Hip Arthroplasty: What it is, Types and Surgery

• Hip arthroplasty is the surgical replacement of a damaged joint with an artificial prosthesis.
• Prosthetic hip replacement is one of the most important medical advances in history, allowing many patients to improve their quality of life.
• Hip arthroplasty can be of different types depending on many factors which are explained below.

The prefix arthro- refers to joint, so the word itself indicates that it is an intervention focused on these structures.

The term arthroplasty refers to surgery performed to replace joints damaged for various reasons, such as hip fractures, osteoarthritis or other rheumatic diseases, with artificial joints called prostheses. 

These prostheses are made of various materials, including various alloys of chromium, cobalt or titanium, as well as high-density polyethylene, which act as the soft parts of the joint, such as the meniscus in knee arthroplasty.

An arthroplasty is a complex surgery that requires a specialised surgeon and a prior individualised study of the patient's characteristics in order to achieve the best results. 

Its main objective is to improve the patient's quality of life by eliminating the pain caused, for example, by osteoarthritis, correcting the deformities caused by it and recovering the mobility lost due to this or other rheumatic diseases.

For this reason, one of the most commonly performed arthroplasties today is hip arthroplasty. This statement makes a lot of sense if we consider that both the hip and the knee are the joints that suffer the most throughout life as they perform many more movements and suffer more pressure than the rest.

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Also, in addition to hip or knee arthroplasty, there are other less common types of arthroplasty which are listed below:

• Shoulder arthroplasty: This surgery involves replacing the shoulder joint due to structural damage caused by severe fractures, arthritis of osteoarthritis, tumours or severe problems in the head of the humerus. This surgery is similar to hip arthroplasty, but adapted to the shoulder joint.
• Elbow arthroplasty: Similar to shoulder arthroplasty, this surgery is mainly performed on people suffering from severe arthritic diseases, with the prosthesis being implanted as a hinge type as well as the joint.
• Ankle arthroplasty: As its name suggests, in this case the joint that is replaced is the ankle, the reasons being the same as in the rest, serious fractures or degenerative diseases.

Just as each patient's case must be individualised according to his or her needs, there are also different types of hip arthroplasty (hip surgery), with some being more suitable for some patients than others.

Several types of hip arthroplasty can be differentiated according to various factors such as the type of hip prosthesis to be implanted, the materials it is made of, the use of bone cement or not, whether it is the first time a hip prosthesis is being fitted or whether an already implanted one is being replaced. 

For any of these arthroplasties, the surgeon will take into account many factors such as the patient's age, the physical activity he or she usually performs, the quality of the bone and the degree of wear or deformity of the joint.

Below we explain the different types of hip replacement:

Partial or Total Hip Replacement

The difference between a partial or total hip replacement is the amount of joint that is replaced. In the case of partial hip replacement, only the femoral head is replaced, while in the case of total hip replacement, both the femoral head and the cup (the hollow in the pelvis where the femur fits) are replaced. 

Whether one or the other procedure is performed depends on the severity of the problem, the patient's characteristics and the surgeon's opinion.

Primary or revision hip arthroplasty

The main difference between the two is that primary hip replacement refers to the implantation of a hip prosthesis in a leg for the first time and revision hip replacement refers to the replacement of a previously implanted hip:

• Primary hip replacements. Primary hip replacements usually have a shorter stem (the elongated part of the prosthesis that is placed inside the femur) than revision hip replacements. This is so that in the event that a revision arthroplasty is necessary, it can be performed more easily. In most cases, the aim is to delay the implantation of the prosthesis as much as possible to avoid patients requiring a prosthesis replacement, as they usually last 15-20 years, although nowadays the techniques have improved so much that it is not a big problem to perform a revision arthroplasty.
• Revision hip replacement. Unlike primary hip replacements, revision hip replacements are larger and are used to replace a worn hip replacement.

Hip arthroplasty by stem length

As previously mentioned, the prosthesis stem is the piece that is implanted in the femoral canal. Depending on the length of the stem, we can differentiate between 3 types of prosthesis:

• Arthroplasty with conventional prosthesis. This type of hip prosthesis has a longer stem. This is the type of prosthesis used in revision arthroplasty, in people who have very poor bone quality or people of very advanced age. The implantation of this type of prosthesis is slightly more complex than in prostheses with a smaller stem, but it is still a highly recommended option in patients with very severe problems of osteoarthritis, deformity and above all pain.
• Short stem hip prosthesis. As mentioned in the previous section, this is the type of prosthesis chosen for primary arthroplasty because it is less invasive in the femoral canal and will allow revision arthroplasty to be performed in the future with a conventional prosthesis without the need for bone cement.
• Arthroplasty with surface prosthesis (resurfacing). This is one of the latest types of prosthesis developed and is mainly used in young patients (under 55 years of age) who, despite leading an active life and having fairly good bone quality, need a hip replacement. This type of prosthesis conserves a greater amount of bone, as they hardly occupy the femoral canal, allowing a longer duration, taking longer to require a short stem or conventional prosthesis, as well as a reduction in wear and tear and the possibilities of dislocation thanks to the different types of materials of which they are composed.

Cemented and uncemented arthroplasty

Cementation during hip arthroplasty refers to whether or not a substance called bone cement is used to fix the stem. Depending on this, a distinction can be made:

• Uncemented hip arthroplasty. In this case, neither of the two components of a prosthesis, whether total or partial, require bone cement to be implanted into the bone.
• Cemented hip arthroplasty. Unlike the case of cementless arthroplasty, in this case both parts of the prosthesis require cement to attach to the bone. These are usually cases in which patients have very low bone quality due to age or diseases that affect bone density such as osteoporosis.
• Hybrid arthroplasty. In this type of arthroplasty, the stem is cemented to the femur while the cup is not.
• Reverse hybrid total hip replacement. Bone cement is placed in the cup while the stem does not require it.

Despite the different classifications mentioned above, hip arthroplasties are a conjunction of all of them, i.e. an arthroplasty can be primary, total, cemented and short stem.

Hip arthroplasty surgery, as previously mentioned, is the intervention that consists of replacing a hip that has been damaged or deteriorated by disease or trauma with an artificial joint.

To carry it out, once the surgeon and the patient have agreed on the hip arthroplasty, the following is done: sometimes the patient is asked to donate blood before the operation in order to transfuse his or her own blood if necessary during surgery, as transfusions of the patient's own blood are the most compatible.

On the other hand, in all operations, a preoperative examination is carried out, consisting of 3 tests:

• Electrocardiogram. This preoperative test will determine the current health of the patient's heart, which is very important to determine the type of anaesthesia to be used and whether the patient is suitable for an operation as important as hip arthroplasty.
• Blood tests. Beforehand, a complete blood test is carried out to detect possible infections, which is important to avoid the possibility of infection of the prosthesis, as well as to know the type of anaesthesia compatible with the patient.
• Chest X-ray. This test, which consists of a chest X-ray, allows the patient to know if the trachea is well positioned for intubation if it is determined, as well as to detect incipient signs of infection by observing the lymph nodes.

After performing these preoperative tests and before the hip arthroplasty operation, the patient will have to consult with the anaesthesiologist about the results of the preoperative tests and have an interview with him/her to determine the type of anaesthesia to be used.

On the day chosen for the hip arthroplasty, the patient is admitted and at the determined time is taken to the operating theatre and the surgery begins:

• The surgeon, anaesthesiologist and some members of the nursing team will be in the operating theatre. On entering, the patient will be positioned as instructed by the surgeon.
• The anaesthesia will be administered intravenously through the patient's arm. The anaesthetist will remain in the operating theatre throughout the operation, monitoring the patient's vital signs and regulating the anaesthesia.
• The surgeon will then clean the area where the surgical approach will be made using an antiseptic solution and then make a vertical incision 20 centimetres long, deep enough to reach the joint.
• The next step is to use a surgical saw to cut the bone at the level of the femoral neck, removing the femoral head affected by osteoarthritis. Afterwards, the surgeon will prepare the femoral canal to insert the stem, which will be done depending on the technique, type of prosthesis and other options that have been chosen (cemented or uncemented hip arthroplasty, short stem prosthesis or resurfacing, etc.).
• After this, the acetabulum of the pelvis is prepared to place the cup, where the femoral head will fit in order to be able to carry out the normal movement of the joint.
• Once the prosthesis is in place, the surgeon repairs any ligaments and tendons that may have been affected and a drain is placed to remove any fluid that may remain in the joint after the operation.
• Finally, the surgical wound is sutured, a bandage is placed on the area and the patient is taken to the recovery room where he or she will finish recovering from the hip arthroplasty.

The duration of hip arthroplasty is between 1 and 2 hours, although it depends on each case. The hospital stay is between 3 and 5 days.

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