What is the indication and procedure for total hip replacement in patients with severe hip arthritis?

Total Hip Replacement for Severe Hip Arthritis

Total hip arthroplasty is strongly indicated for patients with moderate-to-severe symptomatic osteoarthritis with radiographic evidence who have not improved with nonoperative therapy, particularly those with severe joint space narrowing and bone-on-bone changes. 1

Indications for Total Hip Replacement

Primary Indications

• Moderate-to-severe symptomatic osteoarthritis with radiographic evidence of structural damage 1
• Refractory pain or disability despite conservative management 2, 1
• Radiographic evidence of severe joint space narrowing or bone-on-bone changes 1
• Significant functional limitations affecting quality of life 1

Secondary Indications

• Inflammatory arthritis (including ankylosing spondylitis) with hip involvement 2
• Hip dysplasia or deformity causing pain and functional limitation 2
• Avascular necrosis with femoral head collapse

Patient Selection Considerations

• Age is not a limiting factor when significant pain and disability are present 1

• Patients should have failed conservative management including:

  • NSAIDs (first-line drug treatment) 2
  • Physical therapy and exercise programs 2
  • Analgesics for residual pain 2
  • Intra-articular injections when appropriate 2

• Recent evidence from a 2024 randomized controlled trial demonstrates that total hip replacement results in clinically superior reduction in pain and improved function compared to resistance training in patients with severe hip osteoarthritis (11.4 point greater improvement on the Oxford Hip Score) 3

Procedure Components

Anesthesia Options

• Either general or spinal anesthesia is recommended 2
• If using spinal anesthesia, intrathecal morphine 0.1mg may be considered, though risks and side effects should be carefully weighed 2

Pain Management Protocol

1. Pre-operative and intra-operative:

   • Paracetamol (acetaminophen) 2
   • NSAIDs or COX-2 selective inhibitors 2
   • Dexamethasone 8-10mg IV (for analgesic and anti-emetic effects) 2
   • Single-shot fascia iliaca block or local infiltration analgesia 2

2. Post-operative:

   • Continued paracetamol and NSAIDs 2
   • Opioids reserved for rescue analgesia only 2

Surgical Considerations

• Choice of prosthesis should consider patient factors including age, activity level, and bone quality
• Cemented components with polyethylene-on-ceramic articulation may offer cost-effectiveness advantages 4
• Larger femoral head sizes may confer some benefit in terms of stability 4

Expected Outcomes

• Significant pain reduction and functional improvement in 80-90% of patients 4
• Revision rates are generally low (1.6-3.5% at 9 years) 4
• Approximately 27% of patients may still report some pain at 6 months post-surgery, though this often improves with time 5
• Only about 4% develop severe chronic pain requiring revision 5

Post-operative Management

• Early mobilization and rehabilitation are essential for optimal outcomes
• Regular monitoring for complications
• Long-term follow-up to assess implant performance

Potential Complications

• Infection
• Dislocation
• Periprosthetic fracture
• Implant loosening
• Heterotopic ossification
• Leg length discrepancy

Total hip replacement represents a highly effective intervention for patients with severe hip arthritis who have not responded to conservative measures, with significant improvements in pain, function, and quality of life that outweigh the risks associated with surgery.