Hip Replacement – Do I need one, and when is the time right?
I often get asked this question, sometimes not directly.
A person may come for a first assessment complaining of pain in the hip area and thinking the only treatment for hip pain is surgery, since several people they know have had it. Following questioning and examination I am often pleased to be able to reassure them that they do not show signs of hip arthritis and the pain is easily sorted without surgical intervention.
Or, a client turns up in the clinic a few years after a previous visit with hip pain, and a period of self-management. The pain has increased and is becoming more of a hindrance to life. Is it time to go for surgery?
Osteoarthritis (OA) of the hip has two main presentations:
Mild symptoms gradually develop over many years, initially not affecting activities greatly. Painkillers and anti-inflammatories may be used intermittently when it flares up
Non-surgical intervention is appropriate here and can be very effective.
The patient often has not been aware of any hip problem until a sudden onset of severe symptoms. There may be a trigger such as an injury, fall, heavy impact (such as missing the bottom step) or an increase or change in activity.
An x-ray may show advanced OA but the patient may not have been aware of this, although, on reflection, may recall some hip stiffness of an occasional groin strain.
A trial of non-surgical care should be done but, if problems persist, surgery may be indicated sooner.
Symptoms
Pain is commonly in the groin area, and is worse on impact and deep hip bend eg deep squat or reaching to tie shoe laces. Stiffness, with minimal pain may also occur.
Pain may develop and refer to the front of the thigh and knee, maybe into the front and outside of the lower leg, and sometimes in the buttock.
The groin pain may wake the patient at night. If the pain is on the outside of the hip it may be due to a gluteal tendinopathy, which is a different diagnosis and effectively treated by physiotherapy.
What factors influence a decision for surgery to the hip?
X-rays and scans are helpful in determining the state of the hip joint and the amount of cartilage loss, development of bony spurs and narrowing of the joint space. However, an awful x-ray may not correlate with severe symptoms, and vice-versa; someone in severe pain may not demonstrate many changes on imaging.
It is important to consider how the problem is affecting your life. What are you unable to do due to the hip pain or stiffness? Is it keeping you awake at night? What would you like to be able to do if you didn’t have symptoms? Does it stop your sporting or recreational activities?
The decision and timing is a very personal one, with consideration being given to many factors. Your physiotherapist can help talk through the options.
Key criteria for consideration for surgery
Severity impacting function.
Persistent pain
Not responsive to non-surgical therapies despite a good trial and strong compliance.
Marked changes on x-ray or scan.
Due to considerable advances in technology, it is no longer considered an operation only for older people due to failure of the replacement prosthesis after 10 years or so. Suitable younger patients may have hip surgery to transform their lives, and the prosthesis lasts a lot longer than in years past.
Non-surgical management
Non-surgical management works, and can often delay surgery for many years, if not for ever.
This includes education on hip care and an exercise programme specific for hip conditioning. The patient does have to be committed to this and work hard at it over several months. The exercises need to be carefully selected and appropriate for the individual and strengthening should be graded. Supervision from the physiotherapist is important so that adaptations may be made as necessary, pushing into challenges carefully, respecting the individual joint and the whole person.
Hip joint mobilisation techniques performed by a skilled therapist can help with pain relief and range of movement.
Sometimes injections into the joint are appropriate and effective. These are best given under guiding imaging by a surgeon.
Oral tablets such as anti-inflammatories and painkillers should be used and can be helpful in pain relief, facilitating the exercises.
So, to conclude, total hip replacement is not always necessary! Conservative management is definitely worthwhile before considering what is, despite its common and effective use, major surgery.
However, if the decision is made to go ahead, this surgery is brilliant and can transform your life!
Further information:
https://www.vineyhallphysio.co.uk/services/physiotherapy-in-forest-of-dean
https://www.england.nhs.uk/wp-content/uploads/2022/07/Making-a-decision-about-hip-osteoarthritis.pdf
https://www.nhs.uk/conditions/hip-replacement/
https://dralisongrimaldi.com/blog/total-hip-replacement-is-it-time-yet/
https://gloucestershirehipclinic.com/
Pip Deave Oct 2024
