Hip

Hip Pain

Hip arthritis usually presents as "groin pain," hip pain, thigh pain or even knee pain with walking, running or climbing stairs. People often complain of restricted motion that makes it difficult to tie their shoes and cut their toenails. The pain can lead to a decrease in the individual’s activities and may cause the person to limp. Another common complaint that people experience is the feeling that the joint is locked or the sensation the joint will give out.

The patient’s symptoms, physical exam findings and X-rays diagnose hip osteoarthritis. An MRI is rarely needed for arthritis but maybe indicated in some patients with "normal" appearing radiographs to rule out other causes of hip pain (example osteonecrosis).

Osteoarthritis / Degenerative arthritis

Osteoarthritis (OA) also called degenerative arthritis can affect people from young adulthood to the elderly. Osteoarthritis is basically explained as wear and tear of the joint surface. This wear and tear commonly affects the articular cartilage of the hip and knee joints. The articular cartilage is the smooth white surface that covers the end of bones making the joint smooth with reduced friction for movement. When cartilage layer becomes disrupted and the joint surfaces deteriorate this leads to bone on bone arthritis. Bone on bone arthritis can lead to severe pain in some patients.

The cause of osteoarthritis in the hip and knee is unknown but most experts believe there is some genetic predisposition. In addition to genetics, osteoarthritis can be caused from hip dysplasia (the hip socket does not form properly), knee dysplasia (the knee joint does not form properly), avascular necrosis (disruption of the blood supply to the bone), trauma, bleeding into the joint and infection.

Post-Traumatic Arthritis

Post-traumatic arthritis occurs after a serious injury: dislocation or fracture. The injury causes damage to the cartilage, which can lead to hip or knee pain, stiffness and even arthritis over time. The symptoms basically are the same as those described from OA.

Inflammatory Arthritis / Rheumatoid Arthritis

Inflammatory arthritis differs from osteoarthritis in that the arthritis is a systemic disease that can affect multiple joints at once. There are many forms of inflammatory arthritis that include rheumatoid arthritis, ankylosing spondylitis, systemic lupus and others. Rheumatoid arthritis is by far the most common form. The systemic reaction leads to an inflammatory response in the joint that attacks the synovium (lining) of the joint. This leads to increased pain in the hip joint as well as other joints with activity.

The diagnosis of an inflammatory arthritis is by history, physical exam, X-rays, blood tests and possible joint aspiration. The treatment depends on the type and severity of the arthritis. Conservative treatment measures include a variety of medications to control the progression of the systemic disease and the local joint treatments are similar to those used for osteoarthritis. These joint treatments include anti-inflammatories, cortisone injections and viscosupplementation. When the joint becomes resistant to conservative measures the treatment is total joint arthroplasty.

Avascular Necrosis

Avascular necrosis of the hip occurs when the blood supply to the femoral head (ball) is disrupted. AVN can occur for many reasons including injury, excessive alcohol use, steroid use, scuba diving, patients with other systemic diseases but most times the cause is idiopathic or unknown. Patients with AVN can have a wide range of symptoms that range from asymptomatic to severe pain. Left untreated AVN can lead to collapse of the ball and eventually arthritis. AVN commonly presents in the age group of 45-60 years old with patients having increasing hip pain. The diagnosis of AVN starts with an X-ray but may include an MRI. There are many stages of AVN and the stage will determine the treatment options that range from observation, medicines and even surgery. Surgical treatments include core decompression, vascularized fibula graft and total hip replacement.

Trochanteric Bursitis

Some patients present having increasing pain around their hip and they have trochanteric bursitis. Trochanteric bursitis occurs when the bursa overlying the part of the hip bone called the greater trochanter becomes inflamed. The greater trochanter is where the large buttocks muscles insert and so that they slide over the bone the body forms a bursa (fluid sac) to lubricate the area. The bursa is always there but sometimes becomes inflamed for multiple reasons including walking, running, trauma, lying on your side but most often the cause is unknown. Trochanteric bursitis commonly presents with gradual increasing pain on the outside of the hip that may radiate down the outside of the thigh. The pain is commonly described as burning pain or just pain when lying on your side in bed or walking/running. The diagnosis is usually made by history and physical exam with an X-rays to evaluate the hip joint.

Trochanteric bursitis treatment options range from observation to surgery. The vast majority of the time trochanteric bursitis responds to conservative treatments like rest, cortisone injections, physical therapy, stretching, anti-inflammatories, or a combination of these modalities. More often it may take more than one round of treatments for complete resolution of the symptoms. In rare circumstances if the bursitis is resistant to multiple rounds of treatments, surgical management may be required for relief. Surgery entails removing the bursa overlying the hip either through a small incision or arthroscopically.

Conservative Treatment of Arthritis

There are many nonoperative treatment options for the pain caused from hip and knee arthritis but it’s important to know none of these modalities will cure the arthritis. Some treatment options include activity modification, physical therapy, the use of an assistive device (cane or walker) and weight loss. Weight loss is very important because your hips carry up to 10 times your body weight. Losing 30lbs can decrease the forces your hips see by 300lbs. Another mainstay treatment option for hip and knee arthritis is anti-inflammatory medicines like motrin, ibuprofen and naproxen. If these medicines fail there are also prescription anti-inflammatories that can be attempted to treat your pain. Some patients can also get some relief from the use of glucosamine/chondroitin sulfate. The long-term benefits from these drugs have not been established. Another option that can be offered is an intra-articular hip or knee injection with cortisone using imaging for the injection. Physical therapy (PT) is another conservative treatment modality. PT can be used to help strengthen the muscle around the hip or knee, stretch the soft tissues and try to control the pain.

Total Hip Replacement

After a patient has failed conservative treatment modalities the next step in treatment maybe total hip replacement (total hip arthroplasty). Total hip replacement surgery is a very successful procedure that can relieve your pain, increase motion, and help you get back to enjoying normal, everyday activities. There is no "right age" for a hip replacement but younger patients may wear through their hip replacement faster and need a second surgery during their life.

When a total hip replacement is performed the surgeon removes the femoral head off the top of the femur (thigh bone) and then places the femoral component down the inside of the canal of the bone and then places a ball on the top of this implant. The ball is normally made of metal or ceramic. In addition the surgeon also removes the cartilage from the socket and places a metal shell with a special plastic liner into the socket of the patient. Most hip replacements today are done using uncemented, bone in-growth components but in some instances cemented prosthesis are appropriate. In the cementless technique the components are press fit into the bone initially and later the bone will then normally grow into these implants.

Our total joint surgeons use a multi-modal pain control approach to help patients have a better post-operative experience. Our surgeons use the anterior approach, anterior lateral approach and posterior approach for exposure to the hip joint. The Hana table is used in the anterior approach.

Anterior Hip Replacement

Anterior hip replacement surgery is approached from the front of the hip so the hip can be replaced without detaching muscle from the pelvis or femur. This leaves the gluteal muscles that attach to the pelvis and femur undisturbed during surgery, resulting in a much shorter healing process.

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Hip Resurfacing

Younger patients with advanced arthritis of the hip may be candidates for hip resurfacing. With hip resurfacing the ball is not cut off but instead reshaped and a metal cap is placed on the superior portion. The socket is also replaced in similar fashion to a total hip replacement. Hip resurfacing is an alternative to total hip replacement and may conserve bone stock for the younger patients who may need more than one replacement on their lifetime. The risk of dislocation may also be lower in hip resurfacing because of the large ball and socket sizes that are utilized. Hip resurfacing has similar risks to total hip replacement but there are also some additional risks that have been raised. These include femoral neck fracture and metal ion risks. Both are theoretically low but may occur.

Total Hip Revision

Over time if you begin to experience increasing discomfort in your hip, pain, multiple dislocations or other problems, you may need to have your total hip replacement evaluated. Hip replacements may last 10 to 30 years with no problems but some can fail earlier. There are many ways that your hip can fail including infection, loosening, polyethylene wear, dislocations (instability), fracture around the implants, implant failure or other.

If one of these problems occurs you may need a revision or redo surgery to correct the problem. To evaluate your problem we may need to obtain new X-rays, blood work or other imaging to identify the problem. Revision total hip replacements are much different from the first surgery because they can be very complex problems. These surgeries can take a lot longer and do have increased risks associated with them.

Complications of Joint Replacement

Despite being a very successful surgery, there are still surgical risks that can occur either during the surgery or post-operatively. These risks include but are not limited to infection, blood loss needing a transfusion, nerve injury, blood vessel injury, muscle damage, heterotopic ossification, fractures of the bone, stiffness, dislocation, leg length discrepancy, bone loss, anesthesia complications, urinary tract complications, blood clots, pulmonary embolism, loosening of the components, implant wearing out, failure of components, and need for revision for multiple reasons.

Blood clots or deep vein thrombosis (DVT) can occur after any surgery. Blood clots can travel to your lungs and cause a pulmonary embolism. Although this is extremely rare, it can occur and could cause serious medical problems. Infection can also be a very serious complication that may need lead to an extensive revision. Risks of infection increase with obesity, diabetes, kidney failure, liver failure and others.

Dislocation in hips is the most common complication after total hip replacement occurring in 0.5-1.0%. Although it’s rare it usually occurs after the patient places their hip in a position they should not. The risks of dislocations do increase after a revision surgery.