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 recovery.

What 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 joint.

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.

Choosing 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.

Recovering 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 conditioning).

A 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 industry.

Will 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.

---

Discuss in Forums