What Is Hip Surgery? Types, Procedure, and Recovery

Hip surgery is any surgical procedure performed on the hip joint to relieve pain, restore movement, or repair structural damage that conservative treatments have failed to address. The most common form is total hip arthroplasty, in which the damaged ball-and-socket joint is replaced with an artificial implant, but the term also covers partial replacements, arthroscopic repairs, bone-preserving osteotomies, and procedures that treat early bone death before the joint collapses. Which surgery fits a given patient depends on the underlying diagnosis, the person’s age and activity level, and how far the damage has progressed. Modern hip implants now show survivorship above 90% at 20 years, and recovery protocols have shortened hospital stays dramatically compared with a generation ago.

Conditions That Lead to Hip Surgery

Osteoarthritis is the leading reason people end up in an operating room for hip work. As the cartilage lining the joint wears away, the space between the ball of the femur and the socket of the pelvis narrows progressively. In patients who eventually need a total hip replacement, that narrowing averages a fraction of a millimeter per year, but some people lose cartilage much faster, especially older patients and those whose joints lack the bony spurs that normally form around an arthritic hip.¹ By the time a surgeon recommends replacement, the decision typically hinges on how much joint space remains on imaging, how limited the patient’s physical function has become, and whether serious heart disease or other conditions make surgery too risky.²

Avascular necrosis (AVN) is another major driver. When blood supply to the femoral head is disrupted, bone cells die and the ball of the hip slowly crumbles. Long-term corticosteroid use, heavy alcohol consumption, and autoimmune conditions are common non-traumatic triggers. The resulting pain, groin stiffness, and loss of mobility can progress over months to the point where the femoral head collapses entirely.³ Caught early enough, AVN can sometimes be managed with less invasive bone-preserving procedures, but advanced collapse usually calls for joint replacement.

Hip fractures, especially femoral neck fractures in older adults, are the other large category. These are usually treated with some form of arthroplasty rather than internal fixation because the blood supply to the broken segment is unreliable. Younger patients may also need hip surgery for structural problems like hip dysplasia, where the socket is too shallow to hold the femoral head securely, or femoroacetabular impingement (FAI), where abnormal bone shapes cause the hip to pinch during movement.

Total Hip Replacement

Total hip arthroplasty (THA) is the most frequently performed hip operation worldwide. The surgeon removes the damaged femoral head and replaces it with a metal or ceramic ball mounted on a stem that fits into the thighbone. The worn socket is reamed and fitted with a new cup, usually lined with a smooth bearing surface. Modern implant systems can be assembled from modular components, giving the surgeon the ability to fine-tune leg length, offset, and stability for each individual joint during the operation.⁴

Implant designs have evolved substantially since the procedure was pioneered in the 1960s. Early versions had high failure rates, but steady improvements in materials and surgical technique now give contemporary implants the potential to last 25 to 30 years.⁵ A recent large-scale analysis drawing on nearly two million total hip replacements from national joint registries found an all-cause implant survivorship of about 94% at 20 years, with predicted survivorship still above 92% at 25 and 30 years.⁶ That is a remarkable number for an implant that endures thousands of loading cycles every day.

Hemiarthroplasty and When It Is Preferred

A hemiarthroplasty replaces only the ball side of the joint, leaving the natural socket intact. It is most commonly used for older adults with displaced femoral neck fractures. The surgery is shorter and somewhat simpler, which matters in elderly patients who may tolerate a longer procedure poorly. In a large randomized trial comparing hemiarthroplasty with total hip replacement for hip fractures, revision rates and mortality were similar between the two, though total hip arthroplasty produced modestly better scores on pain and function questionnaires.⁷

A Cochrane review of arthroplasties for fragility hip fractures concluded that any functional advantage of total hip replacement over hemiarthroplasty is small and may not be clinically meaningful, and recommended that cemented hemiarthroplasty generally produces the best combination of quality of life and lower mortality risk.⁸ On the other hand, data from a large Medicare cohort showed that dislocation was about twice as common after total hip replacement as after hemiarthroplasty, and reoperation rates were also higher in the total hip group.⁹ The choice between the two comes down to the patient’s age, cognitive function, activity level, and the condition of the acetabular cartilage.

Hip Resurfacing

Resurfacing is a bone-conserving alternative to total hip replacement. Instead of removing the entire femoral head, the surgeon caps it with a smooth metal shell, and a matching metal cup goes into the socket. Because the femoral head is preserved, natural anatomy stays closer to normal. A randomized study found that resurfacing restored the leg-length difference to within a few millimeters in about 86% of patients, compared with 60% for conventional total hip replacement.¹⁰ Resurfacing is typically considered for younger, active patients who want to preserve bone stock in case they need a revision replacement later in life.¹¹ The procedure fell out of favor for a period because certain metal-on-metal bearing designs caused local tissue reactions, but updated designs and better patient selection have led to a measured resurgence.

Hip Arthroscopy

Hip arthroscopy is a minimally invasive procedure in which small incisions allow a camera and instruments into the joint. It has become the primary surgical treatment for femoroacetabular impingement with labral tears, where abnormal bone on the femoral head or socket rim damages the ring of cartilage (the labrum) that seals the joint.¹² The surgeon shaves away the extra bone (cam or pincer lesions) and either repairs or reconstructs the torn labrum. Studies with follow-up to 10 years have confirmed that arthroscopy is effective for this purpose, though labral repair tends to outperform simple labral debridement in longer-term outcomes.¹³

Because arthroscopy does not involve replacing the joint, recovery is faster than after arthroplasty, but it is not a quick fix. Patients typically face months of rehabilitation to regain hip strength and range of motion, and the operation works best when the cartilage surface inside the joint is still in reasonable shape. If advanced arthritis has already set in, arthroscopy is unlikely to provide lasting relief.

Bone-Preserving Procedures

Two other operations deserve mention because they aim to save the natural hip joint rather than replace it. Core decompression is used in early-stage avascular necrosis before the femoral head has collapsed. The surgeon drills one or more channels into the bone to relieve pressure, encourage new blood vessel growth, and halt further bone death. It remains one of the safest and most commonly used interventions at the pre-collapse stage.¹⁴ Once the bone has already crumbled, though, the window for core decompression closes and joint replacement becomes necessary.

Periacetabular osteotomy (PAO) is a major reconstructive operation for hip dysplasia. The surgeon cuts the bone around the hip socket and repositions it so the femoral head is better covered, which improves biomechanics and slows the progression toward arthritis.¹⁵ Long-term data show that more than 75% of hips are still preserved 18 years after the procedure, though by 30 years that number drops to about one third.¹⁶ PAO is most commonly performed in adolescents and younger adults, and the recovery period is considerably longer than for joint replacement because the bone must heal in its new position.

Surgical Approaches for Joint Replacement

Regardless of which implant goes in, the surgeon has to choose a path through the soft tissue to reach the joint. The two most discussed approaches are the direct anterior approach (from the front of the hip) and the posterior approach (from behind). Each has trade-offs. A meta-analysis found that the anterior approach took about 17 minutes longer in the operating room but led to a slightly shorter hospital stay and better early hip function scores at six weeks compared with the posterior approach.¹⁷ Complication rates for dislocation, fracture, and blood clots were similar between them.

The anterior approach appears to cause less muscle damage, as measured by bloodstream markers of muscle breakdown, which may explain the faster early functional recovery some patients experience.¹⁸ By three to six months, though, most studies find that the advantage narrows or disappears. A randomized trial at multiple centers found that length of stay, implant position, and complication rates were similar between the approaches, with only a trend toward better function for the anterior group in the first month.¹⁹ The bottom line is that both approaches work well in experienced hands. Surgeon familiarity and volume likely matter more than the route chosen.

Robotic-Assisted Hip Surgery

Robotic technology in hip replacement has grown rapidly. Systems use preoperative imaging to build a 3D model of the patient’s hip, then guide the surgeon’s instruments during bone preparation and implant placement. In cadaveric testing, a robotic system placed the cup within three degrees and the leg length within one millimeter of the preoperative plan, with manual implantation showing errors several times higher.²⁰ Clinical studies have confirmed better component positioning: in one series, about 90% of robotically placed cups fell within the accepted safe zone for orientation, compared with roughly 78% placed by hand.²¹

The catch is that improved positioning on X-rays has not yet translated into clearly better functional outcomes for patients. Reviews of the evidence consistently find that while robotic hip replacement produces better radiological accuracy, the functional results are similar to those of conventional surgery.²² Whether the precision advantage reduces revision rates over the long term is a question that will take another decade or more of registry data to answer.

Anesthesia Options

Hip surgery can be performed under spinal anesthesia (a numbing injection in the lower back) or general anesthesia (you are fully asleep). For years, there was a strong belief that spinal anesthesia was safer, particularly for older adults at risk of postoperative confusion. A major randomized trial of older hip-fracture patients found no meaningful difference: rates of delirium, the ability to walk independently at 60 days, and mortality were virtually identical between the two.²³

That said, observational data from elective total hip replacement paint a somewhat different picture. A large propensity-matched analysis found that general anesthesia was associated with about a 30% higher odds of any adverse event, longer operating times, and higher rates of blood transfusion compared with spinal anesthesia.²⁴ A meta-analysis also found that spinal anesthesia was linked to less postoperative nausea and a shorter hospital stay.²⁵ The discrepancy between the randomized trial (in fracture patients) and the observational studies (in elective replacement patients) likely reflects different patient populations and surgical urgency. In practice, the anesthesiologist and surgeon tailor the choice to each patient’s medical history and preference.

What Happens During the Procedure

A total hip replacement typically takes one to two hours, though surgical time varies with complexity and approach. After anesthesia is administered, the surgeon makes an incision (anywhere from about 8 to 15 centimeters, depending on technique), moves or splits the surrounding muscles, and dislocates the femoral head from the socket. The worn femoral head is removed, the socket is prepared with reamers, and the new cup is pressed or screwed into place. A trial ball-and-stem assembly is inserted to check leg length and stability before the permanent components are locked in. The wound is then closed in layers.

Blood loss during hip replacement can be considerable, so a medication called tranexamic acid (TXA) is now given routinely. TXA helps blood clot more effectively without raising the risk of dangerous clots elsewhere in the body. A systematic review of randomized trials found that a single dose before surgery reduced the likelihood of needing a blood transfusion, with a number needed to treat of roughly 4 to 8, meaning that for every 4 to 8 patients given the drug, one transfusion was prevented.²⁶ Other studies have confirmed that patients who receive TXA maintain higher blood counts throughout the postoperative period and lose significantly less blood overall.²⁷

Recovery in the First Days and Weeks

The trend in hip replacement recovery has moved sharply toward early mobilization. Many programs now encourage patients to stand and take steps the same day as surgery. A feasibility trial found that patients mobilized on the day of operation reached functional milestones dramatically earlier: they transferred to a chair about 40 hours sooner, walked 10 meters about 24 hours sooner, and managed stairs about 26 hours sooner than patients who started the next day.²⁸ Walking on the day of surgery was also not associated with increased pain or any harm to the new hip.²⁹

For older adults recovering from hip fracture surgery, getting upright early is not always straightforward. A study of Brazilian older adults after hip replacement for fragility fractures found that by day three, only about half could stand and roughly 40% could walk 10 or more steps. Younger age, better cognitive function, greater baseline independence, and the absence of sarcopenia (age-related muscle loss) all predicted faster recovery.³⁰ For these patients, recovery takes considerably longer and the rehabilitation goals may be different from those of a 60-year-old having an elective replacement for arthritis.

Rehabilitation and Strengthening

After the initial recovery phase, structured rehabilitation becomes important for getting the most out of a new hip. Most protocols follow a phased pattern: gentle range-of-motion exercises and walking practice in the first weeks, progressing to formal strength training in the months that follow. One rehabilitation program designed for hip replacement patients used few supervised sessions in the first 12 weeks, then transitioned to supervised, progressive, high-level activity training from weeks 12 to 16.³¹ Progressive resistance exercise targeting the muscles most affected by hip surgery, with weight increases every couple of weeks, has been studied as a way to maximize muscle gains and functional performance after replacement.³²

Pain management during recovery has shifted toward multimodal approaches, combining non-opioid painkillers like anti-inflammatories and acetaminophen with regional nerve blocks, gabapentin, and limited opioid use as needed.³³ This strategy reduces overall opioid consumption. One randomized trial found that adding intravenous acetaminophen to the multimodal cocktail after total hip replacement significantly improved pain scores at 24 hours and lowered the amount of opioid painkiller patients needed.³⁴ The psychological side of recovery also matters: fear of movement (kinesiophobia) after hip surgery can slow functional improvement, which is one reason many programs incorporate education and reassurance alongside physical exercises.³⁵

Preventing Blood Clots After Surgery

Blood clots in the leg veins (deep vein thrombosis) and lungs (pulmonary embolism) are among the most serious risks after hip surgery. Virtually all patients receive some form of thromboprophylaxis. Drug options include low-molecular-weight heparin, direct oral anticoagulants like rivaroxaban and apixaban, warfarin, and plain aspirin.³⁶ A large randomized trial found that aspirin was not inferior to rivaroxaban for preventing clots after hip or knee replacement, with clot rates below 1% in both groups and no significant difference in bleeding complications.³⁷ Mechanical compression devices worn on the legs during and after surgery also help, and a prospective trial comparing them directly against low-molecular-weight heparin found equivalent rates of clots and pulmonary embolism.³⁸

Preventing Infection

Joint infection after hip replacement is rare but can be devastating, sometimes requiring removal of the implant. Prevention starts well before surgery. Expert review has identified seven highly important measures: prophylactic antibiotics, antiseptic skin preparation, surgical team hand antisepsis, sterile gowns, ultraclean operating-room airflow, antibiotic-impregnated bone cement, and active surveillance programs.³⁹ Patient factors matter too. Current evidence emphasizes that blood sugar control, nutritional status, body weight management, and smoking cessation all meaningfully reduce infection risk.⁴⁰ A multi-faceted approach combining bacterial decolonization before surgery, avoidance of anemia, proper patient warming during the operation, wound lavage with antiseptic solution, and antibacterial sutures represents the current best practice.⁴¹

Getting Ready Before Surgery

The concept of “preoperative clearance” has evolved into “preoperative optimization” — instead of simply checking whether a patient is safe enough for surgery, the focus is on getting modifiable risk factors into the best possible range. Evidence-based thresholds that have emerged include a body mass index below 40, adequate blood protein levels, well-controlled diabetes, acceptable hemoglobin levels, and ideally quitting smoking and substantially reducing opioid use at least four weeks before the procedure.⁴² Delaying surgery until these targets are met, even if it means a few extra months of discomfort, appears to pay off in lower complication rates and better outcomes afterward.

When a Hip Replacement Fails

Most hip replacements last decades, but some eventually fail and require revision surgery. A study of over 200 revision operations found that the average time to revision was about seven years, though the range was enormous. The leading cause of failure overall was aseptic loosening, where the implant gradually loses its bond with the surrounding bone, accounting for about half of all revisions. In patients who needed revision within the first five years, instability (the hip dislocating) and infection were the most common reasons rather than loosening.⁴³

Revision surgery is a bigger operation than the original replacement and the recovery tends to be slower. Patients do improve substantially in pain and function, but most of that improvement happens within the first three months after the revision and then plateaus. Compared with primary hip replacement, revision patients tend to end up with somewhat lower function scores at one year.⁴⁴ Patients who had higher pain before surgery and those who experienced surgical complications were most likely to have worse functional outcomes two years down the line.⁴⁵ None of this means revision surgery is not worthwhile — for most patients it still provides meaningful pain relief — but expectations should be calibrated differently than for a first-time replacement.

Implant Component Failure

Though rare, mechanical failure of the implant itself does happen. A five-year survey of over 60,000 hip replacements tracked how often individual components broke or came apart. Femoral stem fractures occurred at a rate of about 27 per 10,000 implants. Complete wear-through of the polyethylene bearing liner was more common in metal-backed socket designs (about 29 per 10,000) than in all-polyethylene designs when adjusted for the much smaller number of all-polyethylene cups used. Ceramic femoral heads fractured at a rate of about 22 per 10,000, though ceramic use at that time was relatively low. Dissociation between the head and the stem was extremely uncommon, occurring in roughly 3 per 10,000 modular femoral components.⁴⁶ Newer materials and manufacturing standards have likely improved these numbers further, but understanding the failure modes helps explain why implant selection and precise surgical technique continue to be refined.

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