Before you need hip replacement surgery abroad with Saint James Hospital, you are likely to have tried other treatments, such as pain relief medication and aids to help you walk.  If these options have failed to deal with the severe pain you’re experiencing in your hip joint and your lack of mobility, then a total hip replacement is probably the route to take. 

Total Hip Replacement surgery, or athroplasty, refashions the entire hip joint by replacing damaged, diseased and painful parts of the hip with an artificial, ‘ball-and-socket’ hip joint (a prosthesis).  

The surgery is a major operation lasting between two and four hours, but it has been performed routinely, safely and widely since its inception in the 1960s.  It is one of the most successful surgical procedures of the last 50 years.  The choice and durability of the prosthetics is constantly improving and today, a range of replacement ‘ball and socket’ hip joints are available, made from non-corrosive metals like steel and titanium as well as plastics and ceramics. 

After surgery, you will need to allow considerable time for convalescence during which you will learn how to gain your mobility again and go about a normal daily routine safely, taking care of your new hip joint.  Total Hip Replacement will enable you to perform the regular activities you enjoyed before your pain and lack of mobility set in, but it won’t enable you to take up certain strenuous activities or sports.    Be realistic about the new lease of life it will give you. 

Your surgical team will talk to you about the after care required, both in Malta and on your return home.  You are likely to require not only our immediate nursing team, but also physiotherapists and occupational therapists.  Once back home, you may need the assistance of any social services too if you feel you may benefit from special household or mobility aids. The range of services you may require needs to be thought through before your operation.  

If all goes to plan, you can expect to need to stay in hospital for around 7 days, and in your chosen accommodation for 14 days, before you will be signed off as fit to travel home. 

Total Hip Replacement is most commonly called for when a person has osteoarthritis in the hip joint.  It is also used to assist people with rheumatoid arthritis, a hip injury or deformity, or a hip damaged by other medical conditions such as bone tumor or bone loss resulting from a lack of blood supply (avascular necrosis). 

Total Hip Replacement is usually the last resort once your doctor has tried non-invasive treatment to relieve your pain and increase your mobility.  The surgery is more commonly carried out on people over 50 years, with the largest age group of candidates between 60 to 80 years old. 

However, younger people who have premature arthritis or have had an injury may be recommended for a total hip replacement.  Younger people may find their consultant advises only a partial hip replacement surgery involving hip resurfacing, which removes less of the bone. 

Rest assured that your surgeon’s recommendation about which operation is best for you is not based on age alone, but also on your general health, and the extent of your disability and pain.  If you have a total hip replacement while young, you should be aware that the prostheses used may only last up to 15 years and you may need revisionary surgery later on in life. 

You are likely a candidate for total hip replacement if you:

• Have hip pain that limits even routine activities  – bending, getting in and out of bed, standing from being seated, bathing, gentle walking, going up and down stairs and so on
• Find that your hip joint pain continues even when you are resting, either during the day or at night
• Pain and stiffness prevent you from moving, lifting or crossing your legs
• Have taken courses of anti-inflammatory medication to no avail
• Have unpleasant side effects from your medication to relieve pain    
• Find that walking aids (canes, sticks etc) are proving useless in giving you greater mobility or reduction in pain and stiffness

What Total Hip Replacement surgery will do

A total hip replacement allows you to go about your daily routine free from the intense original pain and stiffness you experienced before.  You need to be realistic about your life style post-op though as you may not be able to do more than before your pain set in, and possibly less.  Don’t expect to take up strenuously active sports, for instance. 

It is important you follow advice about how you should move, what sports and exercise you can do safely with your new joint, and how to exercise to assist your recovery.  If you once had a routine or job involving lengthy periods of standing, weight bearing, lifting, climbing, or other physical demands, you may find you won’t be able to return to that kind of lifestyle without the possibility of undermining your hip replacement surgery – the threat of hip dislocation, fracture, or undue stress and strain prematurely wearing out the prosthesis.   

The first reliable prosthetic for Total Hip Replacement came on the market in the 1960s, when a replacement ball-and-socket hip joint comprising a metal ball and plastic socket first became available.  Since then, great strides have been made in refining the materials so that today we have components that provide the most frictionless operation of the prosthetic joint as possible. 

Prosthetic materials are biocompatible, which means that they are designed to be accepted by your body.  They are also designed to be as impervious to corrosion and wear as possible.  Today, you find prosthetics made from stainless steel, chrome, cobalt and titanium, as well as ceramics and durable plastics. 

Your surgeon will advise which shape, size and materials are best for your needs.  At Saint James Hospital, we guarantee you will be fitted with prosthetics from leading, international brand-name suppliers.  In the case of hip replacement, our surgical partners in Malta use prosthetics from Johnson & Johnson.  It may also be possible, should your surgeon advise, for you to have custom-made components to improve the outcome of your operation.

The consultation is the most important part of your decision to undergo surgery abroad with Saint James Hospital.  Total hip replacement is a major operation (2-4 hours) which entails not only a fairly lengthy convalescence period but also considerable forethought and preparation. 

You will, for instance, need to be thoroughly examined, and your medical history gone over in great detail.  You may need blood taken to be used in the operation itself, and this may require you to have medication levels altered or to undergo any other medical or even dental treatment you need well before your intended date for hip replacement surgery. 

All this and more needs to be covered at the consultation stage, so that you are prepared and can get the greatest benefit from your hip replacement surgery abroad.  Below, are some of the procedures you may need to undergo during the consultation stage plus things to think about and prepare for.  It is not an exhaustive list, but will give you an idea of the planning required.

Pre-operative assessment

You may be required to have:

A complete physical examination

This can be done by your regular doctor back home. It will, among other things, check your general health and look for any other medical issues that need to be treated prior to hip replacement surgery.  Your physician will look, for example, for diabetes or high blood pressure.  The examination will also assess you physical ability – your strength, the mobility in your hip and other joints and so on.

X-Rays and MRI Scans

These will assist your surgeon in understanding the extent of your hip damage, bone density and so on.

Blood tests and/or blood taken

Blood tests are drawn one or two days before surgery to examine your general health state to determine if any signs of infection are present or to determine how a specific organ is functioning.

Urological examination

If you are prone to urinary tract infections or have a history of prostate problems or cancer, you may need urinary tests.

Dental treatment done prior to surgery

Bacteria can enter the bloodstream during invasive dental work, so many surgeons advise you to have any major dental treatment completed up to two months before surgery, and to delay any for several months post surgery.  This decreases the likelihood of infection around the new hip joint during or post-operatively. 

Other health issues

You are likely also to have your weight and strength assessed.  Since the hip is the body’s major load-bearing joint, it will have greater stress if you are over weight or obese.  Your surgeon and physicians in your home country may advise you to loose weight and adopt as healthy an eating programme as possible in the months before surgery. 

Similarly, smoking can slow down the healing process as well as increase surgical risk, so you are advised to quit permanently if you can, or at least temporarily. 

What to expect from the surgeon

Below, is a general list of topics that apply to most surgical procedures.  You should be prepared to supply information on and/or discuss with your surgeon:

• Your expectations of the surgery
• The likely results of your particular operation
• Any medical conditions, drug allergies and medical treatments
• Use of current medications, vitamins, herbal supplements, alcohol, tobacco and drugs
• Any previous surgery
• Any family history that may be relevant such as instances of arthritis, bone cancer and so on 

During the consultation, your surgeon is likely to:

• Assess your general health
• Evaluate any health conditions
• Discuss the likely results of your surgery
• Discuss the value of and any complications of hip replacement surgery
• Talk about the type of anesthetic used, its effects etc

You may be asked in preparation for surgery to:

• Take or stop certain medications or adjust your current medications
• Have certain lab tests or further medical evaluation
• Refrain from smoking in advance of surgery
• Avoid taking aspirin, anti-inflammatory drugs and herbal supplements as they can increase bleeding

Questions you should ask your surgeon

It is important that you are fully informed of the after care, any possible complications and the likely results of your surgery.  You will also need to know how the procedure is carried out, which type of prosthetic will be used, and how you will need to care for your new hip joint.  Below is a checklist of some key questions to ask:

• How will the surgery be performed?
• Which type of prosthetic is best for me?
• How do I best prepare for the operation?
• Do I need assistance in post-operative care – occupational therapists, physiotherapists, extra help at my accommodation and on my return home?
• What results can I expect?
• What risks and complications may occur? 
• What discomfort will I have? 
• What is my prognosis in the short term (first months to a year) and longer term?
• How long can I expect my new hip joint to serve me, given my lifestyle?
• Are there any activities or environments I should avoid while I recover, and any I need to avoid longer term?
• Following the operation, what exercise can I take and when can I start? 
• What activities can I expect to resume and when? 
• Will I need any revisionary surgery?
• What instructions should I follow after the operation?

Anesthetics & Pre-op

Surgery is performed mostly under general anesthetic, but can be carried out with a spinal epidural which numbs you from the waist downwards although you will be conscious during the operation.

In general anesthesia, you will have an intravenous tube inserted in your arm to administer the medication and fluids required during surgery.  Compression stockings will be placed on both legs to help avoid the risk of deep vein thrombosis.

The Surgery

The operation itself takes between two to four hours depending on the extent of the diseased bone in your hip and the technique involved.  

An incision is made on the side of your hip to allow the surgeon access through the hip ligatures and muscle to your hip joint.  The first procedure is to cut the thighbone (femur) to remove the damaged part. 

The new metal ball and stem are then inserted into the head of the femur.  They can be made firm, ‘cemented’ in place with a dough-like substance which is the most preferred method in hip replacements.  Alternatively, the new ball can be left ‘non-cemented’.  This latter method is more frequently used with hip replacements in younger people as the patient’s own bone is likely to grow and fuse the prosthetic within the femur.  At this stage in the operation, the surgeon will be trying also to ensure that your leg length remains uniform and as it was prior to the intervention.  

The surgeon then works on the socket part of the hip by smoothing any part that is damaged and then fitting the new socket in place before putting the prosthetic joint fully together. Your surgeon will be assessing at this stage the smooth working of the prosthesis before restructuring ligaments and muscle and closing the incision.  The incision is then dressed and drainage tubes inserted and left in place for up to two days to prevent fluid build up. 

Immediate post-op

In the recovery room, you will be attended by nursing staff who monitor your medication and fluid levels, blood pressure, pulse and other major indicators of your general well being following the operation .  They will also be looking for any signs of any deep vein thrombosis building up in your legs or moving to your lungs.

Once your anesthetic has worn off, you will receive pain-relief medication and be encouraged to cough to clear your lungs.  To stabilize your position, you will probably have pillows, a strut or a foam wedge placed between your legs.  Later that day, when you are totally alert, you will be taken to your hospital room. 

The prognosis for success in total hip replacement surgery is good and most people find they have a dramatic reduction in hip joint pain and are able to return to their routine enjoying a far greater quality of life.  If have reasonable expectations about your new lease of life and follow the advice on the care of your new joint, you can expect the long-term gain to far outweigh the short-term discomfort of your operation.

Immediate recovery

For hip replacement surgery to succeed in the early days, you will need to follow clear guidelines on post-operative care and then be prepared to learn how best to carry out daily functions such as getting out of bed, bathing and so on.

Even as early as the day of your operation you may be asked to see if you can sit, aided, dangle your feet over the edge of the bed and gently move your toes. This is to ensure better blood circulation and to help prevent the likelihood of a deep vein thrombosis. 

By day one and two following your operation, you will be asked to make some first, gentle, aided steps.  You may have the services of a physiotherapist in the early days following the operation.  The physiotherapist will help you improve you mobility by working with you to help you walk and do gentle exercises.  You will find you have discomfort during these first days, but try to persevere as it is important for your healing process that the hip is strengthened and that your circulation is improved. 

Your physiotherapist will also be using a variety of aids such as a stroller/walker and crutches.  You will have clear instructions about what to undertake and how much weight/load bearing your new hip can sustain, both short term and long term.  If you had a non-cemented hip replacement, then you can expect to have greater restrictions, between six to eight weeks, while your own bone and muscles grow in place to cement the prosthesis. 

Usually, after about seven to ten days in hospital, and if you have made sufficient progress, free from any complications such as infection or thromboses, you can return to your accommodation to continue the gradual rehabilitation.   

Long-term care

At your accommodation, you will be constantly in touch with and monitored by the after-care team, including nursing staff and a physiotherapist. You will need assistance still to carry out these daily functions so it is important before you arrive in Malta to have discussed with both your surgeon, friends and family both your after-care needs in Malta and on your return home.

Long-term recovery planning will be specific to you and need to be worked out to fit in with your needs and proposed lifestyle and work routine.  However, there is general advice which applies to nearly all people who have had total hip replacement surgery.  Below are some of the common instructions given hip replacement patients:

• Continue with pain-relief medication as long as is recommended by your surgeon, or doctor back home.
• Continue to wear the compression stockings for the first weeks at home.  Since it is very tight, you will need assistance in changing it. 
• Continue the exercises advised by your physiotherapist.  These exercises are designed to build your stamina, encourage circulation and generally help aid your recovery and return to independent living. 

Avoid:

• Certain movements and positions in the first eight weeks post-op
• Do not bend more than 90 degrees, twist or bend sideways at the hip, or twist your hips inward or outwards. Check with your own physiotherapist for precise details.
• Driving for six weeks (or more if advised by your physician)
• Long periods of standing
• Lifting weighty items – for around three months
• Crossing the operated leg over the other one
• Twisting your leg outwards or inwards (duck- or pigeon-toe positions)

There are numerous adjustments you may need to make to your individual lifestyle.  In general, you will be advised to refrain from high-impact sports such as jogging, basketball and tennis.  You will need to take advice about what to avoid and how to tackle other activities such as cycling, golf and skiing.  Some sports have greater risk of causing a fall, even if they are not in themselves impact sports.  Before returning to or taking up any sport or more strenuous activity, seek advice from your physician.

Total Hip Replacements have a good safety record and have been performed as a common, routine operation since the 1960s.  Most people undergoing hip replacements report significant gains in terms of pain reduction and greater mobility. The operation can bring a noticeable improvement in quality of life, and even a ‘new lease of life’ for many people.

However, it is difficult to gauge with total accuracy the results for each individual.  The outcome depends also on the expectations set beforehand about what the surgery can and can’t do to enhance a person’s life. 

It is wise to remember that you are being fitted with a prosthesis, which, while excellent in terms of its composition and functionality, can never replace the strength and durability of a natural, healthy hip joint.  Depending on the age you are at when you undergo the operation, the prosthetic joint may or may not last the rest of your life.  A prosthetic joint will probably give a good 15, even 20 years of service, but younger patients may find that they need revisionary surgery, even another hip replacement during their lifetime.

You should discuss the risks and complications with your surgeon at the consultation stage.  Ideally, you should try to map out what your lifestyle and expectations are as your post-operative routine will have a bearing on the longevity of your prosthesis.