The latest trend in hip replacements

Women take note: not all hip replacements are the same.

My surgeon took one look at my X-rays and said there would be only one cure for me, a total hip replacement.

"You can live your life, or live in pain," said hip specialist Sarah Muirhead-Allwood. Even my untrained eye could see the problem.

The rubbery cushion of cartilage that makes the thigh bone connect smoothly to its ball and socket mechanism was seriously worn away in my left hip. No wonder it hurt so much.

Nancy Durham in recovery mode: do your exercises is her very strong advice. (Richard Devey/CBC)

Osteoarthritis, the cause of my wear and tear, is the most frequent reason for a hip replacement in Canada, a procedure that continues to evolve since it was first tried in the 1800s.

There are now dozens of varieties of artificial hips made from a range of materials as well as whole new approaches to the surgery itself.

One of them, known as resurfacing, has created quite the buzz over the past several years. The very term itself sounds neat, like a little interior decoration to spruce up an old hip. I'll have that, I thought to myself

However, Muirhead-Allwood said no: "The success rate is five times worse in women" and, what's more, she told me, the more conventional total hip replacement could easily last the rest of my life.


With a THR, the entire hip joint is removed and replaced. This involves sawing off the rounded top of the femur — thigh bone — and replacing it with a new artificial joint, effectively a new ball and socket.

A choice of hips: the traditional artificial hip (left) and what's known as the Birmingham hip resurfacing sytstem on the right, which is proving to be not as suitable as it was first thought for some candidates. (Associated Press)

Technically, hip resurfacing is a trickier procedure but it is less drastic. The damaged top of the thigh bone is tidied up, literally getting a new surface.

The big argument in favour of this approach is that it leaves the option for a full THR in future if necessary.

Resurfacing has keen followers who call themselves "surface hippies." Their website flashes pictures of success stories — cyclists, tennis players, skiers and hockey players back in action after surgery — along with their testimonials.

However, orthopaedic surgeons are currently rethinking who makes the best candidate for this approach. At Montreal's Maisonneuve-Rosemont Hospital, for example, resurfacing is now offered only to patients under the age of 40.

Women's bones

One of the problems with resurfacing, as researchers in the U.K., Sweden and Australia have been discovering, is that women's bones, as they weaken with age, are less able to support the demands of the procedure.

Dr. Martin Lavigne (Courtesy Dr. Lavigne)

In the early days, hip resurfacing, often called the Birmingham procedure after the British hospital that pioneered the technique, was thought to allow for a more active lifestyle because it was not as invasive as a total replacement.

However, according to surgeon Martin Lavigne at Montreal's Maisonneuve-Rosmount Hospital, the wrong populations were being compared. In his most recent study, Lavigne and his team looked at 48 young, active hip replacement recipients, half of whom had resurfacing while the rest had a total replacement.

At six months, Lavigne could not find any difference in mobility, balance or a range of regular activities between the groups.

Resurfacing has the advantage of being easier to revise later because most of the femoral bone is preserved. But these days, with hip replacement parts lasting much longer, Lavigne asks, "why take the chance of hip resurfacing failing at five or 10 years when new uncemented total hip replacements with new bearing surfaces are more reliable?"

In 2008, the Australian Orthopaedic Association reported that 5.2 per cent of women who opted for resurfacing needed further corrective surgery five years after the first operation.

This is why my surgeon here in Britain recommended a THR for me. (In Canada, the medical profession prefers to call it total hip arthroplasty, which simply means the surgical construction of a joint.)

My arthritis came on suddenly, just last autumn. I was 55.

During the day, walking to and from work, I had the odd sensation that one leg was shorter than the other. Sometimes I limped, though so slightly I think it was imperceptible to others.

My surgeon told me the earlier the treatment the better the outcome. So I signed up for a THR.

Ever younger candidates

Soon after, though, I started to fret. People who know me were surprised, even shocked. You? You're so active! This gave me second thoughts until I learned that new hips are going to ever younger, active people in huge numbers these days.

Gone are the days when candidates are made to wait until they cannot bear the pain any longer.

Last year, for example, 80 per cent of hip patients at Maisonneuve-Rosemont were under 60, Daniel Lusignan, the research co-ordinator with the Montreal hospital's orthopaedic team, told me.

"We have now a new way of thinking," he said. "As soon as a patient's quality of life is affected, we do the surgery."

New hips can be offered to younger patients largely because today's prostheses last so much longer. In the early days, you'd be asked to wait until your life expectancy more or less equalled the lifespan of a false hip.

But will it squeak?

When you are having an operation like this, people say leave the details to your doctor, don't go online. Are they crazy?

I headed straight for the computer. I'd left my surgeon's office with new questions popping into my head. I wanted more details beyond the three big inherent risks with THR: the possibility of infection in the joint; the risk of dislocation soon after the op; and the possibility of coming out of surgery with one leg shorter than the other.

I tried hard to filter out the unnecessarily terrifying accounts of surgery. I could not, however, resist watching a 15 second YouTube flick claiming to demonstrate a squeaky hip.

This, I learned — worryingly — was no hoax. It turns out that many recipients of a new kind of "durable ceramic" hip prosthesis ended up with hips that squeaked when they walked. Yikes!

A headline across a New York Times story said it all: "That Must Be Bob. I Hear His New Hip Squeaking." I inquired at Muirhead-Allwood's clinic. She would most definitely not be using the allegedly squeaky prothesis.

Operation day

So, on May 20, 2009, I checked into a London hospital to have my left hip bone replaced by titanium and ceramic parts.

Nancy's new hip: X-ray of the hip replacement ball and socket. (Courtesy Bill Newton-Smith)

My soon to be bionic hip would be composed of four elements: a titanium rod inserted into my femur, finished off with a ceramic ball, a liner over that and a titanium shell on top.

My husband and I played backgammon as medical people came and went. One of them wrote my surgeon's initials across my left hip in huge letters in black magic marker. We had the correct side labelled.

A straightforward THR takes about 50 minutes, my surgeon told me. And when my turn was over, I found myself in the most amazing getup. I was wearing Flowtron boots, which are in fact not boots but more like hockey pads, wrapped around your lower legs and attached to a machine that pumps air in and out.

The idea is to squeeze and release your calves to help prevent deep vein thrombosis.

In the aftermath of this procedure, there is an increased risk of having a blood clot, which is why I was also wearing TED (thrombo-embolism deterrent) stockings.

Under doctor's orders, I continued to wear those socks every day and night, for five weeks after the operation.

You must exercise

As soon as I woke, I remembered to start the exercise regime that begins while you're still in bed. The notion had been drilled into me beforehand by nurses and friends who'd had the operation before me.

I slid my heel slowly up the bed, bending my knee (and therefore my hip), and slid it back down again. As for lifting my leg? Impossible. Just trying was too painful; it would be many days before I could do it.

Thrombo sock: designed to squeeze and massage the calf veins to prevent clots from forming. (Nancy Durham/CBC)

Next day, a mere 18 hours after the op, nurses helped me stand and I walked a short distance on crutches with them at my side. The day after that I found myself out in the almost real world of a hospital corridor, on crutches, a physiotherapist beside me. By day three was doing the stairs.

By the time I left hospital on day six, the painkillers having been cut way back, I realised there would be much hard work ahead.

But there was one wonderful realisation: since the surgery I hadn't had a single arthritic ache in my new hip. Amazing.

The next steps

This is one operation, though, where you really do need help during the recuperation period. I am very grateful to my husband — he put on my TED socks, tied my shoelaces and picked up endless things that I dropped.

We transformed our house by raising the couch and a few chairs with some ridiculous looking, elephantine furniture coasters but they really helped. Low seating is out because you are not to bend your hips more than 90 degrees.


Total hip replacements in Canada in 2006-07, excluding Quebec: 24,253.

Per cent of recipients who were 65 or older: 63

Fastest growing group of recipients: men 45 to 54, women 85 and older.

Per cent of hip replacements in 2006-07 that involved resurfacing: 2.7 per cent.

SOURCE: The Canadian Institute for Health Information 2008-09 annual report

There are other restrictions, too. Baths are banned for the first few months because of the risk of dislocation. There is absolutely NO crossing your legs. In bed, you are not supposed to lie on your side.

For five weeks, I went to bed with a pillow between my legs to try to keep me from turning over to my side. 

Then suddenly I was back at my surgeon's clinic for the post-operative check, five weeks after getting my new hip.

Following the rules, I turned up on a warm summer day in my TED socks and with a cane. Following an X-ray and an examination by the surgeon's assistant, I was told I could ditch the walking stick and take off the socks.

I was now also able to step up to more aggressive physiotherapy. I could even try to bend more than 90 degrees and best of all I was told I could now sleep on either side.

That night I had the best sleep I'd had since the onset of the arthritis.

It takes three to six months for a new hip to fully settle in, most surgeons say. Some cases, though, can take up to two years.

It is now two months after my surgery. I'm back at work and, apart from avoiding heavy lifting and refraining from crossing my legs, I can do just about anything.

I am also pain free and every day my new hip feels more a part of me.