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03 / Orthopedic Surgery · open

Total hip arthroplasty

The operation of the century by results: the worn joint is replaced by a cup, a stem and a bearing, and a life's mobility often comes back with it.

Indication: End-stage hip arthritis with failed conservative care; displaced intracapsular neck-of-femur fractures in the right patient.

Part of Orthopedic Surgery →4 stages3 complications to knowopen
A total hip replacement on the post-operative film
Mikael Häggström, M.D · CC0

Read the imaging first

X-ray
Hip X-ray showing the appearance of a comminuted proximal femoral fracture
Hip X-ray · comminuted proximal femoral fracture

Practice before you scrub

Classify the hip fracture

An 84-year-old found on the floor: a shortened, externally rotated leg. AP radiograph of the hip. (Fictional educational case.)

  • The fracture line's address against the capsule is the operation: intracapsular displaced gets replaced, extracapsular gets fixed.
  • The radiograph is read with the patient attached: activity and cognition choose between hemiarthroplasty and total hip replacement.
Practice this image View the anatomy

On the tray for this operation

Test yourself on the tray

Stage

1 / 4

Approach and dislocation

Through a posterior or lateral approach, the capsule is opened and the femoral head dislocated from the acetabulum.

🔧 Scalpel🔧 Electrosurgical pencil🔧 Richardson retractor

Watch for: Sciatic nerve injury (posterior) · Abductor damage and limp (lateral)

Why are we operating?

Total hip arthroplasty replaces both sides of a destroyed joint, the acetabulum and the femoral head, with bearings that let a stiff, painful hip move freely again: for end-stage arthritis it is among the most reliable operations in surgery at restoring quality of life. Every technical choice serves two long-term masters, stability (against dislocation) and longevity (against loosening and infection).

Pulls toward surgery

End-stage osteoarthritis with failed conservative carePain and function costing the life the patient wantsDisplaced intracapsular hip fractures in the active and wellInflammatory and post-traumatic arthritis

Gives the team pause

Active infection anywhere (the implant's sworn enemy)Expectations the bearing cannot meetMedical risk against an elective quality-of-life operation

Shared foundations

Implants, biofilm & the infected metalwork problem

Arthroplasty and fixation both leave foreign surfaces in the body, and infection on an implant follows different rules from infection in tissue: biofilm changes the diagnosis, the drugs and the surgery.

Understand it once, in the specialty hub

What the surgeon is thinking

  • Approach and dislocation

    What does the choice of approach actually trade?

    Each door has a price: posterior approaches risk the short external rotators' repair and posterior stability, lateral ones the abductor mechanism and a limp, anterior ones the femoral exposure. The surgeon's mastery of one approach matters more than the debate between them, but the trade being made should be sayable.

  • Neck cut and acetabular preparation

    Why is cup orientation the operation's geometry exam?

    The acetabular component's inclination and anteversion define the arc through which the hip can move before impinging and levering out: the classical safe zone is a target, and combined version with the stem is the modern refinement. Reaming to bleeding subchondral bone earns fixation; orientation earns stability, and both are set in minutes that last decades.

  • Femoral preparation and implants

    How is stability actually tested before anything is final?

    With trial components: the hip is reduced and taken through the day's real movements, deep flexion, internal rotation, extension-external rotation, watching for impingement and lift-off, while leg length is checked against the references marked earlier. The trial is the rehearsal in which every error is still free.

  • Closure and first steps

    Why does the closure participate in dislocation prevention?

    The capsule and rotators sewn back are the hip's posterior seatbelt: repair quality measurably lowers posterior dislocation. The rehabilitation rules the patient leaves with (what to avoid, for how long) are the same operation continued by other means.

Decision points

  • Cemented or uncemented femoral fixation for a 78-year-old with osteoporotic bone?

    • Cemented stem

      Immediate fixation independent of bone quality, a strong record in older bone, and a small cement-implantation physiology to respect at insertion.

    • Uncemented stem

      Biologic fixation by bone ingrowth: excellent in good bone, but osteoporotic femora fracture at insertion and fix less reliably.

    The bone chooses the fixation: cement compensates for what elderly bone lacks, ingrowth exploits what young bone offers. Registry data, not fashion, is the referee, and the anaesthetist is warned before cement goes in.

  • On trial reduction the hip dislocates in flexion-internal rotation.

    • Diagnose the geometry and correct it

      Impingement source, cup version, stem version, offset and length are each checkable: the fix targets the found fault, not a guess.

    • Accept and rely on precautions

      The wrong answer: instability on the table is instability in the bathroom at 3 a.m., and rehabilitation rules cannot repair geometry.

    Trial instability is a gift: the operation contains its own inspection, and every cause has an intraoperative correction. The discipline is refusing to close over a hip that failed its rehearsal.

Leaving the OR

The handoff

Procedure
Left total hip arthroplasty, posterior approach, cemented stem, uncemented cup
Stability
Trial and final reduction stable through full arc; leg lengths equal on table
Prophylaxis
Antibiotics per protocol; VTE plan prescribed; cement inserted uneventfully
Watch for
Day-0/1 mobilisation, sciatic function documented, wound ooze beyond day 3 taken seriously

A fictional educational patient, handed over the way real ones are.

The postoperative course

  1. POD 0-1Walking with support the same day where pathways allow: early mobilisation is both rehabilitation and VTE prophylaxis.
  2. POD 1-3Home when safe on stairs and the wound is quiet; precautions taught per approach; a persistent draining wound is escalated, not observed politely.
  3. Weeks 2-6Function returns in strides; the wound review that separates normal healing from the early infection whose window for implant-retaining treatment is short.
  4. YearsA bearing under lifelong surveillance in principle: new pain in a previously happy hip is loosening or infection until proven otherwise, the lesson the linked case continues.
Continue this patient as a case

Watch it done

Find Total hip arthroplasty videos on YouTube

What can go wrong

Venous thromboembolismSurgical-site infectionPostoperative bleeding
Live this operation as a case →Live this operation as a case →OR Prep this operationReview the instruments