legs will speed your recovery and make it easier to do the post-operative exercises. Your surgeon or physiotherapist will recommend exercises for you.

    You may also want to prepare your home for when you return from hospital. This may involve rearranging furniture to make it easier for you to move around safely and placing items that you use often at arm level so you don't have to reach for them. It also helps to stock up on non-perishable food, such as frozen or tinned items, so that you don't need to go shopping immediately after your surgery.

    You may need help after surgery. It's a good idea to arrange to have a friend or family member stay with you for a couple of weeks after the operation.

    What is the most common complication of hip replacement surgery and why?

    Answer

    A common complication of hip replacement surgery is dislocation of your joint (the ball part comes out of the socket). This happens to approximately one in 50 people who have a hip replacement. It's important to take care of your new hip to reduce the risk of it happening.

    Explanation

    Dislocation is a possible complication following a total hip replacement. The risk of dislocation varies depending on the surgical technique used and your general health. For example, if the muscles in your hip area are weak, the joint may become loose. Hip dislocation is more common if you have a repeat hip replacement (an artificial hip joint replaced). Your hip is most likely to dislocate soon after your operation – more than half of dislocations occur within four to 12 weeks. This is because the muscles have not fully healed and are therefore weaker.

    You can dislocate your hip if you bend your hip further than a right angle, for example, if you sit in a low chair. You can also dislocate your joint if you cross your legs and lean forward, or if you lie down and lift your waist.

    Dislocation is more common after hip replacement surgery because during the operation your surgeon moves surrounding muscles and tissue out of the way to get to your hip. Your hip joint is then dislocated and some bone is removed to fit the new parts. This results in the normal stability of your hip joint being affected.

    Your surgeon will repair any damage to muscles and tissues that surround your joint, but your joint will only become stable when your muscles around it have fully healed.

    The exercises recommended by your physiotherapist are a crucial part of your recovery, so it's essential that you continue to do them.

    If your hip dislocates often, you may need further surgery. Alternatively, you may be advised to wear a brace (a fitted support) to stabilise your joint and allow the surrounding tissue to heal.

    Why am I unlikely to walk completely normally after hip revision surgery?

    Answer

    Hip revision surgery is more complex and has a greater risk of complications than the original operation. So, you may find that your new joint, although a big improvement on your old joint, may not improve your mobility as much as your original hip operation.

    Explanation

    Repeat hip operations take longer to complete, are more complex and have a greater risk of complications compared with the original operation. Reasons why your mobility may be affected after hip revision surgery are listed here.

    • Infection. With age your immune system weakens and you're more vulnerable to infection. Infection causes pain and swelling, delays healing and affects your overall health. This may limit how much you can exercise straight after surgery, thus slowing down your recovery. If antibiotics don't help to clear an infection, the implant may need to be removed.
    • Scarring. During a repeat operation cuts are made over the original scars, so the tissue may not heal as well as before. Any infection may delay healing and cause scar tissue to form. Scar tissue can make your leg muscles feel stiff and affect your walking.
    • Fragile bones. With age your bones become thinner, so they are more likely to fracture and there is less bone to hold the new implant in place. As a result, your joint is more likely to become loose or dislocate and this can affect your mobility.
    • Leg difference. During hip revision surgery more bone is removed because the old implant has to be taken out before the new one is fitted. So you're more likely to have a shorter leg and a slight limp.

    Hip revision techniques are improving all the time and there is every chance that you will have a good quality of life afterwards. You may always have a limp, but you should be able to continue to do everyday activities, such as getting dressed, climbing the stairs, getting in and out of the bath and walking short distances. For more information and advice about the operation, ask your doctor or surgeon.

    Why is hip revision surgery more complicated than the original hip replacement operation?

    Answer

    Hip revision surgery is more complicated than the original operation because the existing implants and any cement need to be taken out before a new joint can be fitted. Your bones are more likely to fracture and there is less bone to hold the new implant in place. As a result, repeat hip operations take longer to complete and have a greater risk of complications.

    Explanation

    Currently the artificial joints used in hip replacement last about 10 to 20 years, after which your artificial joint may become loose and need to be replaced. The repeat operation is called hip revision surgery.

    During a hip revision operation, the original implants and any cement used to hold them in place need to be removed before the new implants can be put in. Your thigh bone may have grown into the implant, making it more difficult to remove, and your bones will have become thinner with age. As a result, your bones are more likely to fracture and your new joint is more likely to become loose because there isn't enough bone to hold it in place. A hip replacement with a longer stem may need to be used to get a stronger fix.

    Your surgeon may have to rebuild the bone in your hip using bone taken from another part of your body or from your thigh bone. This is called a bone graft. If you have a bone graft, it may take longer to recover as it may restrict your movement and you might need to use crutches for longer.

  • Resources Resources

    Further information

    Sources

    • Total hip replacement. American Academy of Orthopaedic Surgeons. www.orthoinfo.aaos.org, published December 2011
    • Guidance on the selection of prostheses for primary total hip replacement. National Institute for Health and Clinical Excellence (NICE), April 2000. www.nice.org.uk
    • What are the different types of hip replacement surgery? Arthritis Research UK. www.arthritisresearchuk.org, accessed 24 May 2012
    • Metal on metal hips. British Orthopaedic Association. www.boa.ac.uk, accessed 24 May 2012
    • Concerns about metal-on-metal hip implant systems. US Food and Drug Administration. www.fda.gov, published March 2012
    • Joint revision surgery – when do I need it? American Academy of Orthopaedic Surgeons. www.orthoinfo.aaos.org, published September 2007
    • Questions and answers about hip replacement. When is revision surgery necessary? National Institute of Arthritis and Musculoskeletal and Skin Diseases. www.niams.nih.gov, published April 2012
    • Minimally invasive hip replacement. National Institute for Health and Clinical Excellence (NICE), October 2010. www.nice.org.uk
    • Hip resurfacing. American Academy of Orthopaedic Surgeons. www.orthoinfo.aaos.org, published June 2010
    • Personal communication, Mr Roger Tillman, Consultant Orthopaedic Surgeon, The Royal Orthopaedic Hospital NHS Foundation Trust, June 2012
    • Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults. National Institute for Health and Clinical Excellence (NICE), September 2008. www.nice.org.uk
    • Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults. National Institute for Health and Clinical Excellence (NICE), April 2009. www.nice.org.uk
    • Hip fracture. The management of hip fracture in adults. National Institute for Health and Clinical Excellence (NICE), June 2011. www.nice.org.uk
    • Physiotherapy and mobilisation quality statement. National Institute for Health and Clinical Excellence (NICE), March 2012. www.nice.org.uk
    • Activities after hip replacement. American Academy of Orthopaedic Surgeons. www.orthoinfo.aaos.org, published September 2009
    • Antibiotic prophylaxis in surgery. Scottish Intercollegiate Guidelines network (SIGN), July 2008. www.sign.ac.uk
    • What are the possible complications? Arthritis Research UK. www.arthritisresearchuk.org, accessed 27 May 2012
    • Sosna A, Pokorny D, Jahoda D. Sciatic nerve palsy after total hip replacement. J Bone Joint Surg (Br) 2005; 87(B):1140–41. doi:10.1302/0301-620X.87B8.16550
    • Dudda M, Gueleryuez A, Gautier E, et al. Risk factors for early dislocation after total hip arthroplasty: a matched case-control study. J Ortho Surg 2010; 18(2):179–83. www.josonline.org
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    Produced by Polly Kerr, Bupa Health Information Team, July 2012.

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