Understanding Hip Surgery in Older Adults: Hip Replacements, DHS, Hemiarthroplasty and Intramedullary Nails
A practical guide to hip operations, recovery and physiotherapy for patients, families and carers
Hip surgery is common in older adults, particularly following a fall or a fracture. If you or someone you care for has recently undergone hip surgery, you may have heard unfamiliar terms such as hemiarthroplasty, dynamic hip screw (DHS), total hip replacement (THR) or intramedullary nail.
Although these terms can sound complicated, each describes a particular way of treating a damaged hip joint or a broken bone. Understanding the operation can help you know what to expect during recovery, why a walking frame or other walking aid may be needed, and how physiotherapy can help someone regain their confidence and independence. At Physio at Home, we support people across Mid Cornwall with rehabilitation in their own homes following hospital admission, surgery and periods of reduced mobility. In this guide, we explain the main types of hip surgery in straightforward language, explore the differences between them, and look at what recovery and rehabilitation may involve.
1. Why might an older person need hip surgery?
There are two main reasons why an older person might undergo hip surgery: a broken hip following a fall, or a hip joint that has become damaged over time.
Hip fracture following a fall
A hip fracture usually involves a break in the upper part of the thigh bone, known as the femur. It often happens following a fall from standing height, particularly in people whose bones have become more fragile because of osteoporosis. However, a hip fracture can occur following a relatively minor fall, even when someone was previously independent and active. Hip fractures are generally described according to where the bone has broken. The location of the fracture is important because it influences the type of operation the surgeon recommends. Some fractures are treated by fixing the bone together with metalwork. Others are treated by replacing part or all of the hip joint.
Arthritis and wear and tear
Osteoarthritis can gradually damage the cartilage that covers the surfaces of the hip joint. This may cause pain, stiffness, reduced walking ability and difficulty with everyday activities. When symptoms become severe and other treatments are no longer providing sufficient relief, a hip replacement may be recommended. Unlike surgery for a fracture, a planned hip replacement is usually arranged in advance, allowing time for preparation and recovery planning.
2. A quick guide to the different types of hip surgery
Before looking at each operation in detail, it helps to understand the main differences.
Total hip replacement (THR or THA): Both the ball and socket of the hip joint are replaced with artificial components.
Hemiarthroplasty: Only the ball at the top of the thigh bone is replaced. The natural socket remains.
Dynamic hip screw (DHS): A large screw and metal plate hold a fracture together while the bone heals.
Intramedullary nail: A metal rod is inserted inside the thigh bone, with screws helping to stabilise the fracture.
Cannulated screws or other fixation devices: Smaller screws or specialised implants hold certain fractures in position while they heal.
The surgeon chooses the operation according to the fracture's location and stability, the condition of the bone and joint, the person's health, and their usual level of activity.
3. Total hip replacement (THR)
What is a total hip replacement?
A total hip replacement is an operation in which both sides of the hip joint are replaced with artificial components. The hip is a ball-and-socket joint. The ball is the rounded top of the femur, while the socket is part of the pelvis. During a total hip replacement, the damaged ball is removed and replaced with an artificial ball attached to a stem inside the thigh bone. The damaged joint socket is also replaced with an artificial socket, which usually contains a smooth bearing surface.
The new joint is designed to provide a smoother movement and reduce pain.
Why might someone need a total hip replacement?
A total hip replacement is commonly performed for severe osteoarthritis. It may also be used following certain hip fractures, particularly displaced fractures in people who are likely to benefit from the additional function a total replacement can offer. The decision following a fracture is different from the decision for planned arthritis surgery. The surgeon considers the person's medical fitness, mobility before the fracture and likely rehabilitation potential.
What does recovery involve?
Following a planned hip replacement, most people are encouraged to stand and walk with assistance soon after surgery. A walking frame or crutches may be needed initially. Physiotherapy usually focuses on:
Getting in and out of bed safely. - Standing up from a chair and sitting down with control. - Walking safely with an appropriate walking aid. - Practising stairs when necessary. - Improving hip and leg strength. - Gradually increasing walking distance and everyday activity. - Regaining confidence and independence.
Recovery varies considerably. Some people progress quickly, while others need several weeks or months to rebuild their strength, stamina and confidence. A person who was already frail, had limited mobility before surgery or has other health conditions may require a longer rehabilitation period.
Are there any precautions?
Some people receive specific hip movement precautions after surgery to reduce the risk of dislocation. These depend on the surgical approach, implant and individual circumstances. Not everyone receives the same restrictions. Patients should follow the instructions provided by their surgical team rather than relying on general advice found online.
4. Hemiarthroplasty: replacing only the ball of the hip
What is a hemiarthroplasty?
A hemiarthroplasty is a partial hip replacement. The surgeon removes the damaged ball at the top of the femur and replaces it with an artificial ball attached to a metal stem inserted into the thigh bone. Unlike a total hip replacement, the natural socket in the pelvis remains in place. The artificial ball moves against the person's existing socket.
Why is a hemiarthroplasty performed?
Hemiarthroplasty is commonly used to treat a displaced intracapsular hip fracture in older adults. An intracapsular fracture occurs within the capsule surrounding the hip joint, often through the femoral neck, which connects the ball to the rest of the thigh bone. This area has an important blood supply to the femoral head. When a fracture significantly disrupts that blood supply, the natural ball may not heal reliably or may lose its blood supply. Replacing it can therefore be more appropriate than trying to fix it in place. A hemiarthroplasty is often suitable for people whose activity levels, medical circumstances or rehabilitation needs make a partial replacement the preferred option.
What is the difference between a hemiarthroplasty and a total hip replacement?
The main difference is simple:
With a hemiarthroplasty, the ball is replaced but the natural socket remains.
With a total hip replacement, both the ball and socket are replaced.
A hemiarthroplasty is often chosen after a hip fracture because it provides a reliable way to treat the damaged femoral head. A total replacement may be considered for selected people who were more independent before their fracture and are expected to benefit from greater long-term function. Neither operation is automatically better for everyone. The decision is individual.
What does rehabilitation involve?
A hemiarthroplasty is frequently followed by early mobilisation, often beginning on the day after surgery if the person's condition permits. Rehabilitation may involve:
Practising bed mobility and transfers.
Standing with support and progressing to walking.
Learning to use a frame or other walking aid safely.
Improving leg strength and balance.
Building walking tolerance.
Relearning everyday activities such as dressing and preparing simple meals.
Working towards the person's previous level of independence where possible.
Many patients are allowed to put weight through the operated leg as tolerated, but the surgical team's instructions must always be checked. The aim is to restore safe movement and function while allowing the person to recover from both the operation and the wider effects of the fracture.
5. Dynamic hip screw (DHS): fixing the broken bone
What is a dynamic hip screw?
A dynamic hip screw, often shortened to DHS, is a metal fixation device used to stabilise certain fractures of the upper femur. Unlike a hip replacement, it does not replace the ball of the hip. The device usually consists of:
A large screw inserted through the upper femur into the femoral head.
A metal plate attached to the outer surface of the thigh bone.
Smaller screws that secure the plate to the femur.
The large screw sits within a sleeve in the plate. This allows controlled sliding as the fracture settles under load, helping the bone fragments remain supported while healing takes place.
Which fractures are treated with a DHS?
A DHS is commonly used for certain fractures around the trochanteric region of the upper femur, which lies just below the hip joint. These are often called intertrochanteric or trochanteric fractures. The precise fracture pattern matters. A DHS is suitable for many fractures in this region, but other patterns may be better treated with an intramedullary nail.
What happens after DHS surgery?
Because the natural hip joint is retained, recovery involves allowing the fracture to heal while gradually restoring movement and strength. Rehabilitation commonly includes:
Getting out of bed safely.
Practising standing and transfers.
Walking with a frame or other appropriate aid.
Building leg strength.
Improving balance and confidence.
Gradually increasing walking distance.
Returning to personal care and household activities.
Weight-bearing instructions depend on the fracture, the stability achieved during surgery and the surgeon's advice. Many patients are encouraged to weight-bear early, but this should never be assumed without checking the discharge information.
Does the metalwork stay in permanently?
In many cases, the DHS remains in place permanently. It is not normally removed simply because the bone has healed. Removal may be considered if there is a specific problem, but it involves another operation and is not routinely required.
6. Intramedullary nail: a metal rod inside the thigh bone
What is an intramedullary nail?
An intramedullary nail is a metal rod inserted into the central canal inside the femur. The word intramedullary means inside the marrow cavity of the bone. For hip fractures, the nail is often inserted from the upper end of the femur. A large screw or blade passes from the nail into the femoral head to help stabilise the upper part of the fracture. Additional locking screws may be inserted lower down the thigh bone. This is sometimes called a cephalomedullary nail. Like a DHS, it fixes the broken bone rather than replacing the hip joint.
Which fractures require an intramedullary nail?
Intramedullary nails are commonly used for certain trochanteric fractures, particularly unstable fracture patterns, and for subtrochanteric fractures. A subtrochanteric fracture occurs in the upper part of the femur below the trochanters. These fractures can be exposed to substantial forces when standing and walking, so the position and design of the fixation are important. The nail sits within the bone rather than entirely along its outer surface. This can provide useful support for particular fracture patterns.
How does rehabilitation differ from a DHS?
The overall rehabilitation goals are similar: safe mobility, improved strength, better balance and a return to everyday activities. However, the fracture pattern and the stability of the fixation may affect how much weight a person can put through the operated leg. Some patients can weight-bear as tolerated soon after surgery. Others may have specific restrictions. The physiotherapist should work from the documented surgical instructions and adapt walking practice, exercises and transfers accordingly.
Is an intramedullary nail the same as a hip replacement?
No. An intramedullary nail is used to stabilise a fracture. The natural ball and socket remain in place. A hip replacement substitutes one or both sides of the joint with artificial components. This distinction is important because the rehabilitation priorities and any surgical precautions can differ.
7. Cannulated screws and other fixation devices
Not every hip fracture requires a large plate or a long nail. Some fractures, particularly certain fractures of the femoral neck that have not significantly displaced, may be treated with screws to hold the bone fragments in position.
What are cannulated screws?
Cannulated screws are hollow-centred screws that can be guided over a thin wire during surgery. Several screws may be inserted across the fracture to provide stability. They are designed to hold the bone in position while it heals. This is known as internal fixation.
Why are screws used instead of a replacement?
If the fracture is stable and the blood supply to the femoral head is sufficiently preserved, fixing the bone may be an appropriate option. However, the decision depends on the exact fracture pattern and the patient's circumstances. Some femoral neck fractures have a higher risk of displacement, non-union or loss of blood supply, and replacement surgery may be recommended instead.
What does recovery involve?
The rehabilitation plan depends on how stable the fracture is after fixation. Weight-bearing may be allowed as tolerated or restricted for a period. The physiotherapist should establish the permitted level of weight-bearing before progressing walking and exercises.
8. Other hip operations you may hear about
Revision hip replacement
A revision operation is performed when an existing hip replacement needs to be repaired or replaced. Reasons can include loosening, wear, infection, recurrent dislocation or a fracture around the implant. Revision surgery can be more complex than a first hip replacement. Recovery depends on the reason for the operation, the extent of reconstruction and the surgeon's restrictions.
Hip replacement following a fracture around an existing implant
A fracture around an existing hip replacement is called a periprosthetic fracture. Treatment may involve fixation with plates, screws or a nail, revision of the existing implant, or a combination of procedures. These fractures require an individual surgical plan because the stability of the existing implant and the condition of the surrounding bone influence treatment.
Removal or revision of metalwork
Occasionally, a patient may need further surgery because metalwork has become problematic or the fracture has not healed as expected. Metalwork is not routinely removed simply because a person can feel it or because rehabilitation is taking time. Any persistent pain or concern should be assessed by the appropriate clinical team.
9. Why the type of fracture matters
The phrase “broken hip” describes a group of injuries rather than one specific fracture. The surgeon uses X-rays and, when needed, other imaging to identify the fracture location and pattern. Broadly, hip fractures may be described as follows:
Intracapsular fractures occur within the capsule of the hip joint, often through the femoral neck. Some are treated with screws, while displaced fractures in older adults are commonly treated with a hemiarthroplasty or total hip replacement.
Trochanteric fractures occur in the upper femur around the bony prominences below the femoral neck. These are often treated with a DHS or an intramedullary nail, depending on the fracture pattern.
Subtrochanteric fractures occur further down the femur below the trochanters. Intramedullary nailing is commonly recommended for these fractures. These are general patterns, not rules for every patient. The surgical team determines the most appropriate procedure for the individual.
10. What does weight-bearing mean after hip surgery?
One of the most important questions after surgery is: “Can I put weight through my leg?” Weight-bearing instructions describe how much pressure can be placed through the operated leg during standing and walking. Common terms include:
Weight-bearing as tolerated: Put as much weight through the leg as comfort and the clinical instructions allow, usually using a walking aid.
Full weight-bearing: The leg can take the person's full body weight within the agreed rehabilitation plan.
Partial weight-bearing: Only a specified amount of weight is permitted.
Non-weight-bearing: No weight should be placed through the operated leg.
Many older adults are encouraged to mobilise early after hip fracture surgery. NICE recommends surgery with the aim of allowing unrestricted weight-bearing immediately afterwards where possible, and physiotherapy assessment and mobilisation on the day after surgery unless medically or surgically contraindicated. However, individual restrictions still apply. Never assume that someone with a DHS or intramedullary nail can automatically walk without restriction. If the instructions are unclear, contact the ward, fracture clinic or surgical team before progressing rehabilitation.
11. What can patients expect during the first few weeks?
Recovery is not just about the operation. A hip fracture can affect strength, balance, confidence, sleep, appetite and the ability to manage everyday tasks. The first few weeks often involve gradual progress rather than a straight line towards recovery.
Getting moving again
Initially, a person may need help to sit on the edge of the bed, stand up or transfer to a chair. A walking frame is often useful because it provides a wide base of support and allows the person to take some weight through their arms. As strength and confidence improve, the physiotherapist may consider whether a different walking aid is appropriate. The right walking aid is the one that provides sufficient support while allowing the person to move safely and effectively.
Managing fatigue
It is common to feel tired after a fracture and operation. Hospital admission, pain, disrupted sleep, reduced appetite and the effort of relearning movements can all contribute. Short, regular periods of activity with planned rests may be more manageable than attempting too much in one go. A person who is making progress may still need help with washing, dressing, meals and household tasks for a period.
Pain and swelling
Some pain, bruising and swelling around the operated hip and thigh are common during recovery. Pain should generally be manageable with the prescribed treatment and should gradually improve. Follow the advice provided about medication, wound care and activity. Seek prompt medical advice if pain or swelling becomes markedly worse, or if there is new redness, wound discharge or fever. Sudden shortness of breath, chest pain, collapse or other symptoms suggestive of a blood clot or serious complication require emergency assessment.
Confidence after a fall
Some people become frightened of falling again. They may walk very slowly, avoid standing or rely heavily on furniture for support. This is understandable, particularly after a painful injury. Rehabilitation should address confidence as well as physical strength. Practising familiar tasks in a safe environment can help people regain trust in their ability to move.
12. Physiotherapy after hip surgery: why it matters
Physiotherapy plays an important role in helping people regain mobility and independence after hip surgery. The precise programme depends on the operation, the fracture, the person's health and their goals.
Strength and movement
Following a period in hospital and reduced activity, the muscles around the hip and thigh can become weaker. Exercises may be prescribed to improve leg strength, control and the ability to stand and walk. The programme should be tailored to the patient's stage of recovery and surgical restrictions.
Walking practice
Walking is a functional activity that requires strength, balance, coordination and stamina. A physiotherapist can assess walking technique, the suitability of the walking aid, turning, transfers and the ability to negotiate different surfaces. Practice should progress gradually, with attention to safety and fatigue.
Balance and falls prevention
A fall may have been caused by several factors, including muscle weakness, balance problems, reduced vision, medication effects, environmental hazards or an acute illness. Rehabilitation may therefore need to look beyond the operated hip. Depending on the person's needs, a physiotherapist may assess balance, walking, lower-limb strength and falls risk, and recommend appropriate exercises or onward referral.
Returning to everyday activities
The ultimate aim is not simply to walk a certain distance. It is to help the person manage the activities that matter to them. These might include getting to the bathroom independently, preparing meals, climbing stairs, going into the garden or returning to social activities. Rehabilitation goals should be meaningful to the individual and realistic for their circumstances.
13. Recovering at home after hospital discharge
Going home after hip surgery can be a major milestone, but it can also be daunting. A person may have managed short walks in hospital but find that everyday life at home requires much more effort. There may be stairs to negotiate, a bathroom to access, meals to prepare and longer distances to cover between rooms. Family members and carers may also be unsure how much assistance to provide.
Making the home safer
Useful considerations include:
Keeping frequently used items within easy reach. - Removing loose rugs and reducing trip hazards. - Ensuring hallways and walking routes are well lit. - Using prescribed equipment and walking aids correctly. - Keeping a telephone within reach. - Arranging help with shopping, meals and household tasks while mobility is limited. - Following the discharge team's advice about stairs, bathing and transfers.
Equipment should be selected according to the person's needs and the layout of their home.
Supporting someone without taking over
It can be tempting to do everything for someone after surgery, especially when they are vulnerable or frightened. However, where it is safe and appropriate, encouraging the person to participate in everyday tasks can help maintain strength, confidence and independence. This does not mean pushing someone beyond their abilities. It means finding the right balance between support and opportunities to do things for themselves.
When progress is slower than expected
Not everyone recovers at the same pace. Age alone does not determine recovery. A person's health before the fracture, the severity of the injury, complications, nutrition, cognition, mood, support at home and access to rehabilitation can all influence progress. If someone is struggling to mobilise, experiencing persistent pain or losing confidence, a review by the relevant healthcare team may help identify what additional support is needed.
14. Frequently asked questions
Does everyone who breaks their hip need a replacement?
No. Some fractures are treated by fixing the bone with screws, a plate or a nail. Others, particularly certain displaced fractures through the femoral neck, are treated with a partial or total hip replacement.
Is a hemiarthroplasty the same as a total hip replacement?
No. A hemiarthroplasty replaces the ball of the hip, leaving the natural socket in place. A total hip replacement replaces both the ball and the socket.
Does a DHS replace the hip joint?
No. A DHS holds the broken bone together while it heals. The natural hip joint remains in place.
Is an intramedullary nail permanent?
It is generally intended to remain in place after the fracture has healed, unless a specific problem leads the surgical team to recommend further treatment.
How long does recovery take?
Recovery varies considerably. Some people regain much of their previous function over several weeks, while others need months of rehabilitation. Frailty, pre-existing mobility difficulties and complications can extend recovery.
Will someone need a walking frame permanently?
Not necessarily. Some people progress from a frame to crutches or a stick, while others benefit from continuing to use a frame for safety. The decision should be based on their mobility, balance, strength and confidence rather than an arbitrary deadline.
Can physiotherapy take place at home?
Yes. Where a person is medically stable and home-based rehabilitation is appropriate, physiotherapy can help them practise mobility and everyday activities in the environment where they need to function. The programme should follow the surgical team's instructions and complement any rehabilitation already being provided.
15. How Physio at Home can help
At Physio at Home, we understand that returning home after a hip operation can be challenging for both patients and their families. Hospital physiotherapy is an important first step, but some people need further support to rebuild their strength, confidence and independence once they are home. We provide private home-visit physiotherapy across Mid Cornwall, covering the Truro to Falmouth area.
Our physiotherapy service can help with: Mobility and walking: Assessing how someone is managing with their walking aid, practising safe transfers and helping them work towards more confident walking. Strength and balance: Developing an appropriate exercise programme to address weakness, balance difficulties and reduced mobility. Rehabilitation after a hip fracture or replacement: Supporting the return to everyday activities in line with the person's surgical instructions and rehabilitation goals. Falls prevention: Identifying relevant mobility and balance difficulties and advising on appropriate strategies to reduce the risk of further falls. Confidence at home: Helping people practise meaningful tasks in their own environment, such as moving between rooms, managing stairs where appropriate and getting in and out of chairs. Support for families and carers: Providing guidance on safe assistance, activity progression and ways to encourage independence without placing unrealistic demands on the person recovering.
Every person is different. We tailor rehabilitation to the individual's abilities, home environment and goals, working within the guidance provided by their hospital and surgical team.
If you or a family member has recently returned home following hip surgery and would benefit from additional rehabilitation, Physio at Home may be able to help.
Find out more or contact us:
Website: https://www.physioathome.uk/ Physio at Home — private home-visit physiotherapy in Mid Cornwall, from Truro to Falmouth.
Important information
This article is for general educational purposes and is not a substitute for individual medical advice. The type of operation, fracture pattern, weight-bearing instructions and rehabilitation precautions vary between patients. Always follow the advice provided by your surgeon, hospital physiotherapist and other treating clinicians. Seek medical advice if recovery is not progressing as expected or new symptoms develop.
References and further reading
The following sources provide evidence-based information about hip fracture surgery, clinical recommendations and recovery.
National Institute for Health and Care Excellence (NICE). Hip fracture: management (CG124). Clinical guidance, updated 6 January 2023. Includes recommendations on fracture surgery, replacement arthroplasty, fixation methods, weight-bearing and mobilisation. https://www.nice.org.uk/guidance/cg124/chapter/recommendations
Royal Osteoporosis Society. Broken hips, wrists and other bones. Patient information about treatment, healing and recovery after fractures. https://theros.org.uk/information-and-support/living-with-osteoporosis-and-broken-bones/broken-hips-wrists-and-other-bones/
Gloucestershire Hospitals NHS Foundation Trust. Your broken hip. Patient information explaining the different types of hip fracture and surgical treatment. https://www.gloshospitals.nhs.uk/your-visit/patient-information-leaflets/your-broken-hip/
American Academy of Orthopaedic Surgeons (AAOS). Management of Hip Fractures in Older Adults: Clinical Practice Guideline. Evidence-based recommendations on hip fracture treatment in older adults. https://www.aaos.org/quality/quality-programs/hip-fractures-in-older-adults/
Cochrane. Which are the best treatments for hip fractures in older adults? An evidence overview of surgical treatments for hip fractures. https://www.cochrane.org/evidence/CD013405_which-are-best-treatments-hip-fractures-older-adults
National Institute for Health and Care Excellence (NICE). Falls: assessment and prevention in older people and in people 50 and over at higher risk (NG249). Guidance on assessing and reducing falls risk. https://www.nice.org.uk/guidance/ng249
Useful links for patients and families
NHS — Hip fracture: General information about broken hips, treatment and recovery. https://www.nhs.uk/conditions/hip-fracture/
NHS — Hip replacement: Information about hip replacement surgery and recovery. https://www.nhs.uk/conditions/hip-replacement/
Physio at Home: Learn more about home-visit physiotherapy and rehabilitation in Mid Cornwall. https://www.physioathome.uk/
Royal Osteoporosis Society: Information about bone health, osteoporosis and recovering after a fracture. https://theros.org.uk/
NICE — Hip fracture management: Clinical recommendations for professionals and those seeking more detailed information about treatment. https://www.nice.org.uk/guidance/cg124
Article prepared for Physio at Home. Clinical guidance and website links should be reviewed periodically to ensure they remain current.
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