HIP CONDITIONS & SURGICAL TREATMENT
The information outlined below on common conditions and treatments is provided as a guide only and it is not intended to be comprehensive. Discussion with Mr Luscombe is important to answer any questions that you may have. For information about any additional conditions not featured within the site, please contact us for more information.
COMMON CONDITIONS OF THE HIP
OSTEOARTHRITIS
The symptoms of osteoarthritis can vary greatly from person to person, but if it affects the hip, it will typically cause:
• mild inflammation of the tissues in and around the hip joint
• damage to cartilage – the strong, flexible tissue that lines the bones
• bony growths (osteophytes) that develop around the edge of the hip joint
This can lead to pain, stiffness and difficulty doing certain activities.
There’s no cure for osteoarthritis, but the symptoms can be eased using a number of different treatments. Surgery isn’t usually necessary.
LESS COMMON CAUSES
Less commonly, hip pain may be caused by:
• the bones of the hip rubbing together because they’re abnormally shaped – a condition called femoroacetabular impingement
• a tear in the ring of cartilage surrounding the socket of the hip joint – known as a hip labral tear
• hip dysplasia – where the hip joint is the wrong shape, or the hip socket isn’t in the correct position to completely cover and support the top of the leg bone
• a hip fracture – this will cause sudden hip pain and is more common in older people with weaker bones
• an infection in the bone or joint, such as septic arthritis or osteomyelitis – see your GP immediately if you have hip pain and fever
• reduced blood flow to the hip joint, causing the bone to break down – a condition known as osteonecrosis
• inflammation and swelling of the fluid-filled sac (bursa) over your hip joint – a condition called bursitis
• a hamstring injury
• an inflamed ligament in the thigh, often caused by too much running – known as iliotibial band syndrome
WHEN TO SEEK MEDICAL ADVICE
Hip pain often gets better on its own, and can be managed with rest and over-the-counter painkillers, such as paracetamol and ibuprofen. However, see your GP if:
• your hip is still painful after one week of resting it at home
• you also have a fever or rash
• your hip pain came on suddenly and you have sickle cell anaemia
• the pain is in both hips and other joints as well
Go straight to hospital if:
• the hip pain was caused by a serious fall or accident
• your leg is deformed, badly bruised or bleeding
• you’re unable to move your hip or bear any weight on your leg
• you have hip pain with a temperature and feel unwell
Overactivity
If your hip pain is related to exercising or other types of regular activity:
• cut down on the amount of exercise you do if it’s excessive
• always warm up before exercising and stretch afterwards
• try low-impact exercises, such as swimming or cycling, instead of running
• run on a smooth, soft surface, such as grass, rather than on concrete
• make sure your running shoes fit well and support your feet properly
OSTEOARTHRITIS
Osteoarthritis is by far the most common form of arthritis. It is estimated that 25% of females and 16% of males over the age of 60 are symptomatic from osteoarthritis. Over 55,000 hip replacements are performed in the UK each year to treat osteoarthritis. This page concentrates on osteoarthritis.
OA is a degenerative disorder in which there is progressive loss of articular (surface) cartilage accompanied by new bone formation and capsular fibrosis (stiffening). In effect, this is ‘wear and tear’ arthritis. Many joints can be affected or just one.
There are 2 basic types of osteoarthritis; primary and secondary:
PRIMARY
• No obvious cause
• Many joints involved including fingers, big toe, knees, spinal facet joints
• Usually starts in the hands
• Mainly postmenopausal women
• Familial; i.e. can be inherited
• Same pathology as single joint osteoarthritis
SECONDARY
• Estimated 80% of all OA
• Normal cartilage having to cope with an abnormal load
• Abnormal cartilage having to cope with a normal load
• Cartilage break-up occurs due to defective subchondral bone (bone beneath the articular cartilage)
RHEUMATOID ARTHRITIS
Rheumatoid Arthritis is a condition of unknown cause where the lining membrane (the synovium) of joints becomes inflamed. Damage to the joint surfaces follows, resulting in the destruction of the lining cartilage; the joint becomes painful and arthritic. Many joints can be involved, especially those in the hands and feet, but the larger joints such as the hip and knee are also commonly affected.
CAUSES
There is no obvious cause of primary osteoarthritis; causes of secondary OA include:
• Previous trauma (fracture, dislocation and cartilage injuries)
• Developmental disorders causing abnormal anatomy (e.g. hip dysplasia)
• Childhood hip conditions such as Perthes’ Disease
• Miscellaneous conditions such as avascular necrosis
SYMPTOMS
The overwhelming symptom from hip arthritis is pain. The nerve supply to the hip joint is complex, and as a result pain that comes from the hip can be felt in several different sites. Commonly, pain is felt in the groin, but pain can also be experienced down the inside of the leg, into the knee and sometimes down to the ankle. It can also be felt in the buttock, in the top of the thigh, and rarely in the back.
The pain from hip OA is made worse by activities such as walking for any distance and can often disturb sleep. As a result of joint stiffness patients often have difficulty putting on their shoes and socks.
TREATMENT OPTIONS
Many patients with arthritic hips do not need a hip replacement. There are many ways of coping with the pain from hip arthritis; they include:
• Simple painkillers
• Anti-inflammatory medication
• Weight reduction
• Activity modification
• Using a walking stick (using the stick on the SAME side)
• Physiotherapy
• Steroid injection into the hip joint; usually a day case procedure
However, in the majority of cases there comes a point when these are insufficient and the amount of pain and its impact on lifestyle become intolerable. Hip replacement then becomes a sensible treatment option.
Anyone can be affected by avascular necrosis. However, it’s most common in people between the ages of 30 and 60. Because of this relatively young age range, avascular necrosis can have significant long-term consequences.
SYMPTOMS OF LIGAMENT TEARS
Many people have no symptoms in the early stages of avascular necrosis. As the condition worsens, your affected joint may hurt only when you put weight on it. Eventually, the joint may hurt even when you’re lying down. Pain can be mild or severe and usually develops gradually. Pain associated with avascular necrosis of the hip may be focused in the groin, thigh or buttock. In addition to the hip, the areas likely to be affected are the shoulder, knee, hand and foot. Some people develop avascular necrosis bilaterally — for example, in both hips or in both knees.
CAUSES OF AVASCULAR NECROSIS
Avascular necrosis occurs when blood flow to a bone is interrupted or reduced. Reduced blood supply can be caused by:
• Joint or bone trauma. An injury, such as a dislocated joint, might damage nearby blood vessels. Cancer treatments involving radiation also can weaken bone and harm blood vessels.
• Fatty deposits in blood vessels. The fat (lipids) can block small blood vessels, reducing the blood flow that feeds bones.
• Certain diseases. Medical conditions, such as sickle cell anemia and Gaucher’s disease, also can cause diminished blood flow to bone.
For about 25 percent of people with avascular necrosis, the cause of interrupted blood flow is unknown.
RISK FACTORS
Risk factors for developing avascular necrosis include:
• Trauma. Injuries, such as hip dislocation or fracture, can damage nearby blood vessels and reduce blood flow to bones.
• Steroid use. High-dose use of corticosteroids, such as prednisone, is the most common cause of avascular necrosis that isn’t related to trauma. The exact reason is unknown, but one hypothesis is that corticosteroids can increase lipid levels in your blood, reducing blood flow and leading to avascular necrosis.
• Excessive alcohol use. Consuming several alcoholic drinks a day for several years also can cause fatty deposits to form in your blood vessels.
• Bisphosphonate use. Long-term use of medications to increase bone density may be a risk factor for developing osteonecrosis of the jaw. This complication has occurred in some people treated with these medications for cancers, such as multiple myeloma and metastatic breast cancer. The risk appears to be lower for women treated with bisphosphonates for osteoporosis.
• Certain medical treatments. Radiation therapy for cancer can weaken bone. Organ transplantation, especially kidney transplant, also is associated with avascular necrosis.
Medical conditions associated with avascular necrosis include:
• Pancreatitis
• Diabetes
• Gaucher’s disease
• HIV/AIDS
• Systemic lupus erythematosus
• Sickle cell anemia
TREATMENT OF AVASCULAR NECROSIS
The goal is to prevent further bone loss. Specific treatment usually depends on the amount of bone damage you already have.
MEDICATIONS AND THERAPY
In the early stages of avascular necrosis, symptoms can be reduced with medication and therapy. Your doctor might recommend:
• Nonsteroidal anti-inflammatory drugs. Medications, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve, others) may help relieve the pain and inflammation associated with avascular necrosis.
• Osteoporosis drugs. Medications, such as alendronate (Fosamax, Binosto), may slow the progression of avascular necrosis, but the evidence is mixed.
• Cholesterol-lowering drugs. Reducing the amount of cholesterol and fat in your blood may help prevent the vessel blockages that can cause avascular necrosis.
• Blood thinners. If you have a clotting disorder, blood thinners, such as warfarin (Coumadin, Jantoven), may be recommended to prevent clots in the vessels feeding your bones.
• Rest. Reducing the weight and stress on your affected bone can slow the damage. You might need to restrict your physical activity or use crutches to keep weight off your joint for several months.
• Exercises. You may be referred to a physical therapist to learn exercises to help maintain or improve the range of motion in your joint.
• Electrical stimulation. Electrical currents might encourage your body to grow new bone to replace the area damaged by avascular necrosis. Electrical stimulation can be used during surgery and applied directly to the damaged area. Or it can be administered through electrodes attached to your skin.
SURGICAL AND OTHER PROCEDURES
Because most people don’t start having symptoms until avascular necrosis is fairly advanced, your doctor may recommend surgery. The options include:
• Core decompression. The surgeon removes part of the inner layer of your bone. In addition to reducing your pain, the extra space within your bone stimulates the production of healthy bone tissue and new blood vessels.
• Bone transplant (graft). This procedure can help strengthen the area of bone affected by avascular necrosis. The graft is a section of healthy bone taken from another part of your body.
• Bone reshaping (osteotomy). In this procedure, a wedge of bone is removed above or below a weight-bearing joint, to help shift your weight off the damaged bone. Bone reshaping might allow you to postpone joint replacement.
• Joint replacement. If your diseased bone has already collapsed or other treatment options aren’t helping, you might need surgery to replace the damaged parts of your joint with plastic or metal parts. An estimated 10 percent of hip replacements in the United States are performed to treat avascular necrosis of the hip.
• Regenerative medicine treatment. Bone marrow aspirate and concentration is a novel procedure that in the future might be appropriate for early stage avascular necrosis of the hip. Stem cells are harvested from your bone marrow. During surgery a core of dead hip bone is removed and stem cells inserted in its place, potentially allowing for growth of new bone.
LABRAL TEAR SYMPTOMS
Symptoms of a labral tear include pain in the hip or groin. A clicking or locking of the joint can occur. Stiffness and restricted mobility in the hip joint is likely. Symptoms may come on suddenly following an impact or trauma but can also develop gradually if the joint progressively degenerates.
ANATOMY
The socket of the hip joint that the thigh bone sits in is called the acetabulum. This is lined by a ring of cartilage called the labrum. The labrum supplies cushioning and support for the hip joint. Tears can occur in the labrum, also known as a hip labral tear or acetabular labral tear. Tears to the labrum are being diagnosed more often due to the improvements and wider availability of MRI scans which is the only way to diagnose a labral tear 100%.
CAUSES
Labral tears can be acute, caused by trauma such as traffic accidents, collisions and bad falls, falling on to the outside of the hip or twisting on a hip that has a lot of weight on it.
They can also be of gradual onset through repetitive strain on the hip for example in golfers can also be a factor as can impingement of the labrum, known as Femoroacetabular impingement. Two types of impingement can occur either in isolation or some athletes may have both types at the same time.
Cam impingement
Cam impingement occurs when the neck of the femur or thigh bone becomes enlarged or thickened due to additional bone growth. This then impinges on the hip joint and over time causes injury to the labrum. This is also known as a Ganz lesion and is present in almost 80% of patients with femoralacetabular impingement.
It is not known exactly what causes cam impingement. One theory is overloading the growth plates of the femur as an adolescent. Repetitive twisting forces at the hip during activities such as hurdling, horse riding and breastroke swimming may contribute to the deformity. Another theory is genetic factors in that it is simply hereditory as siblings are much more likely to develop impingement.
Pincer Impingement
Pincer impingement occurs when there is a bony growth or spur at the acetabulum which impinges on the femur.
TREATMENT OF LABRAL TEARS
Treatment usually requires surgery known as debridement via an arthroscopy (key-hole surgery). The torn part of the labrum is removed. Generally results from this procedure are very good. A rehabilitation program should be followed after surgery to restore full strength and movement to the hip joint and prevent further injuries or instability. If left the injury could degenerate into a worn hip joint with eroding of the hard cartilage on the ends of the bone and development of Osteoarthritis in the hip.
Surgery
Surgery to repair a torn labrum may consist of removing the torn tissue and cleaning out fragments from the joint.
In FAI, bone overgrowth — called bone spurs — develop around the femoral head and/or along the acetabulum. This extra bone causes abnormal contact between the hip bones, and prevents them from moving smoothly during activity. Over time, this can result in tears of the labrum and breakdown of articular cartilage (osteoarthritis).
TYPES OF FAI
There are three types of FAI: pincer, cam, and combined impingement.
• Pincer. This type of impingement occurs because extra bone extends out over the normal rim of the acetabulum. The labrum can be crushed under the prominent rim of the acetabulum.
• Cam. In cam impingement the femoral head is not round and cannot rotate smoothly inside the acetabulum. A bump forms on the edge of the femoral head that grinds the cartilage inside the acetabulum.
• Combined. Combined impingement just means that both the pincer and cam types are present.
CAUSE OF FAI
FAI occurs because the hip bones do not form normally during the childhood growing years. It is the deformity of a cam bone spur, pincer bone spur, or both, that leads to joint damage and pain. When the hip bones are shaped abnormally, there is little that can be done to prevent FAI.
It is not known how many people have FAI. Some people may live long, active lives with FAI and never have problems. When symptoms develop, however, it usually indicates that there is damage to the cartilage or labrum and the disease is likely to progress.
Because athletic people may work the hip joint more vigorously, they may begin to experience pain earlier than those who are less active. However, exercise does not cause FAI.
SYMPTOMS
The most common symptoms of FAI include:
• Pain
• Stiffness
• Limping
Pain often occurs in the groin area, although it may occur toward the outside of the hip. Turning, twisting, and squatting may cause a sharp, stabbing pain. Sometimes, the pain is just a dull ache.
TREATMENT OPTIONS
Nonsurgical Treatment
Activity changes. Your doctor may first recommend simply changing your daily routine and avoiding activities that cause symptoms.
Non-steroidal anti-inflammatory medications. Drugs like ibuprofen can be provided in a prescription-strength form to help reduce pain and inflammation.
Physical therapy. Specific exercises can improve the range of motion in your hip and strengthen the muscles that support the joint. This can relieve some stress on the injured labrum or cartilage.
Surgical Treatment
Many FAI problems can be treated with arthroscopic surgery. Arthroscopic procedures are done with small incisions and thin instruments. The surgeon uses a small camera, called an arthroscope, to view inside the hip.
During arthroscopy, your doctor can repair or clean out any damage to the labrum and articular cartilage. He or she can correct the FAI by trimming the bony rim of the acetabulum and also shaving down the bump on the femoral head.
Some severe cases may require an open operation with a larger incision to accomplish this.
The snapping sensation occurs when a muscle or tendon (the strong tissue that connects muscle to bone) moves over a bony protrusion in your hip.
Although snapping hip is usually painless and harmless, the sensation can be annoying. In some cases, snapping hip leads to bursitis, a painful swelling of the fluid-filled sacs that cushion the hip joint.
Snapping hip can occur in different areas of the hip where tendons and muscles slide over knobs in the hip bones.
• Outside of the hip. The most common site of snapping hip is at the outer side where the iliotibial band passes over the portion of the thighbone known as the greater trochanter. When the hip is straight, the iliotibial band is behind the trochanter. When the hip bends, the band moves over the trochanter so that it is in front of it. The iliotibial band is always tight, like a stretched rubber band. Because the trochanter juts out slightly, the movement of the band across it creates the snap you hear. Eventually, snapping hip may lead to hip bursitis. Bursitis is thickening and inflammation of the bursa, a fluid-filled sac that allows the muscle to move smoothly over bone.
• Front of the hip. Another tendon that could cause a snapping hip runs from the front of the thigh up to the pelvis (rectus femoris tendon). Snapping of the rectus femoris tendon is felt in the front of the hip. As you bend the hip, the tendon shifts across the head of the thighbone, and when you straighten the hip, the tendon moves back to the side of the thighbone. This back-and-forth motion across the head of the thighbone causes the snapping. In addition to the rectus femoris tendon at the front of the hip, the iliopsoas tendon can catch on bony prominences at the front of the pelvis bone.
• Back of the hip. Snapping in the back of the hip can involve the hamstring tendon. This tendon attaches to the sitting bone, called the ischial tuberosity. When it moves across the ischial tuberosity, the tendon may catch, causing a snapping sensation in the buttock region.
• Cartilage problems. The labrum that lines the socket of the hip can tear and cause a snapping sensation. Damaged cartilage can loosen and float in the joint causing the hip to catch or “lock up.” This type of snapping hip usually causes pain and may be disabling.
CAUSE OF SNAPPING HIP
Snapping hip is most often the result of tightness in the muscles and tendons surrounding the hip. People who are involved in sports and activities that require repeated bending at the hip are more likely to experience snapping hip. Dancers are especially vulnerable.
Young athletes are also more likely to have snapping hip. This is because tightness in the muscle structures of the hip is common during adolescent growth spurts.
TREATMENT OPTIONS
Initial treatment typically involves a period of rest and modification of activities. Depending upon the cause of your snapping hip, your doctor may also recommend other conservative treatment options.
Physical Therapy
Your doctor may prescribe exercises to stretch and strengthen the musculature surrounding the hip. Guidance from a physical therapist may also be recommended.
Iliotibial band stretch
◦ Stand next to a wall for support
◦ Cross the leg that is closest to the wall behind your other leg.
◦ Lean your hip toward the wall until you feel a stretch at the outside of your hip. Hold the stretch for 30 seconds.
◦ Repeat on the opposite side.
◦ Perform 2 to 3 sets of 4 repetitions each side.
Piriformis stretch
◦ Lie on your back with bent knees and feet flat on the floor.
◦ Cross the foot of the affected hip over the opposite knee and clasp your hands behind your thigh.
◦ Pull your thigh toward you until you feel the stretch in your hip and buttocks. Hold the stretch for 30 seconds.
◦ Repeat on the opposite side.
◦ Perform 2 to 3 sets of 4 repetitions each side.
Corticosteroid Injection
If you have hip bursitis, your doctor may recommend an injection of a corticosteroid into the bursa to reduce painful inflammation.
Surgical Treatment
In the rare instances that snapping hip does not respond to conservative treatment, your doctor may recommend surgery. The type of surgery will depend on the cause of the snapping hip.
• Hip arthroscopy. During hip arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your hip joint. The camera displays pictures on a television screen, and your surgeon uses these images to guide miniature surgical instruments. Because the arthroscope and surgical instruments are thin, the surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.Hip arthroscopy is most often used to remove or repair fragments of a torn labrum.
• Open procedure. A traditional open surgical incision (several centimeters long) may be required to address the cause of the snapping hip. An open incision can help your surgeon to better see and gain access to the problem in the hip.
However milder forms of DDH may not be picked up until adulthood when the hip becomes increasingly symptomatic. The problem is that with the shallow socket the forces going through the hip are concentrated over a smaller area causing increased wear and arthritis.
The consequence of this is that the ball is no longer as round as it is meant to which leads to increased forces in the joint and subsequent wear ultimately leading to the development of osteoarthritis.
HIP SURGERY
It is the plastic liner that wears out with time, probably related to activity levels. Technological advances, however, have produced bearing surfaces which can withstand higher activity levels and will therefore wear out more slowly. These newer bearing surfaces are either metal-on-metal or ceramic-on-ceramic. Patients who are young and physically active may benefit from these newer hip replacements since the risk of implant failure is reduced.
HIP RESURFACING
Recent attention has focussed on Hip Resurfacing. Here, the acetabulum (socket) is replaced with a metal cup and the femoral head (ball) is shaped to allow a metal surface replacement to be implanted.
Hip resurfacing has the potential benefit of preserving femoral bone; the use of a metal-on-metal bearing couple should reduce the amount of wear and therefore increase implant survival.
However the long-term effects of metal-on-metal bearing surfaces have been shown to cause high levels of (cobalt and chromium) metal ions in the blood. These metal ions have been linked to some forms of cancer (particularly lymphomas and leukaemias). Although there is no proof that the risk of these cancers is increased in patients with hip resurfacing, these findings have caused concern amongst orthopaedic surgeons.
Other potential problems with hip resurfacing are the risk of fracture of the femoral neck (1-3%) and the need to remove more bone from the pelvis than a conventional hip replacement to allow the cup to be inserted. The scar from a hip resurfacing procedure is much larger than that for a conventional hip replacement and the operation usually takes longer. Recovery for both operations is very similar.
Whilst knowledge of the options available is useful to patients, the surgeon should choose the most appropriate type of hip replacement for each patient.
WHAT ARE THE BENEFITS OF HIP REPLACEMENT?
The majority of patients experience the following benefits following hip replacement:
Abolition or at least a significant reduction in hip pain
Improvement in life quality
Return to normal daily activities and low impact sports
Sleeping without pain
Improvement in leg strength as a result of a return to more normal levels of activity
Years of reliable function
THE OPERATION
Patients are usually required to attend a Pre-admission Clinic a couple of weeks before the proposed operation date; investigations will be undertaken and the operation discussed.
Hip replacement surgery involves an inpatient stay of 3-5 days; the patient will generally be admitted the day before the operation. The consultant and anaesthetist will see the patient prior to surgery and the hip undergoing the replacement will be marked.
Most hip replacements are performed under a spinal anaesthetic (where the patient is awake but normally sedated), but occasionally a general anaesthetic is used. The hip is dislocated so that the damaged femoral head can be removed and replaced with a femoral component (the ball), the stem of which is inserted down the centre of the thighbone. The damaged acetabulum of the pelvis is shaped so that the new prosthetic socket can be inserted.
At the end of the operation a drain may be inserted into the hip joint to draw off excess blood. (The use of drains is a contentious issue and many orthopaedic surgeons now do not regularly use them.) A dressing is applied to the wound. Foot pumps, elastic stockings and occasionally an injection to thin the blood are used to lower the risk of blood clots forming in the legs.
POST OPERATIVE RECOVERY
Post-operative pain is normal after a hip replacement. It can be controlled by many methods, from pain pumps (Patient Controlled Analgesia, PCA) to simple tablets, and usually lessens dramatically after the first 2-3 days. The pain of arthritis usually disappears within a day or two of surgery.
Occasionally, the bladder stops working after a spinal anaesthetic; a catheter may need to be inserted into the bladder for a day or two. Once removed, most people have normal return of bladder function.
Blood tests and X-rays will be taken in the early post-operative period to ensure that blood levels have not substantially changed and that the hip replacement is in a satisfactory position.
REHABILITATION
The physiotherapists will assist patients in mobilising after the operation and will supervise an exercise programme. It is extremely important that patients follow this exercise programme and take the necessary precautions with their new hip.
Patients can usually return to work after 8-12 weeks although this period may be longer for heavy manual work. By three months most patients can participate in low impact sports such as golf, bowls, cycling and swimming.
COMPLICATIONS
The majority of patients undergoing hip replacement do not experience any complications. In fact 95-98% of patients are extremely happy with their hip replacement and report that it has given them back their life. However no operation can guarantee success.
Complications can occur as a result of the anaesthetic, the hip replacement itself or as a general result of having major surgery:
Infection
The risk of infection after hip replacement is about 1%. The majority of infections are superficial and require nothing more than antibiotics. Occasionally, however, further surgery is required to deal with infection, and rarely the hip replacement needs to be removed until the infection is under control.
Antibiotics are used in every hip replacement and the operation is performed under sterile conditions.
Deep vein thrombosis (DVT) and Pulmonary embolus (PE)
Blood clots can form in the veins (DVT), break off and travel around the bloodstream and lodge in the lungs (PE). This can be life threatening, but the risk is very low.
Measures that are taken to reduce the risk of DVT and PE are the use of foot pumps and elastic stockings, blood thinning injections and early mobilisation.
Dislocation
Since an artificial hip joint is not as stable as your own original joint there is a risk that it may dislocate; the risk is approximately 2%. The hip is most unstable during the first 6-12 weeks; after this dislocation is rare.
Leg length inequality
In some cases the leg length must be lengthened in order to stabilise the hip and thereby reduce the risk of dislocation. It is very difficult to ensure a resulting equal leg length during hip replacement surgery, but most patients (80%) do not notice any great difference after their operation. Any minor leg length discrepancy can be treated with a heel raise.
Nerve damage
Occasionally one of the nerves supplying the leg is stretched and does not function properly for a period of time. The most common effect of this is to cause a foot drop. Over 90% of these nerve injuries recover on their own without the need for further surgery.
Wear
95% of modern conventional hip replacements will last for 10-15 years. Technological advances, however, have produced bearing surfaces such as metal-on-metal or ceramic-on-ceramic which can withstand higher activity levels and will probably last much longer.
When the hip replacement wears out, small wear particles are produced which can eventually cause the hip replacement to become loose and painful. In this situation, the hip replacement may need to be revised. (See Revision Hip Replacement)
The arthroscope is an excellent means of examining the whole of the hip and many conditions can be treated at the same time. Hip arthroscopy is a developing technique and is only practised by highly specialised orthopaedic surgeons.
INDICATIONS FOR HIP ARTHROSCOPY
There are several indications for undertaking arthroscopy of the hip:
• General diagnostic purposes; for example in early osteoarthritis
• Torn acetabular labrum: the labrum is trimmed to a stable rim or occasionally repaired
• Damaged articular (surface) cartilage; the damaged area is trimmed so that it has a stable margin. Deep defects may need microfracture where a small, sharp pick is used to perforate the underlying bone and encourage healing
• Removal of loose bodies (cartilage or bone that has broken off)
• Resection of inflamed lining tissue (synovectomy)
• Treatment of hip impingement. Resculpting of the femoral neck can be performed arthroscopically. This can be combined with labral repair
THE OPERATION
Most arthroscopic hip surgery is undertaken as an inpatient procedure and is performed under general anaesthesia. Patients are admitted on the day of surgery and need to remain fasted for 6 hours prior to the procedure. The hip undergoing the procedure will be identified and marked prior to the anaesthetic.
Traction is applied to the leg to allow access to the hip joint and x-ray is used throughout the procedure. The arthroscope is introduced through a small (approximately 0.5-1.0cm) incision on the outer side of the hip. A second incision on the front of the hip is made to introduce the instruments that allow examination of the joint and treatment of the problem. Usually a third incision over the outer part of the hip is also required, particularly if resculpting for impingement is planned.
Local anaesthetic is administered into the hip by the surgeon at the end of the procedure. This usually provides 8-12 hours of pain relief. A dressing pad is applied to the operated hip.
POST OPERATIVE RECOVERY
Once the patient has recovered their intravenous drip is removed and they are shown a number of exercises to complete.
The surgeon sees the patient and explains the findings of the operation and what was undertaken during surgery.
Pain medication will be provided and should be taken as directed.
The pad can be removed after 24 hours and waterproof dressings applied over the wounds.
The patient will be mobilised with the help of the physiotherapists. Crutches are usually necessary.
REHABILITATION
Following surgery patients are given an instruction sheet showing exercises that are helpful in speeding up recovery.
Strengthening the buttock (glutei) and thigh muscles (quadriceps and hamstrings) is very important; cycling (stationary or road) and swimming are excellent ways to build these muscles up and improve movement. Core stability is also an important issue to address.
Return to driving and work is variable and usually at the patient’s discretion.
COMPLICATIONS
General Anaesthetic risks are extremely rare. Occasionally patients have some discomfort in the throat as a result of the tube that supplies oxygen and other gases.
The risk of complication from arthroscopic hip surgery is also rare and is generally related to the use of traction or the creation of skin portals for access. Occasionally stiffness of the hip will prevent arthroscopy from being possible; sometimes symptoms may be made worse by arthroscopy (<5%). Complications specific to Hip Arthroscopy can include: • Temporary nerve paralysis causing numbness over the side of the leg or in the groin • Pressure areas in the groin from the traction post • Damage to the cartilage or labrum within the hip joint • Postoperative bleeding • Deep Vein Thrombosis • Infection • Stiffness • Injury to vessels, nerves or a chronic pain syndrome • Progression of the disease process OUTCOME
The early results of arthroscopic resculpting to treat femoroacetabular impingement are very encouraging. Eighty five percent of patients report marked improvement in symptoms at 1 year. The long term results are not yet known, however, occasionally there is more damage in the hip than was initially thought; this can affect the recovery time.
If the cartilage in the hip is significantly worn out then arthroscopic surgery has only about a 75% chance of improving symptoms in the short to medium term: more definitive surgery (e.g. hip replacement) may be required in the future.
In general arthroscopic surgery does not improve hips that have well established osteoarthritis but may give symptom relief for a period of time. This is useful in young patients who are not keen on joint replacement.
More recently, Hip Arthroscopy has been used to perform hip resculpting, the advantages being smaller scarring, reduced morbidity and faster recovery. The aim of hip resculpting is to remove some of the bone from the femoral neck to prevent it from causing damage to the labrum, and to allow greater movement – particularly flexion – of the hip. If the labrum has already been damaged it can be repaired or the damaged area removed during the resculpting operation.
The anticipation is that by preventing damage to the labrum and effectively making the femoral head more spherical, the development of osteoarthritis of the hip can be delayed or even prevented.
The long term results of hip resculpting are not known although the early results are encouraging. NICE recommendations state that patients undergoing this procedure should be followed up on a long term basis; results should be properly documented and audited. Hip resculpting is an operation that should only be performed by surgeons with experience of the technique.
INDICATIONS FOR HIP RESCULPTING
There are several indications for undertaking resculpting of the hip:
• Symptomatic femoro-acetabular impingement (with x-ray evidence)
• Normal cartilage (i.e. no evidence of arthritis) – hip arthroscopy may be needed beforehand to prove this
THE OPERATION
Patients are usually required to attend a Pre-admission Clinic a couple of weeks before the proposed operation date; investigations will be undertaken and the operation discussed.
Hip resculpting surgery involves an inpatient stay of 3-4 days; the patient will generally be admitted the day before the operation. The consultant and anaesthetist will see the patient prior to surgery and the hip undergoing the procedure will be marked.
Hip resculpting is usually performed under a general anaesthetic. There are 2 different surgical approaches (other than the arthroscopic approach) that can be used.
The first involves cutting through the bone on the outer side of the femur (a trochanteric osteotomy) and retracting this segment of bone in order to gain access to the hip joint. The hip is dislocated very carefully and the damaged area of bone on the femoral neck removed. Any labral tears are repaired if possible or removed if they are beyond repair. At the end of the operation the hip is relocated and the cut segment of femoral bone reattached with screws.
The second involves a smaller incision over the front of the hip (the mini-anterior approach). The hip joint can then be opened and the cause of the impingement removed. The labrum can be repaired at the same time.
At the end of the procedure a dressing is applied to the wound. Foot pumps, elastic stockings and occasionally an injection to thin the blood are used to lower the risk of blood clots forming in the legs.
POST OPERATIVE RECOVERY
Post-operative pain is normal after hip resculpting. It can be controlled by many methods, from pain pumps (Patient Controlled Analgesia, PCA) to simple tablets, and usually lessens dramatically after the first 2-3 days.
Blood tests and X-rays will be taken in the early post-operative period to ensure that blood levels have not substantially changed and that sufficient bone has been removed.
REHABILITATION
The physiotherapists will assist patients in mobilising after the operation and will supervise an exercise programme. It is extremely important that patients follow this exercise programme and take the necessary precautions. A period of 4 to 6 weeks of non-weight bearing with the aid of crutches is advised to allow the soft tissues and bone to heal. If the labrum has been repaired then hip flexion will be limited for the first 4 weeks to protect the repair.
COMPLICATIONS
Any medical complication can occur after hip resculpting, although infection, deep vein thrombosis and pulmonary embolus are rare.
Complications specific to the operation include:
Persistance of symptoms
Patients may still have hip pain even after adequate resculpting
Progression to osteoarthritis
Whilst resculpting is performed to hopefully reduce the risk of osteoarthritis, there are no guarantees and OA may still develop (usually years) after resculpting
Avascular necrosis of the femoral head
The reported risk of this is very low (< 1%) but if it develops it can have catastrophic implications for the hip; subsequent hip replacement may be necessary.
Non-union of the trochanteric osteotomy
This is where the cut part of the femur fails to unite to the rest of the bone after surgery. Re-operation to re-fix the segment, possibly with the use of a bone graft may be required
Stiffness
Occasionally scarring around the hip causes stiffness. This usually responds well to physiotherapy.
Numbness
Occasionally the nerve that supplies the skin on the outer part of the thigh (called the lateral cutaneous nerve of the thigh) can be stretched during surgery and a numb patch subsequently develops. This usually resolves after 6 months but in rare cases can be permanent.
OUTCOME
The long term outcome of hip resculpting is not yet known. The hope is that it will at least delay if not negate the need for future hip replacement in many patients. Early reports suggest that in the short-term, relief of symptoms is usually achieved.
CAUSES OF THR FAILURE
The most common cause of hip replacement failure is aseptic loosening due to implant wear, although other factors such as infection, trauma and recurrent dislocation can all result in the need for revision surgery.
ASEPTIC LOOSENING
The most widely used hip replacements consist of a metal ball articulating with a plastic (polyethylene) socket. Although these implants are designed to withstand the substantial forces that are transmitted across the hip joint during everyday activities (e.g. up to 6 times body weight when walking normally), the friction of the articulating surfaces results in wear of the plastic socket over time.
As the socket wears, small particles of polyethylene are generated. These particles then activate the body’s immune system, triggering an inflammatory response and causing the bone around the hip replacement to be reabsorbed. The result is that the hip replacement becomes loose and painful; this is known as aseptic loosening. As a consequence the hip replacement often needs to be revised.
IMPLANT WEAR
Post-operative pain is normal after hip resculpting. It can be controlled by many methods, from pain pumps (Patient Controlled Analgesia, PCA) to simple tablets, and usually lessens dramatically after the first 2-3 days.
Blood tests and X-rays will be taken in the early post-operative period to ensure that blood levels have not substantially changed and that sufficient bone has been removed.
TECHNOLOGICAL ADVANCES
Technological advances have produced bearing surfaces with increased longevity which may therefore benefit patients who are young and physically active. Ceramic-on-ceramic bearing surfaces are extremely hard wearing and perform best in terms of laboratory results. Metal-on-metal bearing surfaces also perform well but concerns exist regarding the high level of metal ions released in to the blood by the articulation of these bearing surfaces. (See Hip Resurfacing section.)
INFECTION
A small percentage (about 0.5-1%) of hip replacements become infected. Patients who have had multiple operations on the hip are at higher risk of infection.
If the infection is suspected quickly enough, surgery can be undertaken to wash out the infected hip replacement, change the femoral head (and acetabular liner if an uncemented hip has been used), and thereby clear the infection. High doses of intravenous antibiotics are then required for a period of generally 6-12 weeks to ensure that the infection doesn’t recur.
Occasionally the infection persists and the hip replacement must then be removed and a temporary ‘spacer’ inserted. Once the infection has cleared, revision surgery can be performed, usually at least 3 months later.
The possibility of infection should be excluded by tests before any revision hip replacement surgery is performed. These tests include blood tests (inflammatory markers), x-rays, possibly a bone scan and often a biopsy of the tissues around the hip replacement.
TRAUMA
Trauma, such as a fall that causes a fracture of the femur around the hip replacement, can result in failure of the THR. Often the fracture can be fixed and the hip replacement left in place, but if the hip replacement is loose then revision is necessary.
RECURRENT DISLOCATION
Most dislocations occur within 3 months of the initial hip replacement surgery. After 3 months the scar tissue has matured and dislocation is much less likely. When a hip replacement dislocates the soft tissues are damaged and further dislocation is more likely to occur, although this is not inevitable. If the hip dislocates several times it is likely to require revision surgery to prevent further dislocation.
More often than not the cause of the dislocation is that the patient has not followed post operative precautions and has put the hip in an unstable position. There are times, however, when dislocation can be attributed to surgical error. In this instance correction of a wrongly positioned implant is more successful at stabilising the hip than revision hip replacement.
Patients who have had multiple operations on the hip are at higher risk of recurrent dislocation.
REVISION HIP REPLACEMENT SURGERY
Revision hip replacement surgery involves an inpatient stay of 7-10 days. The surgery is complicated, technically demanding and whilst the risks are the same as for primary THR, the rate of complication is much higher. It should be undertaken by surgeons who have an interest in and are specialised in revision hip surgery.
Revision hip replacements are usually performed under a combined (spinal and general) anaesthetic. The old hip replacement is removed with great care in order to protect the surrounding bone. If the original implant was cemented, the cement is generally removed as well. Often there has been significant bone loss as a result of aseptic loosening; a bone graft or additional prosthetic implants may be necessary to allow the revision hip replacement to be properly aligned, orientated and stable.
At the end of the operation a drain is usually inserted into the hip joint to draw off excess blood. A dressing is applied to the wound. Foot pumps, elastic stockings and occasionally an injection to thin the blood are used to lower the risk of blood clots forming in the legs.
No two revisions are the same; possible difficulties encountered are bone loss, instability causing dislocation, infection, fracture and stiffness. Highly specialised implants may be necessary and the results are not as good as for standard primary hip replacement. However, the majority of patients are very satisfied with the results of revision surgery and obtain very good relief of pain and return to function.
POSTOPERATIVE RECOVERY AND REHABILITATION
The postoperative recovery from revision hip surgery is similar to that of primary hip replacement. Occasionally a period of restricted weight bearing with the aid of crutches (usually 6-12 weeks) may be necessary. Physiotherapy is essential to assist patients in mobilising after the operation.
WHAT APPROACH DOES MR LUSCOMBE USE?
Mr Luscombe uses a posterior approach which allows excellent access to both the acetabulam and femur while preserving the important hip abductor muscles. The approach allows the muscles to be mainly split rather than cut allowing faster and improved recovery. The size of the incision will vary depending on each individual patient.
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