A total hip endoprosthesis replaces both parts of the destroyed joint: the femoral head on the thigh bone and the hip socket in the pelvis. The artificial joint consists of:
- Stem (titanium or cobalt-chromium alloy) — anchored in the thigh bone
- Head (ceramic or metal) — replaces the femoral head
- Socket (metal with a plastic, ceramic or metal insert) — in the pelvic bone
The anchoring is done with cement (especially in the softer bone of older patients) or without cement (in good bone). The choice is made individually by the surgeon — in older patients with osteoporosis in old age, cementing is more common.
→ On the overall perspective of joint replacement in old age: Joint replacement in old age.
Two completely different clinical situations lead to a total hip replacement in old age:
Elective total hip replacement for hip osteoarthritis
The typical situation: years of increasing hip pain, restricted walking distance, nocturnal pain, conservative therapy exhausted. The operation is planned, the timing can be chosen. This opens up space for structured prehabilitation — and thus for considerably better results. The basis for this is a geriatric assessment.
Total hip replacement after a proximal femoral fracture
The other situation: a fall, a fracture, the need for rapid treatment within 24 to 48 hours. No time for prehabilitation, often a fragile state of health, frequent concomitant diseases. The mortality is significantly higher here — not because of the implant, but because of the starting situation and the systemic strain.
The SOG study (Surgery in the Oldest-Old) reports a one-year mortality of 26.5 percent for patients over 90 years of age after a hip-related fracture. For an elective total hip replacement over 80, it is 2 to 5 percent depending on the quality of care. This difference says everything about the importance of the starting situation and the care structure.
In my own clinic, the Main-Kinzig-Kliniken Schlüchtern, the number of hip-related fractures almost doubled between 2019 and 2025 — from 109 to 217 cases per year. A considerable proportion of these patients receive endoprosthetic treatment. We have expanded the orthogeriatric structure accordingly: geriatric co-care from admission, standardized delirium screening, systematic medication review, early mobilization on the first postoperative day.
→ On the femoral neck fracture in old age as the most common indication for a hip prosthesis in old age.
Surgical technique has made considerable progress in recent years. Three approaches are used:
- Anterior approach (Direct Anterior Approach, DAA): Muscle-sparing, faster mobilization in the first few days, with good results in experienced hands.
- Lateral approach (anterolateral): A classic alternative, somewhat more muscle detachment, but very well established.
- Posterior approach (posterior): The most common approach worldwide, good visibility for the surgeon, a somewhat higher risk of a posterior dislocation in the first months.
Which approach is chosen depends on the surgeon’s experience, the anatomy and the surgical plan. For the patient, the choice is usually less significant than the surgical team’s experience with the respective approach.
For patients over 75 — and all the more over 80 — the structured geriatric pre-examination is part of the standard:
- Frailty assessment: Clinical Frailty Scale. From CFS 5 caution is required, from CFS 7 the indication should generally be reconsidered. More on the frailty syndrome. In addition, a structured frailty screening is recommended.
- Cognition test: MMSE or MoCA. Pre-existing dementia in old age is the strongest single predictor of postoperative delirium.
- Nutritional status: MNA. Malnutrition in old age is an independent risk factor for wound healing and infection.
- Medication review: Anticoagulants, benzodiazepines, anticholinergic substances — each preparation must be checked for necessity and alternatives. The key terms being deprescribing and polypharmacy in old age.
- Social environment: Who provides support at home? Is the home barrier-free? Stairs? A bathtub instead of a shower?
→ On the comprehensive assessment of surgical risk in old age: Surgical risk in old age.
The first three days after a total hip replacement are the key to the later course. In modern fast-track protocols the following applies:
- Mobilization on the day of surgery or at the latest on day 1 — first at the edge of the bed, then with a walking aid
- Multimodal pain therapy with minimal opioid burden — this reduces the risk of delirium
- Delirium screening at least once a day by the nursing team
- Glasses, hearing aid, dentures available — sensory impairments promote delirium
- Actively ensure hydration and nutrition — lack of fluids is a common delirium trigger
- Thrombosis prophylaxis, respiratory therapy, secretion mobilization
→ For details on the recognition and treatment of a postoperative delirium: Delirium in older people.
???? When admitting an older relative for a planned total hip replacement: bring the current medication list, glasses, hearing aid and a picture from familiar surroundings. These seemingly small things measurably reduce the risk of delirium.
The acute phase in hospital is typically followed by:
- Geriatric early rehabilitation: for complex or multimorbid patients directly in the acute hospital. More on this: Geriatric early rehabilitation.
- Follow-up rehabilitation (AHB): three weeks of inpatient rehabilitation in a specialized facility.
- Outpatient physiotherapy: continuation over weeks to further increase mobility — particularly important in preventing falls in old age and as part of fall prevention.
The load on the operated leg is determined by the surgeon — with cemented prostheses usually full weight-bearing from the first day, with cementless ones often restricted for a few weeks.
The prognosis of modern total hip replacements is very good with careful selection and aftercare:
- Long-term survival of the prosthesis: 90 to 95 percent after 15 years
- Patient satisfaction: over 90 percent report a significant improvement in pain and function after one year
- Revision rate: about 1 percent per year, mostly due to aseptic loosening
The most important complications to keep an eye on:
- Dislocation (dislodgement of the prosthesis): Risk of 2 to 5 percent, especially in the first months. Consistent observance of the positioning rules is important.
- Periprosthetic fracture: Fracture of the bone around the prosthesis, rare but consequential. Prevention through treatment of the underlying osteoporosis in old age.
- Periprosthetic infection: 1 to 2 percent risk, often difficult to treat. Oral hygiene and a dental check-up before and after the operation are important.
- Postoperative delirium and POCD: 20 to 40 percent in this age group — our strongest lever for improvement through targeted delirium prevention.
- Thrombosis and pulmonary embolism: Rare with adequate prophylaxis.
In modern orthopedic centers, geriatric co-care over the age of 75 is standard. Where this does not happen automatically, you should actively request it — at the latest in one of the following constellations:
Leading Medicine Guide lists a number of experienced orthopedic and trauma surgeons specializing in endoprosthetics. The combination of orthopedic excellence and geriatric co-management is a proven and evidence-based foundation for good results in modern care structures — especially in advanced age. Geriatric traumatology provides the structural framework for this.
