Total Hip Replacement

What is hip replacement?

Total hip replacement (THR) is surgery to replace a worn or damaged hip joint with an implant. The damaged ball (the top of the thigh bone) and the socket (the acetabulum in the pelvis) are removed and replaced with a new ball on a stem, and a new cup with a smooth bearing surface. Together, they restore a gliding, pain-free joint.

Hip replacement is one of the most successful operations in modern medicine. For the right patient, it reliably relieves pain, restores mobility, and returns people to the activities they’ve been missing - walking, golf, cycling, gardening, and getting through the day without thinking about their hip.

Dr de Hoog performs approximately 150-200 hip and knee replacements each year across his Townsville practice. His hip replacement practice is built around four specific clinical decisions - the direct anterior approach, hip resurfacing for selected patients, robotic assistance on the MAKO (Stryker) platform, and delivery through a dedicated Enhanced Recovery After Surgery (ERAS) pathway. Each of these is discussed below.

When is hip replacement considered?

Hip replacement is generally considered when:

• Hip pain is persistent despite non-surgical treatment
• Pain is limiting daily activities - walking, sleeping, putting on shoes and socks, driving
• Imaging confirms significant joint damage (most commonly from osteoarthritis, but also from avascular necrosis, inflammatory arthritis, developmental hip dysplasia, or previous trauma)
• You’ve genuinely trialled non-operative treatment

Before recommending surgery, Dr de Hoog will typically want to see that you’ve tried one or more of: activity modification, weight management where relevant, simple analgesia, physiotherapy and strengthening, a walking aid if appropriate, and in selected cases an intra-articular injection.

Hip replacement is an elective operation. The right time to proceed is when hip pain is interfering with your life more than the surgery and recovery would. That decision is always made together.

The direct anterior approach

The direct anterior approach (DAA) is Dr de Hoog’s preferred method for total hip replacement. The hip is accessed from the front of the leg, working between the natural planes of the muscles rather than cutting through them. The key muscles responsible for hip strength - the gluteal abductors at the side, and the external rotators at the back - are left intact.

What this means in practice:

• Earlier mobilisation. Most patients are walking with aids on the day of surgery and independently within the first week.
• No hip precautions. Because the soft tissues behind the hip are preserved, there are no standard restrictions on sitting low, crossing your legs, or bending forward. You can sleep on either side, sit in a normal chair, and put on your own shoes and socks from day one.
• Lower dislocation risk. Preserving the posterior soft tissues reduces the risk of the hip dislocating compared with approaches that divide those structures.
• Accurate component positioning. With the patient lying on their back, Dr de Hoog can directly confirm leg length, offset and implant orientation during the operation.

DAA is well suited to most patients, but not every patient. Body habitus, prior hip surgery, and certain anatomical factors can occasionally make a different approach safer. Dr de Hoog will discuss this openly with you if it applies in your case.

Robotic-assisted hip replacement

Dr de Hoog is trained on both of the major robotic platforms used in Australia - MAKO (Stryker). Robotic assistance isn’t a separate operation; it’s a tool used during the procedure to plan and execute bone preparation and implant positioning with greater precision.

How it works:

• Before surgery, a CT scan of your hip is used to build a three-dimensional model of your anatomy.
• A surgical plan is built on that model - the size, position and orientation of the cup and stem are planned to match your individual anatomy and to restore your leg length and offset.
• During the operation, the robotic arm provides real-time feedback and physical guidance as Dr de Hoog prepares the bone and positions the implants, keeping the surgery within the pre-operative plan.

What the evidence shows. Robotic assistance has been shown to improve the accuracy of implant positioning and the restoration of leg length and offset in hip replacement. Whether this translates into better long-term function for every patient is still being studied. What’s clear is that the technology gives the surgeon better information during the operation - which matters most in patients with complex anatomy, unusual bone shape, or a higher-than-average risk of implant malposition.

Not every hip replacement needs robotic assistance, and Dr de Hoog will discuss whether it adds value in your specific case.

Enhanced Recovery After Surgery (ERAS)

Dr de Hoog delivers all his hip and knee replacements through a dedicated Enhanced Recovery After Surgery (ERAS) pathway. ERAS is an evidence-based, multidisciplinary approach to joint replacement surgery that coordinates every stage of care - from the first preoperative appointment through to discharge - with the goal of getting patients out of hospital sooner, back on their feet faster, and through recovery with fewer complications.

Approximately 95% of Dr de Hoog’s hip and knee replacement patients are discharged home within 24 hours of surgery - the day after their operation.

ERAS is not about rushing patients out. It’s about getting every element of care right so that early, safe discharge is the natural outcome.

What the pathway looks like in practice:

• Preoperative optimisation - medical conditions (anaemia, diabetes, cardiac fitness) are identified and addressed before surgery, not after. Patients are supported with pre-habilitation exercises to enter surgery in the best possible condition.
• Clear patient education - you’ll know, before the day of surgery, what to expect hour-by-hour, what recovery looks like, and how to manage your first few days at home.
• Reduced fasting and carbohydrate loading - rather than the traditional overnight fast, ERAS uses shorter fasting times and carbohydrate drinks before surgery. This reduces postoperative nausea, preserves muscle, and speeds recovery.
• Spinal anaesthetic with light sedation - avoids general anaesthetic in most cases, which means less grogginess, less nausea, and better early pain control.
• Multimodal pain relief - rather than relying on strong opioids, pain is managed with a combination of paracetamol, anti-inflammatories, and local anaesthetic infiltration around the hip. This consistently delivers better pain control with far fewer side effects.
• Tranexamic acid - a medication given at the time of surgery that significantly reduces blood loss and the need for transfusion.
• Same-day mobilisation - you’ll be up and walking within hours of the operation, not the next day. The muscle-sparing direct anterior approach supports this particularly well.
• Discharge the following day - for around 95% of patients, discharge home happens within 24 hours of surgery.
• Supported recovery at home - you go home with a clear written plan, pain medication, and a scheduled timeline of follow-up with physiotherapy and the clinic.

Why this is better for you:

• Lower infection risk. Hospitals are where hospital-acquired infections happen. Less time in hospital means lower exposure and a reduced risk of wound or chest infections.
• Lower risk of blood clots. Early mobilisation is the single most effective way to reduce the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) after joint replacement.
• Better pain control with fewer side effects. Multimodal analgesia reliably outperforms opioid-heavy regimens - both for pain relief and for avoiding nausea, constipation, and the grogginess that high-dose opioids cause.
• Faster return to independence. Patients who recover at home tend to walk sooner, move more confidently, and regain independence faster than those spending multiple nights in hospital.
• Less post-operative confusion, particularly in older patients. Sleeping in your own bed, with your own routine, in a familiar environment significantly reduces post-operative delirium - a common and underappreciated complication of longer hospital stays.
• Higher patient satisfaction. Patients who go through ERAS pathways consistently rate their overall surgical experience more positively than those on traditional, longer-stay pathways.
• Better long-term outcomes. Reduced surgical stress, preserved muscle strength, and earlier return to movement all contribute to a better-functioning hip at 6 and 12 months.

ERAS isn’t the right fit for every patient. If you live alone without support at home, if you have significant medical conditions that require longer monitoring, or if your individual circumstances make early home recovery less safe, a longer hospital stay is always available. Dr de Hoog will discuss the right pathway for you - the goal is always the safest and most effective plan for your individual circumstances, not the fastest one.

What the operation involves

Before the day. You’ll have pre-admission appointments, blood tests, imaging (including the planning CT scan if robotic surgery is planned), and a review with your anaesthetist. You’ll also meet the physiotherapy team and start any pre-habilitation exercises as part of the ERAS pathway.

On the day. Most patients have a spinal anaesthetic combined with light sedation, rather than a full general anaesthetic. This tends to mean less nausea, better pain control in the first 24 hours, and a faster return to feeling yourself.

The procedure. The operation itself typically takes 60 to 90 minutes. A single incision is made on the front of the upper thigh (usually 8-12 cm). The hip is replaced through this incision, with robotic guidance used where appropriate to keep the surgery within the pre-operative plan. Blood loss is modest, transfusion is rare, and tranexamic acid is given routinely to minimise blood loss further.

After surgery. You’ll be up and walking within a few hours of the operation. For approximately 95% of patients, discharge home happens within 24 hours - the day after surgery - as part of the ERAS pathway described above.

Recovery timeline

Every patient recovers at their own pace, but these are realistic expectations for most:

• Day of surgery - standing and walking within a few hours
• Day 1 (discharge day) - walking independently on the ward, stairs practice, and home for most patients within 24 hours of surgery
• Week 1 - walking at home with a frame or crutches, short distances
• Weeks 2-3 - off most walking aids, returning to light desk work
• Weeks 4-6 - walking without aids, returning to more demanding work, exercise bike, pool walking
• Weeks 6-12 - golf, bushwalking, cycling, most recreational activities
• 3-6 months - higher-demand activities; most patients feel their hip is “theirs” again
• Up to 12 months - subtle improvements in strength and endurance continue

Patients who are fitter beforehand, lean, and without other medical issues tend to recover at the faster end of these ranges. Your individual plan will be discussed with you.

Risks

Hip replacement is a very safe operation, but like any major surgery it carries risks. The most important to understand:

• Infection - approximately 1 in 100 cases. Management ranges from antibiotics to further surgery in severe cases.
• Dislocation - uncommon after DAA, particularly after the first few months. Rate is typically well under 1%.
• Blood clots (DVT / PE) - reduced by early mobilisation (a cornerstone of the ERAS pathway), compression stockings, and blood-thinning medication.
• Leg length difference - small differences of a few millimetres are common and usually imperceptible. Larger differences are uncommon with careful pre-operative planning and robotic assistance when used.
• Nerve irritation - a patch of numbness on the outer thigh (lateral femoral cutaneous nerve) is not unusual after DAA. It’s typically temporary and rarely troublesome.
• Periprosthetic fracture - rare (~1%), more common in patients with weaker bone.
• Implant wear or loosening - occurs over many years; addressed with revision surgery if and when needed.
• Medical and anaesthetic complications - individualised to your overall health.

Dr de Hoog will discuss your specific risk profile with you. Patients with diabetes, a higher BMI, a smoking history, or significant medical conditions carry higher risks, and these are best addressed before surgery where possible - another reason the ERAS preoperative optimisation step matters.

How long do modern hip replacements last?

This is the question almost every patient asks. The honest answer draws on Australian data.

The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) tracks every hip and knee replacement performed in Australia - with more than 2.28 million procedures recorded since 1999, it is one of the most comprehensive joint replacement registries in the world. Its 2025 Annual Report provides the most up-to-date picture of how modern hip replacements perform over time.

For modern primary total hip replacements performed for osteoarthritis, the registry reports approximate survivorship (the implant still in place and working) of:

• Approximately 95% at 10 years
• Approximately 92% at 15 years
• Approximately 91-94% at 20 years

Dr de Hoog’s typical bearing choice is a ceramic head on a highly cross-linked polyethylene liner - now the most widely used bearing combination in primary hip replacement worldwide. Ceramic-on-highly-cross-linked-polyethylene has been in clinical use for more than 20 years, and both the AOANJRR and the UK National Joint Registry have shown it to be one of the best-performing bearing combinations over 15- and 20-year follow-up, with revision rates consistently at the lower end of the range above.

The significance of this is worth understanding. Twenty years ago, wear of the bearing surface was one of the leading causes of hip replacement failure over time. With contemporary ceramic-on-crosslinked-polyethylene bearings, bearing wear has been almost eliminated as a cause of revision - and the failure modes that do occur (infection, periprosthetic fracture, dislocation) are relatively rare and unrelated to the bearing material. In practical terms, this means a modern hip replacement is far more likely to last a patient the rest of their life than earlier generations were.

Longevity depends on your age at surgery, activity level, bone quality, and the implant chosen. Younger and more active patients tend to wear their implants harder, although the margin of difference with modern bearings is much smaller than it used to be. Your individual expected outcome is something Dr de Hoog will discuss with you in the context of your age, health, and goals.

Who is - and isn’t - a good candidate?

Hip replacement is most appropriate when:

• Non-surgical treatment is no longer adequate
• Pain is affecting your daily function and quality of life
• Imaging supports the clinical picture
• You’re medically fit for anaesthesia and surgery
• You’re committed to the rehabilitation process

It’s reasonable to delay or reconsider if your pain is intermittent and well-controlled, if you haven’t yet trialled non-surgical options, if there is active infection elsewhere in the body, or if medical issues (diabetes control, cardiac assessment, weight, smoking) should be optimised first.

A note on hip resurfacing. For a small group of patients - typically younger, active men with good bone quality - hip resurfacing is an alternative to traditional hip replacement. Dr de Hoog offers resurfacing in selected cases and will discuss whether it’s a realistic option for you.