A Guide to Getting and Recovering from a Hip Replacement

I hate to be the bearer of bad news, but if you have worn through the
cartilage in one of your hips, the only solution is to get a hip
replacement. On the plus side, most people that get a hip replacement
can return to full activities (including heavy lifting) after a
roughly six-month recovery period. Still, a hip replacement is a
major operation, and it makes sense to do everything you can to
ensure the best possible outcome. In what follows, I will outline
what type of hip replacement I had done (you have choices), as well
as what I did to recover. My hope is that, by reading about my
experience, you will be able to have a successful operation and

kind of hip replacement should you get?

The most common type of
hip replacement is a total hip replacement (THR). When a patient
undergoes a THR, the entire head of his femur is removed. It is
replaced by a (usually) ceramic ball, which is attached to a metal
stem that is inserted into what remains of the femur. A (usually)
ceramic cup is inserted into the acetabulum and the ball and cup form
the new hip joint. Often, but not always, a plastic cap made of
highly cross-linked polyethylene (XLPE) is inserted between the
ceramic ball and cup.

A less common type of
hip replacement is a total hip resurfacing (HR). When a patient
undergoes a HR, the head of the femur is reshaped so that it can be
fitted with a (usually) metal cap. A (usually) metal cup is inserted
into the acetabulum. And the metal cap and cup form the new hip

The main advantages of
a HR are:

1. The patient retains
more of his femur. If a revision surgery is needed in the future, a
patient can get THR. By contrast, if a patient that initially
underwent a THR requires a revision surgery, he will have much less
of his femur to work with, and the results of his revision will not
be optimal.

2. Some doctors claim
that a HR gives patients a “more natural” hip than a THR would.
As the statement “more natural” has no concrete meaning, it is
hard to verify this claim. However, it is worth noting that
professional athletes in various sports (e.g. ATP player Andy Roddick
and NHL player Nicklaus Backstrom) have resumed their professional
athletic careers after undergoing a HR whereas there are no examples
(at least that I am aware of) of professional athletes successfully
returning to their sport after a THR.

Additionally, according to a recent study, patients
that have had a THR in one hip and a HR on the other tend to prefer
the hip that has had a HR.

The main disadvantages
of a HR are:

1. There is a risk that
the head of the femur will fracture in the first six or so months
after a HR operation. Because of this, a HR is usually not advised
for older men or for women, as they tend to have weaker and/or
smaller bone structure.

2. The metal-on-metal
interface of a HR releases metal ions into the blood. These ions must
be filtered by the kidneys. It is not clear that the filtration of
metal ions causes kidney damage. But, if one has early signs of
chronic kidney disease, it may be better to opt for a THR.
Alternatively, some HR surgeons are now offering ceramic-on-ceramic
(CoC) prostheses.

If you are a male under
60 and have been lifting weights, your bones will be strong and, as
such, the risk of fracturing your femur after a HR is small. This,
combined with the potential benefit of having a “more natural”
hip as well as a better outcome in a revision surgery if it is
needed, make the HR the best option. Indeed, as a 41 year-old male
with 20+ years of lifting experience, this was the option I chose.

a surgeon

Unfortunately, despite
the (what I see as obvious) advantages of HR, there are not many
surgeons that perform this operation. Additionally, the HR operation
is more complicated to perform than a THR. As such, you definitely
want to make sure that whatever surgeon you choose has many, many,
many HR “reps” before he operates on you. Unfortunately,
this means that your options will be somewhat limited and you will
likely have to travel to get a HR operation. Here are a list of HR
surgeons that I would be willing to have operate on me:

1. Koen De Smet

2. James Pritchett

3. Thomas Gross

4. Edwin Su

There are certainly
well-trained surgeons that are not on the list above; I am only
listing the surgeons on whom I did extensive research. As you do your
own research, I highly recommend the Surface Hippy website.

I chose to have my
operation done by Koen De Smet. And, I am quite satisfied with the
result. The pain I felt in my hip prior to my operation was gone
immediately after the operation (though, there were other pains due
to cutting tissue, which took a few months to go away). At the time I
write this, about eight months post-op, I would say my hip feels
almost normal.

from your operation

As mentioned above, one
of the main risks of the hip resurfacing operation is that you could
fracture the head of the femur. In planning my recovery, I wanted to
avoid this outcome at all costs. I had read or heard somewhere (I
think in a YouTube video by Dr. Thomas Gross, mentioned above) that
it would take my femoral neck about 6 months to acquire 90% of the
strength it had prior to the operation. So, I chose to squat no more
than my body weight (190 lbs) during the first five months after my
operation. My reasoning for choosing this limit was as follows: I was
able to walk and stand on one leg without crutches within a few days
of my operation. If my bones could handle my entire body weight on
one leg, then they could hold twice my body weight on two legs.

About a week after my
operation, I started doing goblet squats while holding a 25-lb
dumbbell. I did goblet squats because my hip lacked the flexibility
it had prior to the operation, and the range of motion about the hip
when doing a goblet squat is less than the range of motion about the
hip in a back squat. I squatted every other day and added about 5 lbs
every 2nd workout. After building up to about 65 lbs, I had enough
flexibility in my hip to do barbell back squats and so I switched to
doing these. I continued doing 3 sets of 20 reps every other day
while slowly adding weight until I was doing around 185 lbs.

This took about five
months. At that point, I started adding 5 lbs every workout and, when
I could no longer do 3 sets of 20 reps, I focused on doing as many
reps as I could. At around 7 months post-op, I was able to squat 315
lbs for a set of 5, which was roughly what I was capable of doing
prior to my operation. So, in a sense you could say I had “fully
recovered” – or at least I had regained my strength. However, my
hip did not (and still does not) have the same range of motion that
it had prior to my operation.

I do not know if it
will ever regain the range of motion it had prior to my operation.
But, it is not a huge concern for me, as I can squat below parallel
without difficulty and I can sprint up the very long outdoor
staircase near my office (which is my preferred modality for

note on costs and insurance

As a hip replacement is
a major operation and will affect the quality of your life for years,
you should make your decision about where to get an operation based
primarily on health considerations and not on cost. However,
financial considerations are an unfortunate reality for many.

As I noted above, I
chose to have my HR operation performed by Dr. Koen de Smet, which
meant that I had to travel to Belgium to have my operation. The total
cost to have the operation was about 20,000 Euros. Additionally, my
insurance provider treats all out-of-country procedures as
“in-network” meaning they cover 90% of the costs. As such, the
cost to me was only 4,000 Euros. Had I gotten the operation in the
United States, my out-of-pocket expenses would have been higher, as
the total cost of a HR in the United States is around ~100,000 USD
and part of that cost would have been “out-of-network.”

I would highly
encourage you to discuss with your insurance provider if they will
cover your operation should you choose to have it done outside of the
United States. Most insurance companies in the United States are
aware that they stand to save thousands of dollars if they allow you
to get the operation abroad. So, it behooves them to allow you to get
the operation outside of the United States healthcare system

you “wear out” your prosthetic hip if you squat and deadlift?

Some surgeons may
counsel against barbell training after getting a hip replacement
because they think you will wear out your new hip joint. Not only is
there a lack of evidence to support this claim, but the advice to not
train is probably harmful. One of the main mechanisms by which hip
replacements (of either sort) fail is “stress shielding,” which
refers to the loss of bone due to decreased or modified stress on the
femur after getting a THR or HR. Doing squats and deadlifts places
stress on the femur, stimulates bone growth and helps prevent stress
shielding. So, you absolutely should be squatting and/or deadlifting
after getting your hip replaced. If your surgeon says otherwise, you
may want to find another surgeon.

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