Total Hip Replacement in India and UAE | Complete Patient Guide

• ELIGIBILITY CRITERIA:

• Radiographically confirmed advanced hip arthritis (Kellgren-Lawrence Grade 3–4) or AVN (Ficat-Arlet Stage III–IV) unresponsive to ≥3–6 months of conservative management (physiotherapy, NSAIDs, intra-articular corticosteroid or hyaluronic acid injections)

• Persistent moderate-to-severe hip pain (VAS ≥6/10 or WOMAC pain subscale ≥40) significantly limiting activities of daily living

• Post-traumatic arthritis following acetabular fracture, femoral neck fracture with malunion, or failed internal fixation

• Inflammatory arthropathies (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis) with joint destruction refractory to disease-modifying anti-rheumatic drugs (DMARDs) or biologic therapy

• Avascular necrosis secondary to corticosteroid use, alcohol dependency, haemoglobinopathy (sickle cell disease), or idiopathic causes

• Failed prior hip procedures (hemiarthroplasty, surface replacement, osteotomy)

• REQUIRED PRE-OPERATIVE DIAGNOSTICS:

• Weight-bearing AP pelvis and lateral hip X-rays (Dunn view) with templating for implant sizing

• MRI of the hip (if AVN, labral pathology, or soft-tissue assessment required)

• Dual-energy X-ray absorptiometry (DEXA scan) for bone mineral density — critical for implant fixation planning in osteoporotic patients

• Full blood count, renal and hepatic function panel, coagulation profile (PT/INR/aPTT), HbA1c (target <8% perioperatively), and serum albumin (nutritional status)

• Electrocardiogram (ECG) and echocardiography (ECHO) if cardiac comorbidity or age >65

• Chest X-ray and pulmonary function tests if significant respiratory history

• Urinalysis and urine culture to exclude urinary tract infection prior to implanting prosthetic material

• Blood group and cross-match; preoperative autologous donation considered where indicated

• CONTRAINDICATIONS (ABSOLUTE):

• Active systemic or local infection (septic arthritis, osteomyelitis, bacteraemia) — surgery deferred until eradication confirmed

• Severe uncorrected coagulopathy or haematological malignancy precluding safe surgery

• Recent myocardial infarction (<6 weeks) or unstable angina without cardiological clearance

• Inadequate bone stock or active Charcot neuropathic arthropathy (relative; requires specialist planning)

• CONTRAINDICATIONS (RELATIVE — OPTIMISATION REQUIRED):

• BMI >40 kg/m² (elevated risk of wound complications, dislocation, and implant loosening — weight loss and bariatric evaluation recommended)

• Poorly controlled diabetes mellitus (HbA1c >8%)

• Active tobacco smoking (impairs wound healing and osseointegration — cessation ≥6 weeks preoperatively advised)

• Severe peripheral vascular disease or lymphoedema of the operative limb

• Immunosuppressed state (transplant recipients, patients on high-dose steroids or biologic DMARDs — drug holiday planning required with rheumatologist)

SURGICAL APPROACHES:

1. Posterior Approach (Moore/Southern Approach) — Historically the most widely used approach worldwide. Provides excellent acetabular visualisation and is extensile. Carries a marginally higher historical dislocation risk (~2–3%), largely mitigated by posterior capsular repair and modern component positioning protocols. Preferred for complex primary and revision cases.

2. Direct Anterior Approach (DAA / Hueter Approach) — Internervous, intermuscular plane between sartorius/rectus femoris (femoral nerve) and tensor fasciae latae (superior gluteal nerve). Preserves posterior soft-tissue envelope, reduces dislocation risk, and typically enables faster functional recovery (ambulation same day or day 1). Requires specialised operative table (Hana table or equivalent) and carries a learning curve for femoral preparation. Increasingly preferred for active, younger patients and outpatient THR programmes.

3. Direct Lateral Approach (Hardinge Approach) — Offers good joint exposure with moderate soft-tissue disruption through partial detachment of the gluteus medius. Lower dislocation risk than posterior approach. Risk of transient or permanent superior gluteal nerve injury and abductor weakness is the primary limitation.

4. Two-Incision / MIS (Minimally Invasive Surgery) Approaches — Reduced incision length (6–10 cm vs. conventional 20–30 cm), less soft-tissue disruption, lower blood loss, and shorter hospital stay. Require robotic or fluoroscopic guidance to ensure accurate component positioning through limited visualisation.

IMPLANT BEARING SURFACE OPTIONS:

• Ceramic-on-Polyethylene (CoP): Highly durable, low wear, and most commonly used globally. Fourth-generation highly cross-linked polyethylene (XLPE) with Vitamin E stabilisation has dramatically reduced osteolysis risk.

• Ceramic-on-Ceramic (CoC): Lowest in-vitro wear rate; preferred for younger, highly active patients. Risk of audible squeaking (~1–2%); catastrophic fracture extremely rare with modern alumina-zirconia composites (e.g., Biolox Delta).

• Metal-on-Polyethylene (MoP): Reliable long-term data; cobalt-chrome femoral head on XLPE liner remains a cost-effective and durable option.

• Metal-on-Metal (MoM): Largely abandoned outside select surface replacement indications due to adverse local tissue reactions (ALTR) and elevated cobalt/chromium ion serum levels.

FIXATION METHODS:

• Cementless (Press-Fit) Fixation: Porous-coated or trabecular titanium components (e.g., Trabecular Metal, Tritanium) achieve biological osseointegration. Preferred for patients <70 years with good bone stock.

• Cemented Fixation: Polymethylmethacrylate (PMMA) bone cement; faster primary fixation; preferred in osteoporotic bone, elderly patients, or revision settings.

• Hybrid Fixation: Cemented femoral stem with cementless acetabular cup — widely used in Europe with strong long-term registry data.

ADVANCED TECHNOLOGIES:

• Robotic-Assisted THR (Mako Robotic-Arm, Smith+Nephew CORI, Stryker): CT-based preoperative 3D planning followed by intraoperative robotic arm assistance constraining acetabular reaming and cup placement to within ±1° and ±1 mm of the planned target. Reduces outlier cup position rates from ~30% (manual) to <5% (robotic), lowering dislocation risk and improving leg-length restoration. Available at select JCI-accredited centres in India (Mumbai, Delhi, Hyderabad, Chennai) and UAE (Dubai, Abu Dhabi).

• Computer Navigation (Brainlab, Stryker NAV3i): Real-time intraoperative feedback on component orientation without preoperative CT; reduces radiation exposure versus robotic CT-based systems.

• Patient-Specific Instrumentation (PSI): Custom-manufactured cutting jigs based on MRI/CT data — particularly useful in dysplastic hips, complex deformity, or revision scenarios.

• Dual Mobility Cups: Polyethylene mobile-bearing liner within a fixed metal shell; highly effective in reducing dislocation risk in high-risk patients (prior spine fusion, neuromuscular conditions, or revision surgery).

• Outpatient/Same-Day THR: Feasible in carefully selected patients (ASA I–II, BMI <35, strong social support) within robust ERAS programmes; now offered at several accredited centres in India and UAE.

PRE-ARRIVAL (4–6 WEEKS BEFORE TRAVEL):

• GAF Healthcare coordinates remote consultation with the treating arthroplasty surgeon via video link; patient shares X-rays, MRI, and blood reports digitally for review and implant templating

• Surgeon provides a personalised surgical plan specifying approach, implant system, and fixation method

• Pre-admission optimisation: HbA1c control, cessation of antiplatelet agents (aspirin 7 days, clopidogrel 5 days, with cardiologist input), cessation of biologics/DMARDs per rheumatologist guidance, iron supplementation if anaemic, physiotherapy for quadriceps and gluteal strengthening

• GAF Healthcare assists with e-Medical Visa application (India) or entry visa arrangement (UAE), air ticket booking, and pre-operative accommodation

DAY OF ADMISSION (Day 0):

• Hospital admission; anaesthesia assessment (spinal anaesthesia with sedation is the preferred modality for THR — lower DVT risk, reduced blood loss, and faster recovery versus general anaesthesia)

• Baseline blood tests, ECG confirmation, consent process

• Marking of operative limb; antibiotic prophylaxis (cefazolin 2g IV, or vancomycin if MRSA risk) administered 30–60 minutes pre-incision

• Tranexamic acid (TXA) 1–2g IV at induction and/or topical intra-articular instillation to minimise haemorrhage

INTRAOPERATIVE (Day 0, 60–120 minutes):

• Spinal anaesthesia administered; patient positioned per surgical approach (lateral decubitus for posterior/lateral; supine for anterior/robotic)

• Joint exposed; femoral head dislocated; neck osteotomy performed at planned level using templated guide

• Acetabulum reamed to press-fit dimension; cup and liner impacted or cemented with confirmed position via robotic/fluoroscopic feedback

• Femoral canal broached sequentially; trial reduction confirms leg length, offset, and stability; definitive stem and head component inserted

• Wound closure in layers; subcuticular skin closure; no drain in most ERAS programmes

• Patient transferred to recovery with PCEA (patient-controlled epidural analgesia) or continuous adductor/femoral nerve block and multimodal oral analgesia regimen

POST-OPERATIVE — IN-HOSPITAL (Days 1–5):

• Day 1: Physiotherapist-assisted standing and ambulation with walking frame; hip precautions taught (posterior approach: avoid flexion >90°, internal rotation, and adduction for 6 weeks; anterior approach: fewer restrictions)

• DVT prophylaxis initiated (LMWH — enoxaparin 40mg SC daily, or rivaroxaban 10mg oral daily) — continued for 35 days post-discharge

• Pain managed with paracetamol, celecoxib, pregabalin, and ice therapy — opioids reserved for breakthrough use

• Daily wound checks; drains removed if placed; haemoglobin monitored — IV iron infusion if Hb <9g/dL without transfusion indication

• Day 2–3: Stairs training; independent ambulation with forearm crutches; occupational therapy for ADL adaptations

• Day 4–5: Discharge to hotel or serviced apartment upon achieving functional discharge criteria (independent ambulation 50m, safe stair negotiation, wound dry and intact)

POST-DISCHARGE — IN-COUNTRY RECOVERY (Weeks 2–8):

• Week 2: Wound review and suture/staple removal; repeat blood count; X-ray to confirm implant position

• Week 4: Gait assessment; transition from forearm crutches to single cane; hip ROM measured

• Week 6 milestone: Most patients achieve independent ambulation without aid; hip flexion 90–100°; cleared for economy short-haul flight with LMWH cover on travel day

• Weeks 6–8: Surgeon's clearance assessment for long-haul international travel; compression stockings and in-flight exercises mandatory

POST-RETURN HOME (Months 2–6):

• Month 3: Return to driving (left hip: 4–6 weeks; right hip: 6–8 weeks, or per local law); return to office/sedentary work by week 6, manual labour by month 3–6

• Month 6: Full functional recovery expected; swimming and cycling initiated; low-impact sports (golf, doubles tennis) typically permissible

• Month 12: Final functional outcome assessment; Harris Hip Score (HHS) and Oxford Hip Score (OHS) recorded; most patients achieve HHS >80 (good-to-excellent)

• Ongoing: Annual implant surveillance X-ray; serum metal ion monitoring if MoM or large-head MoP bearing used