Recovering from a hip replacement

Most of my hip replacement patients are up and walking with a walker the same day, home within one to three days, onto a cane by week two, and back to normal life without any aid by about six weeks; anything still improving has improved by a year. Along the way it is normal to bruise down the thigh, to be more sore in the evenings, and to hit a discouraging plateau at three to four weeks.

What is not normal, and earns a call to the office the same day: pain that climbs instead of settling, a wound turning more red, a genuine fever, or new calf pain on one side. Sudden breathlessness or chest pain is the emergency department now, not a telephone call. This page takes you through recovery week by week — what helps it along, what sets it back, and exactly when to reach me.

The pain you wake up with is not the pain you came in with

This is the single most useful thing to understand before your operation and too few patients are told it. The deep groin ache that made you stop going out disappears the moment the arthritic joint is removed. What you feel afterwards is a different pain: soreness in the thigh and buttock from the operation itself.

It is sharper, worse with movement and better with rest, and it fades week by week. Patients who are not told this lie awake on the first night trying to work out whether the operation worked. The moment most of my patients remember is the first time they put the foot on the floor, because that is when they notice the arthritis pain has gone.

Week by week, the way my patients actually go

When	What most of my hip patients are doing
Day of surgery	Standing and walking a short distance with a walker, a few hours after the operation
Day 1 to 3	Home for most patients. Walker indoors. Visiting nurse and physical therapist. Sleeping badly
Day 5 to 7	Dressing off, showering once the wound is dry. Bruising spreads down the thigh and looks alarming; it is not. Patients who work from home are often back at it this week
Week 2	Off strong pain medication for most. Walker to a cane. Driving if the left hip was operated on
Week 3 to 4	Cane outdoors only or put away. Back to desk work. This is where people plateau and get discouraged
Week 6	I see you. Precautions lifted in most patients. Walking without aids. Right-hip driving
Month 3	Golf, cycling, swimming. Heavy manual work. Most patients have stopped thinking about the hip
Month 12	The end point. Anything still improving has improved

What the fastest recoverers do differently

They walk. Little and often, several times a day, rather than one long walk that leaves them wrecked.

They stay ahead of the pain in the first week by taking medication on schedule rather than waiting until it hurts.

They set the house up before the day rather than after.

They use ice. Twenty minutes at a time, several times a day, for the first fortnight. It is unglamorous and it does more for swelling than anything else I can offer.

And they do not compare themselves with somebody who had a knee replaced. Do not do this. Getting a hip done is like visiting your mother and getting a knee done is like visiting your mother-in-law. A hip recovers faster and further than a knee, and comparing the two makes one of you miserable for no reason.

What sets recovery back

Sitting in a low soft chair and then hauling yourself out of it. That is the most common cause of a bad evening in week two.

Doing a full day of activity in one go because you felt well in the morning.

Loose rugs, which are what people fall on.

Abandoning the walker before you are steady, because a fall in the first six weeks is the one event that genuinely sets this back.

Ice and snow. I am direct about this: do not walk on ice, and do not shovel snow. Falls on ice after a joint replacement can undo a great deal.
Ladders. I discourage them generally, because I have seen bad injuries from ladder falls. The exception is somebody who uses one for work and is trained to.

The six weeks of precautions and what happens at the end

If I approached your hip from behind, I ask for six weeks of three things: do not bend the hip past a right angle, do not cross your legs, and do not let the knee roll inwards. A pillow or wedge between the thighs at night, which also helps patients who find side-sleeping difficult. A raised toilet seat and a firm chair with arms.

Those exist to protect the muscle and capsule repair at the back of the hip while it heals into bone. When it has healed they are not needed and I lift them.

Patients are regularly surprised by that, because a friend has told them they can never cross their legs again. In my practice that is not true.

What is not lifted is impact. An artificial joint has no capacity to repair itself. Running and jumping shorten its life. Being active does not, and being active is the entire point of having done this.

Getting back to work

Work	When, in my patients
Working from home	Often the same week as the surgery
Desk work with a commute	Two to four weeks
Teaching, standing most of the day	Four to six weeks
Retail and hospitality with lifting	Six to ten weeks
Heavy manual labour	Around three months
Police and fire, full duty	A functional decision rather than a date, commonly three to six months
Transit and railroad, safety-sensitive duty	Governed by the employer medical standard; start the paperwork early
Union trades and ladders	Around three months, and ladders only where the trade requires it and the person is trained
A long train commute with platform stairs	Plan for it. Tell me at the first visit and we work backwards from it

 

Flying, and patients who travel to me

A number of my patients come from outside New York, including from Canada. Everything possible is done before they travel, including assessment and optimisation of their medical conditions. After surgery they have one postoperative visit at about a week and then they go home.

What I tell them about the flight: walk as much as the aircraft allows, keep yourself very well hydrated, and do your ankle pumping exercises in the seat. I tell them to walk until a member of the cabin crew makes them sit down, because I would rather over-correct than under-correct.

For patients travelling shorter distances the same principles apply on a long train journey.

Airport security and scanners

We used to issue cards for airport detectors and we no longer do, because no card exempts anybody from screening and the Transportation Security Administration does not require one.

What I would rather you knew is the opposite of what most people assume. A walk-through metal detector is more likely to pick up a joint replacement than a modern body scanner is, because the detector generates a field that passes through you while millimetre-wave scanners only read the surface. In one published series of shoulder replacement patients, 303 of 662 flights produced a screening alarm. Simply tell the officer you have a joint replacement and expect to be screened further.

I will add an observation. Some of my patients report passing through an airport detector without their implant being detected at all. That is uncommon, and frankly it says more about the detector than about the implant.

Magnetic resonance imaging: your hip replacement is safe in a scanner. It causes distortion on images taken close to it, so tell the radiographer which side and which implant. Computed tomography, dental x-rays and mammograms present no issue.

Antibiotics before dental work, and where I part company with the guideline

This is the clearest example on my website of a place where I do something other than what the current guideline advises, so you are entitled to the guideline and my reasoning side by side.

The guideline: in November 2024 the American Academy of Orthopaedic Surgeons, together with the American Association of Hip and Knee Surgeons and endorsed by the American Dental Association and the Infectious Diseases Society of America, published guidance stating that routine antibiotics before a dental procedure may not reduce the risk of a joint replacement becoming infected. The American Dental Association reached a similar position in 2015. An older recommendation limited antibiotic cover to the first two years after surgery.

What I ask my patients to do: take an antibiotic before any dental procedure that involves work on the gums or breaks the lining of the mouth, and to continue doing so for life.

My reasoning, which travels with the recommendation every time I give it. Bacteria from the mouth enter the bloodstream during that kind of dental work. An artificial joint has no blood supply of its own and no immune defence at its surface, which is why it is a surface bacteria settle on.

I have personally seen joint infections occur several years after the replacement, following an infection in the mouth. The two-year rule never made sense to me on those grounds: nothing about the joint changes on the day the two years expire. Weighing a single dose of an oral antibiotic against the year that a deep joint infection costs a patient is not, in my judgement, a close call.

The counter-argument deserves stating fairly. There is no randomized trial showing that this prevents infection. Ordinary chewing and brushing produce far more cumulative bacteria in the bloodstream than occasional dental visits do. And antibiotics are not free of harm, with allergy, resistance and gut infection all real. A reasonable surgeon can weigh this differently from me, and many do.

Tell your dentist that this is your surgeon’s instruction and that it differs from the current guideline. If they want to discuss it, my office will take the call.

Which dental work this applies to

It applies to procedures that manipulate the gum tissue or perforate the lining of the mouth: extractions, deep cleaning below the gum line, periodontal treatment, implant placement, and root canal work extending past the tip of the root.

It does not apply to a routine filling above the gum line, dental x-rays, an orthodontic adjustment, or a local anesthetic injection through healthy tissue.

The usual regimen is a single dose of an oral antibiotic taken shortly before the appointment, and your dentist will prescribe it. If you are allergic to penicillin, tell them, because the alternative agents have changed in recent years.

Separately: no elective dental work at all in the first three months after your joint replacement.

When to telephone me and when to go straight in

Emergency department now: sudden breathlessness, chest pain or coughing blood. Difficulty breathing is the symptom I most want acted on rather than watched, because that is the one that can represent a clot in the lung. A calf that is hot, swollen and painful. A temperature that is genuinely high. A wound that opens. A fall in which the hip pops and the leg goes short and turns inwards.

Telephone the office the same day: redness spreading outwards from the wound, fluid still coming from the incision after five days, pain climbing rather than settling after about day four, inability to pass urine, or a calf ache on one side.

Safe to watch: bruising spreading down the thigh and turning yellow-green, ankle swelling at the end of the day, a numb patch beside the scar, clicking from the joint, and exhaustion in week two.

On fever specifically: a mild temperature in the first days is common after a joint replacement and is usually not infection. A great many patients who report a fever are describing feeling warm rather than a measured high temperature. What concerns me is a genuinely high temperature, or a mild one alongside a wound that is changing.

There is somebody in my office seven days a week including holidays. Missed calls are returned automatically by our system and we can message you securely by text. I would far rather hear from you on day two about something that turns out to be nothing than on day twelve about something that is not.

What I check at six weeks

I see you at six weeks rather than at two. Some surgeons use a two-week visit and occasionally a patient is told my office has made a mistake. It is not a mistake. There is very little I can usefully do at two weeks that the visiting nurse and the visiting physical therapist are not already doing, and everything else is manageable by telephone or by secure message. Bringing a patient in at two weeks for my convenience rather than theirs is not a service. If there is an issue, you come in immediately.

At six weeks I watch your gait as you come in, before I look at anything else. I check the wound, the range of movement, and whether the leg lengths feel equal to you as well as measuring equal to me. I take an x-ray. And I lift the precautions if the repair has had its time.

After that I see patients at a year and then periodically for the long term. Long-term follow-up on a joint replacement is not a formality: wear and loosening are silent for a long time and are far easier to deal with when found on a film than when found because the hip has started hurting.

If you move away, have a hip x-ray every few years and send it to somebody. That is the whole request.

A note on scans after your replacement

Patients ask whether they should have a magnetic resonance imaging scan afterwards to see how things are healing, or to look at scar tissue. I do not advise it and I very rarely order one.

The reason is that a scan taken in the postoperative period shows changes that are simply part of healing, and those changes look like something when they are nothing. It generates worry and occasionally generates an intervention, without improving anything.

Scar tissue forms differently in different people and there is no useful way to predict it from a picture. If a specific problem develops that requires that kind of imaging, we will order it with the correct technique for a joint containing metal. Routinely, no.

What I am looking for at a year

A patient who is completely free of pain. Not the film. I treat patients rather than x-rays, although in practice the two usually travel together.

The patients I count as a complete success are the ones who have forgotten which side it was. In most of my hip patients that point is reached somewhere between three and twelve months.

What a healed hip replacement looks like

Films from my own patients after surgery. This is what the first three months are working towards.

 

 

 

 

 

 

Who pays me for recovery advice

No manufacturer of implants, braces, equipment or rehabilitation services pays me anything. Recovery products are sold hard to patients after joint replacement, so nothing recommended here has a commercial interest behind it.

What actually drives a hip recovery

Most of what determines how a hip replacement recovery goes is not surgical, and I would rather say that plainly than take credit for it.

The patients who do best walk little and often, stay ahead of the pain in the first week rather than chasing it, set the house up before the day rather than after, and use ice more than they expect to. None of that is complicated and all of it is theirs rather than mine.

On follow-up I take a position some colleagues do not share. There is very little I can usefully do at two weeks that the visiting nurse and therapist are not already doing, and bringing a patient into an office at two weeks for my convenience rather than theirs is not a service. If something is wrong they come in immediately, which is a different matter.
Long-term follow-up is not a formality. Wear and loosening are silent for years and are far easier to deal with when found on a film than when found because the hip has started to hurt.

 

This page describes my own practice and judgement. It is not medical advice for your situation. Please see a physician about your own condition.