a man hiking near a beautiful vista
With a new hip, hiking and other active pursuits are once again possible. (Photo/Creative Commons)

Think you need a new hip? Here’s some square advice

When a friend of mine went to China a couple of years ago, he experienced difficulty navigating the Great Wall because of osteoarthritis of his hip. When he got back home and had to crawl up the steps to his bedroom, he realized it was time to have his hip replaced.

He was not alone in his decision. Not by a long shot. According to the Centers for Disease Control and Prevention, 332,000 hips are replaced in the United States each year. The driving factor to undergo hip replacement is usually obvious, but not always. Sometimes it can be a challenging decision.

We often hear about people having hip replacements because of a broken hip due to falling, but hip surgery is more commonly performed because of osteoarthritis (OA) of the hip. OA is regularly seen in X-rays of those over 65, but surprisingly not all patients with OA are symptomatic.

OA occurs because of a non-uniform breakdown of joint cartilage. Risk factors include genetic predisposition, old age, history of joint trauma, increased bone mass, having participated in weight-bearing sports, or occupations involving prolonged standing or heavy lifting.

Additionally, there are many medical conditions that can predispose someone to OA. These include developmental deformities, gout, Paget’s disease, hypothyroidism and hyperparathyroidism.

Diagnosing hip OA is based on history, a physical exam and X-ray findings. Twenty percent of the time, both hips are affected, so a thorough examination of both hips should be performed not only to diagnose OA, but to exclude other causes.

Typically, pain from OA is related to activity. It starts gradually and increases with continued joint effort. Though it is helped by rest, as OA progresses, pain at night or at rest becomes more frequent.

We often hear about people having hip replacements because of a broken hip due to falling, but hip surgery is more commonly performed because of osteoarthritis.

There are many common masqueraders of hip arthritis, so it’s important to consider other possibilities. It’s disheartening when a patient has hip replacement only to find he or she is no better off than before — because a different cause of pain was overlooked.

One of the treatment goals is to reduce pain and maintain function. Acetaminophen (Tylenol) is traditionally the first-line analgesic treatment in doses up to 3000 mg a day.

If there is an inadequate response, low dose non-steroidal anti-inflammatory drugs such as Ibuprofen (Advil, Motrin) or Naproxen (Aleve) are usually added or substituted. However, these drugs have risks, such as peptic ulcer bleeding, so medicines to protect the lining of the stomach are usually co-prescribed.

Lifestyle interventions include physical or aquatic therapy, education about daily life modifications, exercise programs and weight loss in overweight or obese individuals. Acupuncture appears to help 30 to 50 percent of the time, and the use of a cane may help if balance is an issue.

When OA causes chronic discomfort and significant functional disability, surgery is usually considered, with a preference to operate sooner rather than later.

Most joint implants made with all ceramic materials, or with metal and plastic, can be expected to last 20 to 25 years or more. Stay away from the all-metal implants, which have safety and longevity problems.

The type of surgery the orthopedist performs (anterior, posterior or lateral), or the type of incision, is less important than the surgeon’s experience and whether the procedure is followed by ample physical therapy.

The orthopedic surgeon you choose should have done at least 100 procedures and perform at least 30 per year.

Hip prostheses are designed for people of normal weight. In fact, many orthopedists refuse to do surgery if someone has a body mass index over 40 and will make weight loss mandatory for someone with a BMI in the 30s.

Before surgery, try to get in the best physical shape you can to strengthen your legs and arms. You may want to see a physical therapist beforehand so it will be easier for you to move afterward.

Instructions from your physical therapist may include learning how to use a cane or crutches, how to get up and down from the toilet or how to navigate stairs.

Prior to surgery, consider getting a raised toilet seat, installing grab bars in the shower, and having a firm chair with arm rests and straight back. After surgery, avoid low chairs or sofas, and when sitting in your car, your knees should be lower than your hips.

Before his surgery, my friend purchased a hip kit, which included tools to help him get dressed and pick up items from the floor so he could avoid excessive hip bending. Also, make sure you complete dental work at least six weeks before surgery to prevent seeding of bacteria from the gums to the new hip prosthesis.

After surgery, most people are discharged the same day (or one day later). Mobility right off the bat is crucial because immobility can lead to a blood clot in the leg, followed by pulmonary embolism, which can be fatal.

My friend who went to China was followed closely by physical and occupational therapists for the first few weeks at home. He was given specific exercises to restore movement and strengthen his hip. It’s not an easy process to recover from hip surgery, but he was determined to do well. By six months, he was back on his bicycle and happy he made the decision he did.

Dr. Jerry Saliman

Jerry Saliman, MD, retired from Kaiser South San Francisco after a 30-year career and is now a volunteer internist at Samaritan House Medical Clinic in San Mateo.