Conversations for Confidence: Expert Answers on Hip Surgery

Many people don't realize how much we rely on our hips until they start hurting. If hip pain disrupts your daily life, you may wonder if hip replacement surgery is the best option for you.

In a recent webinar, Matthew Mangini, MD, orthopedic hip and knee surgeon at The Christ Hospital Health Network, discussed types of hip pain, treatment options, and what to expect before and after hip replacement surgery.

Discover what you need to know to take the next step in your hip healthcare journey.

How to Recognize Hip Pain: Common Symptoms

Hip pain most often shows up during everyday movements. It may hurt when you sit down, walk, or really, any activity where you rotate or turn your hips.

Symptoms can include:

• Joint-related pain in the front of the hip or groin region
• Soft tissue-related pain on the outside or back of the hip
• A constant dull ache
• Sharp, stabbing pain when you rotate or move certain ways

How you feel depends on what's causing your hip pain. A surgeon like Dr. Mangini can help determine the cause.

"There is a lot of overlap between the knee, the hip, and the back," he says. "It's our job to sort through those things and identify the main source."

The Difference Between Arthritis, Bursitis, and Tendonitis

A few different conditions can result in hip pain, including arthritis, bursitis and tendonitis.

Arthritis

Hip arthritis is a breakdown of the protective cartilage in the hip joint. As a result, people can experience:

• Inflammation and pain in the front of the hip or groin
• Bone spurs (osteophytes)
• Reduced range of motion

"The '-itis' part of 'arthritis', or anything in medicine, means inflammation," explains Dr. Mangini. "With arthritis, as the cartilage wears out, you don't have a nice, smooth surface. It doesn't protect the bone anymore, and that causes inflammation in the hip."

Bursitis

Bursitis usually happens when a small fluid-filled sac (bursa) that crosses the IT (iliotibial) band gets inflamed. The IT band extends from your pelvis, over a bony bump (greater trochanter) and down to the knee.

You may feel:

• Discomfort near the outside (lateral side) of the hip
• Sharp, achy pain right over the outer hip bone

Tendonitis

Tendonitis can cause several muscles that cross the hip joint to break down or become inflamed, resulting in hip pain. The type of pain you feel usually depends on the affected muscles:

• The hip flexor (iliopsoas) tendon can mimic joint pain and flares with hip flexion, or when you lift the knee towards your chest.
• The hamstring often causes more posterior (back side) hip pain.
• Abductor muscle issues tend to cause more side pain and sometimes weakness, a limp, or pelvic tilt when you walk.

What's Happening Inside an Arthritic Hip

When you have arthritis in your hip, the cartilage that cushions your bones eventually wears away. End-stage arthritis means bone is rubbing against bone - and that's painful. Your body responds in a few ways:

• It makes fluid to stabilize the hip, which often leads to people unconsciously holding the hip and knee slightly flexed. Over time, this position can create a flexion contracture (cannot fully straighten the leg).
• The body forms bone spurs to spread stress over a larger surface area, causing bones to rub (impingement) and more pain with hip movement.
• Surrounding muscles weaken from lack of use, which contributes to stiffness and pain. After hip surgery, rehab is important, so the muscles have time to "catch up."

Nonsurgical Treatment for Hip Pain

When Dr. Mangini explains treatment options for hip pain, he describes them as a spectrum. At the far end of the spectrum is hip replacement. But before that, nonsurgical interventions can help reduce pain:

• Healthy weight: Maintaining a healthy weight can reduce stress on your joints.
• Modified activities: Sometimes, avoiding or modifying activities or movements that trigger pain can be enough.
• Physical therapy: Therapy is most effective early in the process to maintain range of motion and muscle strength. However, it can be less helpful, or even counterproductive, once a hip is very degenerated.
• Anti-inflammatory medications: Certain medications can help manage pain from inflammation.
• Steroid injections: An injection to the hip joint can provide meaningful pain relief, sometimes lasting several months.

For bursitis and tendonitis, therapy and anti-inflammatories (oral or topical, such as Voltaren gel) are the main types of treatment. Some people also receive targeted injections around the bursa or tendons.

Your response to an injection can help confirm the diagnosis. For example, if a joint injection provides only short-term, partial relief, your pain may be from another source, such as bursitis.

"We can do steroid injections to calm the inflammation down, and our PM&R colleagues can help with targeted injections to identify the source of pain from there," Dr. Mangini says.

Deciding It's Time for a Hip Replacement

When you meet with an orthopedic surgeon at The Christ Hospital, it doesn't always mean you need immediate surgery. The right treatment for you depends on where you fall on the arthritis spectrum. Some patients with severe hip arthritis may skip therapy and injections altogether. Others may benefit from more diagnostic treatment first.

"We're always trying to collaborate with patients, their lifestyles, and their responsibilities, to ensure their pain is managed," says Dr. Mangini. "With a lot of ongoing issues, surgery is going to be the last step."

X-rays are a standard starting point for diagnosis in most patients. You may also need an MRI when X-ray findings don't match symptoms, especially in younger patients. An MRI can help your doctor check for issues, such as labral tears, avascular necrosis (blood supply disruption in the femoral head), hip impingement, or hip dysplasia.

If you and your surgeon decide hip replacement is right for you, you'll want to think about the best timing. Dr. Mangini says it's important to make sure it's a good time in your life for surgery and recovery.

Preparing for Hip Replacement Surgery

According to Dr. Mangini, medical optimization, not the surgery itself, is often the more involved part of the hip replacement process. The goal is to make sure your surgeon can do the procedure as safely as possible. Some ways to lower your risk of complications include:

• Making sure any heart, lung, or kidney conditions are as under control as possible
• Reducing body mass index (BMI), though there's no strict threshold
• Managing diabetes, ideally with hemoglobin A1C under seven percent
• Completing any dental work at least six weeks before surgery and avoiding it for three months after to reduce the risk of infection

Most patients see their primary care provider for a medical history, physical, EKG, and blood work before surgery. Those who already see a specialist, such as cardiologist or a nephrologist, usually need to see them within about 30 days of their surgery day for surgery clearance. Your surgery team guides you through this process.

"We want to minimize the number of risk factors we have for complications as much as possible," Dr. Mangini says. "We know not everyone's going to be in perfect health, but hopefully, we can manage all those conditions at a steady state."

What to Expect on Hip Surgery Day

Surgery day can often feel like a whirlwind. But a team of experts is there to support you throughout the process. Here's what you can expect:

1. Park in the garage (or use valet) at the Joint & Spine Center, and go to the B level.
2. Check in for surgery and go to the pre-op area, where a pre-op nurse starts an IV and gets you settled.
3. Meet with your surgeon, who confirms the surgery plan and answers last-minute questions.
4. Meet with the anesthesia team to review the type of anesthesia you'll receive (spinal or general). They usually perform a nerve block before surgery to help with postoperative pain.
5. Move to the operating room (OR) for surgery.

"There's an excellent team in place," says Dr. Mangini. "I get a lot of positive feedback about everyone through all phases of the care you'll receive."

Surgical Approaches: Anterior vs. Posterior

There are three main approaches to hip surgery:

• Direct anterior hip replacement: A direct, typically minimally invasive approach done on a specialized table. There can be a higher risk of wound complications in patients with overlapping abdominal skin or tissue near the incision site.
• Anterior-lateral hip replacement: Like direct anterior, except patients lie on their side, with a more side-based incision.
• Posterior hip replacement: Performed with the patient on their side. Your surgeon will split the IT band and part of the gluteus maximus, both of which will be repaired at the end of the procedure. Dr. Mangini uses this type of surgery for all revision surgeries because of the visibility it provides.

Whether your surgeon takes an anterior or posterior approach depends on your specific needs.

"I take it on a patient-by-patient basis based on their anatomy and if they have any prior incisions," says Dr. Mangini. "I tailor what I think is the right approach to that patient."

Recovery differences between anterior and posterior approaches are modest. Studies suggest patients may be off a walker roughly three days sooner with an anterior approach. The posterior approach has historically had a reputation for higher dislocation rates, but with modern techniques, current studies show no meaningful difference in dislocation rates between the approaches.

What Happens During Hip Replacement Surgery

So, what does "getting a new hip" actually involve? No matter the approach, Dr. Mangini says the basic steps are the same:

1. Your surgeon makes a cut along the neck of the femur and removes the diseased femoral head at the top of your leg.
2. They expose the socket of the hip (acetabulum) and clean out any bone spurs.
3. Using an instrument called a reamer, they make a new socket to wedge (press fit) into the bone. Your own bone will grow into it in roughly six to 12 weeks. Sometimes a screw provides extra stability.
4. On the femur side, it's a similar approach: your surgeon gradually shapes the canal to match a press-fit stem implant, which has a special coating to encourage bone growth.
5. Before your surgeon places and connects the final implants, they insert a trial or temporary implant to make sure the leg length, hip position, and stability are good.
6. After removing the temporary implants, your surgeon begins final placement, where they add a plastic liner inside the socket and a ceramic head on top of the femoral stem.

Most procedures take about an hour, with some additional time for closing the incision with stitches or staples.

"We're doing four to eight joint replacements a day, so we're able to continually perfect our craft," says Dr. Mangini.

Recovery After Hip Replacement

Overall recovery from hip replacement surgery varies by patient.

Anesthesia and Pain Management

After surgery, most patients go to the post-anesthesia unit for up to an hour, depending on the type of anesthesia you receive. Many patients receive a spinal anesthetic, which numbs you from the waist down. Compared to general anesthesia, this option has fewer side effects, including no nausea.

You will likely receive a nerve block before your surgery and local pain medication around the incision to help manage your pain right away. Many patients receive tranexamic acid (TXA) during surgery to help reduce blood loss and inflammation.

After surgery, pain typically lasts a few days to a couple of weeks, but it's often less severe than the pain you had going into surgery.

"I often hear from patients, even in the recovery area, that their hip already feels better," says Dr. Mangini. "It's pretty amazing. The pain you had whenever you would move your hip or twist your hip, a lot of that deep-seated pain is gone really, really quickly."

You can expect to manage pain with anti-inflammatories, acetaminophen, muscle relaxers, and opioid medications as needed. Most patients use opioid medication for less than a week, and many for only a few days.

Same-Day Surgery vs. Overnight Stay

About 90 percent of patients go home the same day as their surgery. After surgery, you'll spend time in post-anesthesia recovery, then move to a same-day surgery area. A therapist gets you walking with a walker, practicing stairs, and completing activities of daily living, such as getting on and off the toilet.

Some patients, because of medical monitoring needs, age, or limited support at home, need to stay at the hospital overnight. They usually follow the same recovery steps before going home the next day.

The First Few Weeks and When You Can Return to Work

You can put weight on your new hip and move it immediately after surgery. For the first few weeks, Dr. Mangini recommends using a cane or walker, even if it feels unnecessary. He says the worst thing you can do early on is fall. Walk around the house about every hour to avoid blood clots, but avoid longer outings, such as errands or the mall.

Here's his advice on other activities:

• Normal day-to-day activities (including stairs): It's fine to do these activities right away.
• High-impact activities (running or jumping): Avoid high-impact activities, including pickleball, for the first three months while the implant is growing into the bone. Light exercise, such as biking, walking, or swimming, is fine after your incision fully heals.
• Golf: You can start chipping and putting about two weeks after surgery, swinging irons at six weeks, and hitting a driver at around three months.
• Return to work: For desk jobs or remote work, you can usually return in one or two weeks. For more physically demanding jobs, it's usually at least six weeks.
• Driving: Don't drive until around four weeks after a right hip replacement, since it can take time for your brake reaction time to return to normal. Left hip patients can drive sooner, when you are off heavy pain medication and can safely get in and out of the car.

Physical Therapy

Dr. Mangini refers all his hip replacement patients to physical therapy. Early therapy focuses on calming inflammation and pain before progressing to strengthening exercises.

How long you need physical therapy varies widely. Some patients meet their goals after a few sessions, while others need weeks to months of therapy to fully regain normal strength and gait.

"Putting in a new hip is going to allow for smooth range of motion again," he says. "But your muscles then have to catch up and that process can take time - which is why physical therapy after surgery is so important."

Am I Too Young for Hip Surgery?

Age, by itself, doesn't disqualify you from hip replacement surgery. Dr. Mangini has performed hip replacements in teenagers and in patients close to 90 years old. The deciding factor is whether hip pain is limiting your ability to do the activities that matter to you.

Modern implants are now expected to last around 30 years or longer, which has made surgeons more comfortable performing replacements in younger, active patients instead of asking them to wait.

"The bottom line is: if you have a degenerated hip, age is not a factor,," says Dr. Mangini. "Whether you're young or old, age is not a disqualifier for hip surgery if you're active and moving and that's slowing you down."

What's Next in Hip Replacement Technology

As with many medical specialties, technology continues to advance. For hip replacements, these include:

• Robotic-assisted hip surgery: Dr. Mangini doesn't use this approach yet, noting that research hasn't shown it to produce better results than standard techniques.
• Artificial intelligence (AI): Researchers are exploring how AI might eventually help individualize implant positioning to support hip mechanics and reduce dislocation risk. Dr. Mangini currently uses AI-assisted software during anterior hip surgery to help calculate leg length, offset, and component positioning from intraoperative X-rays.
• Smart implant technology: Currently, this technology is only available for knee replacements but can remotely monitor activity such as step count, help catch issues earlier, and reduce the need for in-person follow-up visits.

Why Choose The Christ Hospital Health Network for Hip Care

At The Christ Hospital Health Network, we have the highest joint replacement volume in the region. Our five orthopedic surgeons, with support from advanced practice providers (APPs) and physician assistants (PAs), treat hip pain at nine office locations. We provide arthritis care, hip replacements, treatments for hip fractures, nonoperative treatments, and many more areas of care.

"The ultimate goal is to help you keep doing whatever activities you want to do," says Dr. Mangini. "If it's playing pickleball and golf, that's great. If you want to ski, that's great. All those things you can do with a hip replacement."

To schedule an appointment with a joint replacement specialist, call 513-654-9789 or complete this form to request a call back.

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