Total Hip Replacement Surgery: What to Expect

What Is Total Hip Replacement?

Total hip arthroplasty (THA) — commonly called total hip replacement — is a surgical procedure in which the damaged surfaces of the hip joint are replaced with prosthetic components. Both the femoral head (ball) and the acetabulum (socket) are replaced.

THA has one of the highest patient satisfaction rates of any surgical procedure in medicine — over 90% of patients report significant pain relief and functional improvement. Modern implants last 15–25 years in most patients.

Who Is a Candidate?

THA is typically recommended for patients with:

End-stage hip osteoarthritis causing disabling pain
Rheumatoid or inflammatory arthritis of the hip
Osteonecrosis (avascular necrosis) of the femoral head
Fractures of the femoral head or neck (in older patients)
Hip OA unresponsive to extensive conservative treatment
Significant functional limitations (difficulty walking <1 block, rising from chairs)

Age alone is not a contraindication — outcomes are excellent from age 20 to 90 with appropriate patient selection.

Implant Components

Acetabular component (socket):

Metal shell (titanium or cobalt-chromium) with a porous coating for bone ingrowth
Inner liner: polyethylene (plastic), ceramic, or metal

Femoral component (ball and stem):

Titanium or cobalt-chromium stem that fits inside the femoral canal
Ball head: cobalt-chromium or ceramic, available in various sizes

Bearing surfaces (where ball meets socket):

Metal on polyethylene: The most common; proven long-term durability
Ceramic on polyethylene: Reduced wear, low friction
Ceramic on ceramic: Very hard wearing; occasional squeaking
Metal on metal: Largely abandoned due to metal ion concerns

Surgical Approaches

Posterior Approach (Most Common — ~65% of cases)

Access from the back of the hip; excellent exposure, familiar to most surgeons. The posterior capsule and external rotators are repaired at the end of surgery. Higher historical risk of posterior dislocation, though this risk is minimized with modern techniques and capsular repair.

Anterior Approach (Direct Anterior)

Access from the front of the hip, between muscle planes — no muscles are cut. Patients often have faster early recovery and lower dislocation risk. Technical demands are higher for the surgeon and requires specialized positioning tables.

Lateral/Anterolateral Approach

Access from the side; some detachment of the abductor muscles required; can cause limp if abductors don't heal fully.

Day of Surgery

Pre-Operative Preparation

Pre-operative exercise ("prehabilitation") strengthens hip and core muscles
Arrange home modifications: grab bars, raised toilet seat, shower chair
Pre-operative blood donation may be discussed (rare with modern blood conservation)
Anesthesia pre-assessment
NPO from midnight

Anesthesia Options

Spinal anesthesia (most common): Numb from the waist down; sedation given for comfort; associated with less blood loss and lower complication rates than general anesthesia
General anesthesia: Full sleep throughout procedure
Nerve blocks: Added to control post-operative pain; hip block protocols reduce narcotic use significantly

Surgical Steps (60–90 minutes)

Positioning per surgical approach (lateral, supine, or prone depending on approach)
Sterile prep and draping
Incision and approach to the hip joint
Hip dislocated to expose femoral head
Femoral head removed with an oscillating saw
Acetabulum reamed (enlarged) to appropriate size
Acetabular shell press-fit into position; liner inserted
Femoral canal prepared with broaches
Trial components tested for stability, leg length, and range of motion
Final implants inserted
Hip reduced and stability confirmed in multiple positions
Closure in layers; drain placed

Post-Operative Care

Most THAs involve 1–2 night hospital stays; expedited protocols allow same-day or next-day discharge in appropriate, well-prepared patients.

Risks and Complications

Dislocation: The replaced hip can dislocate if moved into extreme positions; most common with posterior approach historically (now minimized with precautions and capsular repair)
Infection: Deep periprosthetic joint infection (PJI) — rare (<1%) but serious; may require revision surgery
Blood clots (DVT/PE): Anticoagulation is standard prophylaxis
Leg length discrepancy: Usually <1 cm; may be noticeable
Implant loosening: Long-term complication; may require revision
Nerve injury: Sciatic or femoral nerve; rare
Fracture: Periprosthetic fracture
Wear and revision: Implants have a lifespan; younger patients more likely to need revision

What to Bring

Comfortable, loose-fitting clothing with elastic waist
Slip-on shoes (you won't tie laces for weeks)
All required grab bars and safety equipment at home
Arranged help for 4–6 weeks
Long-handled shoe horn, sock aid, grabber tool