Total Hip Replacement: The Pre-Operative Guide

🦴 What is hip osteoarthritis, and why does surgery come up?

The hip is a ball-and-socket joint: the round head of the thigh bone turns inside a cup-shaped socket in the pelvis, and both surfaces are covered by a layer of slippery cartilage. In osteoarthritis this layer gradually becomes thin and uneven; once the cartilage wears away completely in an area, bone grinds on bone, the body builds bony spurs at the joint margins, and the joint grows stiffer and more painful by the day.

The pattern of complaints is usually familiar: pain in the groin or the front of the thigh that sometimes radiates toward the knee and worsens with walking and long standing, brief morning stiffness, growing difficulty with simple tasks such as putting on socks and tying shoes, a gradual limp, and in advanced stages night pain that breaks your sleep. Most patients who undergo hip replacement are between 50 and 80 years old, although there is no absolute age or weight restriction for this operation. Osteoarthritis is the most common cause, but avascular necrosis of the femoral head, untreated developmental dislocation and old joint injuries can all arrive at the same point.

Surgery is not the first option. Clinical guidance considers therapeutic exercise the core treatment of osteoarthritis for every patient, alongside weight control, suitable pain relief and, when needed, a cane. Surgery comes up when pain and limitation persist despite serious non-surgical treatment, disturb your sleep, walking or daily tasks, and imaging shows advanced destruction of the joint. Importantly, clinical guidance explicitly states that age, smoking, coexisting conditions or excess weight alone should not block a referral for joint replacement; the assessment is made case by case with the surgeon.

⏳ What happens if you don't operate?

The most honest point first: hip replacement is an elective operation, not an emergency. Hip osteoarthritis does not threaten your life, and if non-surgical treatment gives you an acceptable life, waiting is a reasonable decision. The main criterion for this operation is your quality of life, not the X-ray alone.

But indefinite postponement is not free either, and its cost is mostly functional rather than a danger to life:

• Your final result depends on your starting point. In studies, patients who entered joint replacement with much poorer function and strength did not catch up, after surgery, with those who had been operated on earlier.
• Muscle weakness accumulates. Pain leads to inactivity, inactivity wastes the buttock and thigh muscles, and those same muscles are the engine of your rehabilitation after surgery.
• The joint stiffens and shortens. An arthritic hip gradually locks into a bent position, the useful length of the leg decreases, and a long-standing limp drags the lower back and the opposite knee into the problem.
• Progressive deformity makes the surgery more technical. Bone loss in the socket and deformity of the femoral head make the reconstruction harder; the operation never becomes too late, but it does not stay simpler either.

🏋️ Preparing before surgery

In meta-analyses of randomized trials, exercise before joint replacement improved function and strength before the operation and moved the start of rehabilitation forward; the evidence for the hip is less certain than for the knee, but its direction is clear: the stronger you walk into the operating room, the higher the point you start your recovery from.

Preparing your body

• Stop smoking; it is one of the cheapest things you can do for wound healing and fewer complications.
• Bring blood sugar, blood pressure and anemia under control with your physician before surgery.
• Treat any infected tooth or purulent gum disease before the operation; an infectious focus far from the hip can still endanger an artificial joint.
• The skin over the hip and thigh must be healthy. Show any wound, infected pimple, scratch or fungal infection to your surgeon before surgery.
• If you are overweight, losing weight helps — but do not treat it as a reason to postpone the referral.

Preparation exercises

These two basic exercises keep the muscles around the hip awake without loading the joint; your physiotherapist tailors your personal program.

Preparing your home

• Get a walker or a pair of crutches in advance and practice walking with them.
• Remove slippery rugs and loose cables from your paths; the route from bed to bathroom must be flat and well lit.
• Arrange a Western-style toilet or a raised toilet seat; you will not be using a squat toilet in the first weeks.
• Prepare a firm chair with armrests and a high seat; very low chairs and soft sofas make standing up hard for a freshly replaced hip.
• Get slip-on shoes and a sock aid or a long shoehorn, so the first weeks do not force you into deep bending to dress your feet.
• If your bedroom is upstairs, arrange a place to sleep on the ground floor for the first weeks, and prepare the first days' meals in advance.

🏥 The day before surgery and the day of surgery

The day before

• Fasting: Exactly as instructed by the anesthesia team. Get the fasting start time from them, not from other people's experience.
• Medications: Bring the full list of your medications, supplements and herbal products. Daily medications — especially blood thinners and diabetes drugs — must be coordinated with the surgeon and anesthesia team in advance; never stop or add any drug on your own.
• Bathing: Shower the night before or the morning of surgery as the hospital instructs. Do not shave the surgical area at home; tiny scratches can become entry points for infection.
• Bring along: ID and insurance documents, recent X-rays and lab tests, your medication list, the walker or crutches, loose comfortable clothing, and closed non-slip shoes.
• Remove nail polish and jewelry, and arrange a companion for the day of surgery and the first days at home.

The day of surgery

The sequence is similar in most centers: admission and changing into surgical clothing, vital signs and an IV line, meeting the anesthesiologist and signing the consent form, and the surgeon marking the correct leg. That marking is a standard safety step; if it is missed, remind them yourself. You are then taken to the operating room. Your family stays in the waiting area the whole time, and after the operation the surgeon informs them of the result.

⚕️ How is the operation performed?

Anesthesia

This operation is done under either spinal anesthesia or general anesthesia, and the choice depends on your own situation: coexisting conditions, medications, the state of your spine, and your preference. The final decision is made with you by the anesthesiologist at the pre-operative visit. Under spinal anesthesia you are awake but numb from the waist down, and you usually receive a sedative as well.

What happens in the operating room

The operation usually takes 1 to 2 hours. In this practice's common scenario, the surgeon makes the incision on the outer side of the hip, over the bony prominence at the top of the thigh (the direct lateral approach). To reach the joint, part of the attachment of the hip abductor muscle is lifted aside and is repaired precisely at the end of the operation — which is why strengthening this very muscle has a special place in rehabilitation. Other approaches, such as the posterior and the anterior, are also common worldwide; comparative studies find the differences mostly limited to the first weeks, and the long-term results of the approaches are similar.

Once the joint is open, the worn head of the thigh bone is removed. The socket in the pelvis is reamed and prepared for a metal cup, and a smooth liner is placed inside it. A metal stem is then seated inside the canal of the thigh bone, and a new round head is mounted on it; this head sits inside the cup and rebuilds the same ball-and-socket joint.

The components are fixed in one of two ways: "uncemented", where bone gradually grows onto the implant's porous surface, or "cemented", where bone cement holds them in place. The choice between the two — or a combination of both — is made during the operation itself, based on the actual quality of your bone, and both methods have proven results. At the end the surgeon checks the stability of the joint and the length of the leg, closes the layers and the muscle repair, and applies the dressing. You are then taken to recovery and monitored until your consciousness and vital signs are stable.

🗓️ After surgery at a glance

Most patients stay 1 to 2 nights in hospital. Contrary to common belief, you are not going to spend weeks in bed: with the care team's approval, standing and taking a few steps with a walker usually begins the day of surgery or the next morning, and physiotherapy starts in the first days.

The broad lines of the first weeks are: pain control with your discharge prescription, an anticoagulant and frequent movement to prevent blood clots, a wound check with removal of sutures or staples usually around two weeks (14 days) after surgery, and daily exercise of the buttock and thigh muscles. If your surgeon has written specific movement restrictions for your first weeks, that sheet is the rule; there is no single rule that fits every patient and every approach.

The full details of wound care, the step-by-step exercise program, warning signs and a safe return to activity are covered in a separate guide: the complete guide to care and rehabilitation after total hip replacement.

🎯 Returning to daily life — answers to your 20 questions

These are the questions patients usually ask before deciding on surgery. The times are common ranges, not rules; your own care team's specific instructions come first.

1) How much pain will I have after surgery, and how long does it last?

The first days are the most painful part of the journey and are controlled with your discharge prescription. Many patients report from the very first weeks that the deep, grinding pain they had lived with for years is gone, and what remains is wound and muscle soreness that keeps fading. Pain that does not respond at all to the prescribed painkillers is not normal and must be reported.

2) How many nights will I stay in hospital?

In most cases 1 to 2 nights. The exact duration depends on pain control, your ability to walk with a walker, your general condition and your home situation. Discharge happens when you can move about with an aid and know your medication and exercise plan.

3) When can I put weight on the operated leg?

In a primary, uncomplicated replacement you usually bear weight as tolerated with a walker from the day of surgery or the next day. This is one of the important differences between joint replacement and many other operations. If your discharge sheet specifies a weight-bearing restriction, that takes precedence.

4) How long will I need the walker and cane?

Most patients start the first weeks with a walker, then progress to a cane and then to independent walking. The criterion for giving up the aid is not a date: you must walk without limping, without fear of falling, and with confident balance. Because the hip abductor muscle was repaired in this approach, rushing to drop the aid only makes the limp permanent.

5) When are the sutures or staples removed?

Usually around two weeks (14 days) after surgery, at the wound-check visit. If absorbable subcuticular sutures were used, there is nothing to remove and the wound is simply examined. Until then, follow the dressing and shower instructions on your discharge sheet.

6) When does physiotherapy start, and how long does it take?

In the very first days of your hospital stay. The structured program usually continues for several weeks to a few months, and most of it consists of exercises you do daily at home. Hip rehabilitation focuses especially on the buttock and abductor muscles, so that walking without a limp returns.

7) When can I drive?

The common advice is about 4 to 6 weeks after surgery; in studies measuring brake reaction time, it returned to pre-operative levels around 4 weeks after a right hip replacement. The conditions matter more than the date: you must be off opioid painkillers, able to get in and out of the car without pain, and able to perform an emergency stop. For a left hip in an automatic car it usually becomes possible earlier.

8) When can I go back to desk work?

Seated jobs usually become possible sooner than physical ones, and many patients return part-time or remotely within the first weeks. The practical conditions are pain control without opioid painkillers and being able to stand up and take a few steps every hour. A high chair with armrests is a better choice than a soft, deep sofa.

9) What about standing or heavy work?

In a systematic review of studies, the average time to return to work after joint replacement was about 8 to 12 weeks, with manual and physically demanding jobs at the end of that range or later. Heavy lifting, repeated ladder climbing and long periods of standing should be resumed gradually and with your surgeon's approval.

10) How do I go up and down stairs?

The simple rule is: going up, the sound leg leads; going down, the operated leg and the cane lead. Keep one hand on the rail at all times, and if someone accompanies you, have them stand one step below you on the way down. Take the stairs one at a time, without hurrying, in the first weeks.

11) How should I sleep?

Sleeping on your back with the legs slightly apart is the safe position of the first weeks. If you sleep on your side, do so as your care team advises and usually with a pillow between the knees, so the operated leg does not cross the midline. Ask at the wound-check visit when sleeping positions are fully released.

12) When can I shower?

This depends on your dressing type and must be read from your discharge sheet: often sooner with an intact waterproof dressing, and usually a few days later with a standard one. Until the wound is fully closed, baths, pools and public bathing are off limits. A shower chair and a non-slip mat genuinely reduce the risk of falling.

13) How do I pray (salat)?

In the first weeks, praying seated on a chair is the accepted solution that puts no load on the fresh joint. Kneeling, sitting cross-legged and repeatedly rising from the floor are exactly the movements that stress a newly replaced hip the most at first. Returning to prostration and floor sitting should be gradual and approved by your care team.

14) When is sexual activity possible again?

Usually after a few weeks, once pain is controlled and the wound has closed. At first choose positions that do not force the operated leg into extreme rotation or spreading; simple positions lying on the back are the most reliable. If you have a specific question, raising it with your care team is completely normal.

15) When can I travel or fly?

Short trips with regular stops to walk become possible sooner. For flying, especially long flights, coordinate with your surgeon before buying the ticket; long immobility raises the risk of blood clots and you may have specific advice. During any trip, keep moving your ankles and stand up every hour or two.

16) Which sports are suitable after hip replacement?

Unrestricted walking, swimming, a stationary bicycle, golf and light hiking are among the recommended low-impact activities. They are good for the joint and also for your weight and heart health. Any sport should be started gradually and with your care team's approval.

17) What about running, football and impact sports?

Most surgeons advise against high-impact activities such as running, jumping and contact sports after joint replacement, because repeated impact loading accelerates wear of the bearing surface and raises the long-term risk of loosening. If a particular sport matters to you, discuss it with your surgeon before the operation so your expectations are realistic.

18) What about sitting on the floor and the squat toilet?

In the first weeks use a Western-style toilet and chairs, and avoid floor sitting, cross-legged positions and squatting; these force the hip into deep bending and rotation. A gradual return to floor sitting becomes possible for many patients, but its timing and limits are set by your care team based on your approach and your own condition.

19) Will my legs be different lengths after surgery?

During the operation the surgeon balances leg length together with joint stability, and a noticeable difference is rare. Feeling that the operated leg is longer is common in the first weeks and usually passes, because a joint that stayed short and bent for years has now been straightened. If a noticeable difference persists after a few months, an assessment — and if needed a simple shoe insert — is the answer.

20) How long does the artificial joint last?

In analyses of national registry data, about 89 percent of total hip replacements were still in place at 15 years, and close to 60 percent at 25 years. A younger age at surgery, high body weight and impact activities increase the chance of needing revision surgery. Periodic follow-up, even when nothing is wrong, is part of protecting that longevity.

✅ Summary and the next step

Total hip replacement is an elective decision whose goal is less pain and a return to daily life — and at that goal it ranks among the most successful orthopedic operations. Its right time is when pain and limitation, despite serious non-surgical treatment, dictate your life: not earlier at the first diagnosis, and not so late that you enter surgery weakened and deconditioned. Preparing before surgery, from strengthening the buttock muscles to preparing your home, shortens your road back.

To learn more about this area of care, see the joint replacement and reconstruction page.

📚 Scientific sources

View scientific sources

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2. NICE guideline NG226: Osteoarthritis in over 16s — diagnosis and management — nice.org.uk
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4. Punnoose A, et al. Prehabilitation for Patients Undergoing Orthopedic Surgery. JAMA Netw Open 2023;6(4):e238050 — doi.org
5. Fortin PR, et al. Preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum 1999;42(8):1722–1728 — pubmed.ncbi.nlm.nih.gov
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