Hip
Hip Replacement
If your hip has been damaged by arthritis, fracture, or other conditions, common activities such as walking, putting on your socks and shoes, or getting out of a chair can be painful and difficult. You may even feel uncomfortable at rest.
If medications, changes in your activity level, and the use of walking aids such as a cane are not helpful, you may want to consider hip replacement surgery. By replacing your diseased hip joint with an artificial joint, hip replacement surgery can relieve your pain, increase motion, and help you get back to enjoying normal, everyday activities.
First performed in 1960, hip replacement surgery is one of the most important surgical advances of the last century. Since then, improvements in joint replacement surgical techniques and technology have greatly increased the effectiveness of this surgery. Today, more than 193,000 total hip replacements are performed each year in the United States. As the population ages over the next decade, this procedure is expected to become even more common. Patients who undergo hip replacement are typically 60 to 75 years old. More than 90 percent of hip replacements last for 10 years or more.
Causes
The hip is one of your body's largest weight-bearing joints. It consists of two main parts: a ball (femoral head) at the top of your thigh bone (femur) that fits into a rounded socket (acetabulum) in your pelvis. Bands of tissue called ligaments connect the ball to the socket and provide stability to the joint. The bone surfaces of your ball and socket have a smooth durable cover of articular cartilage that cushions the ends of the bones and enables them to move easily. A thin, smooth tissue called synovial membrane covers all remaining surfaces of the hip joint. In a healthy hip, this membrane makes a small amount of fluid that lubricates and almost eliminates friction in your hip joint.
Normally, all of these parts of your hip work in harmony, allowing you to move easily and without pain. Unfortunately, some people develop chronic hip pain. The most common cause of hip pain is arthritis which is the result of lifelong wear and tear, previous injury, or mechanical abnormalities related to how the hip developed. Arthritis slowly develops over a period of years. Symptoms increase gradually over time. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease.
Some bone diseases may contribute to the development of hip arthritis. Patients with arthritis may also have brittle bones (osteoporosis).
Osteoarthritis usually occurs after age 50 and often in an individual with a family history of arthritis. It may be caused or accelerated by subtle irregularities in how the hip developed. In this form of the disease, the articular cartilage cushioning the bones of the hip wears away. The bones then rub against each other, causing hip pain and stiffness.
Rheumatoid arthritis is an autoimmune disease in which the synovial membrane becomes inflamed, produces too much synovial fluid, and damages the articular cartilage, leading to pain and stiffness.
Traumatic arthritis can follow a serious hip injury or fracture. A hip fracture can cause a condition known as avascular necrosis. The articular cartilage becomes damaged and, over time, causes hip pain and stiffness.
Symptoms
Hip arthritis typically causes pain that is dull and aching. The pain may be constant or it may come and go. You may feel pain in the groin, thigh and buttock. You may also have pain in the knee (referred pain). Walking, especially for longer distances, may cause a limp. Some patients may need a cane, crutch or walker to help them get around. Pain usually starts slowly. It gets worse with time, and higher activity levels.
Climbing stairs can be difficult. Many patients with hip arthritis have to use a stair rail or stop on each step to get up and down. Dressing, tying shoes and clipping toenails can be difficult or impossible. You may have pain when you rest. Pain may interfere with your sleep.
Diagnosis
If you are experiencing any of the above symptoms, please consult with an orthopedic specialist. An evaluation consists of several components:
- A medical history, in which your orthopedic specialist gathers information about your general health and asks you about the extent of your hip pain and your ability to function.
- A physical examination to assess your hip's mobility, strength and alignment.
- X-rays to determine the extent of damage and deformity in your hip.
- Occasionally blood tests, a Magnetic Resonance Image (MRI), or a bone scan may be needed to determine the condition of the bone and soft tissues of your hip.
Your orthopedic surgeon will review the results of your evaluation with you and discuss whether hip replacement surgery is the best method to relieve your pain and improve your mobility. Other treatment options such as medications, physical therapy or other types of surgery also may be considered.
Treatment
The first treatment your doctor may recommend is to take prescription or over-the-counter, anti-inflammatory medications. These include ibuprofen (Motrin® or Advil® acetaminophen (Tylenol® or mild combination narcotics (Tylenol® with codeine). Some nutritional supplements may also provide some relief. These include glucosamine. Short-term physical therapy may help with strength and stiffness.
For more advanced arthritis, you may need to use a cane in the hand opposite the affected hip. This transfers weight away from the affected hip. It can improve walking ability. Using a walker may help patients who have more trouble walking. These measures usually improve pain and function. But arthritis is progressive. Even with treatment, it gets worse over time. Weight loss can help decrease stresses on all of the joints. If you are overweight, you should strongly consider losing weight.
The decision whether to have hip replacement surgery should be a cooperative one between you, your family, your primary care doctor, and your orthopedic surgeon. The process of making this decision typically begins with a referral by your doctor to an orthopedic surgeon for an initial evaluation. Your orthopedic surgeon will explain the potential risks and complications of hip replacement surgery, including those related to the surgery itself and those that can occur over time after your surgery.
Although many patients who undergo hip replacement surgery are age 60 to 80, orthopedic surgeons evaluate patients individually. Recommendations for surgery are based on the extent of your pain, disability and general health status, not solely on age.
You may benefit from hip replacement surgery if:
- Hip pain limits your everyday activities such as walking or bending.
- Hip pain continues while resting, either day or night.
- Stiffness in a hip limits your ability to move or lift your leg.
- You have little pain relief from anti-inflammatory drugs or glucosamine sulfate.
- You have harmful or unpleasant side effects from your hip medications.
Treatment Options: Surgical
Even when you get all of the right non-surgical treatments, problems with pain and mobility sometimes get worse. In this case, the doctor may recommend surgery. Surgical options include:
Arthroscopy: Arthroscopy of the hip is a minimally invasive, outpatient procedure. It is relatively uncommon. The doctor may recommend it if the joint has evidence of torn cartilage or loose fragments of bone or cartilage.
Osteotomy: Candidates for osteotomy include younger patients with early arthritis, particularly those with abnormally shallow hip socket (dysplasia). The procedure involves cutting and realigning the bones of the hip socket and/or thighbone. This creates a more normal relationship between the ball and socket. It decreases pressure in the joint. In some cases, this may delay the need for replacement surgery for 10 to 20 years.
Total Hip Replacement: The doctor may recommend hip replacement when all of the above measures have been considered or have been tried and failed. Traditional hip replacement surgery involves making an 8 to 12 inch incision on the side of the hip. The muscles are split or detached from the hip. The hip is dislocated. The ball of the femur is removed. The hip socket is prepared by removing any remaining cartilage and some of the surrounding bone. The cup implant is pressed into the bone of the socket. It may be secured with screws. A bearing surface is inserted into the socket.
Next, the femur is prepared by removing some bone from the inside of the thigh bone. A metal stem is placed into the thigh bone to a depth of about 6 inches. The stem implant is either fixed with bone cement or is implanted without cement. Cementless implants have a rough, porous surface. It allows bone to adhere to the implant to hold it in place. A ball is then placed on the top of the stem. The ball-and-socket joint is recreated.
Minimal Incision Hip Replacement: Minimal incision hip replacement surgery lets the surgeon perform hip replacement through one or two smaller incisions. Compared with most people getting hip replacements, candidates for minimal incision procedures are typically thinner, younger, healthier and more motivated to have a quick recovery.
The artificial implants used for the minimally invasive hip replacement procedures are the same as those used for traditional hip replacement. Specially designed instruments are needed to prepare the socket and femur and to place the implants properly. The artificial hip is implanted in the same way. But there is less soft-tissue dissection than with longer incisions.
Reported benefits of less invasive hip replacement include:
- Less pain
- More cosmetic incisions
- Less muscle damage
- Rehabilitation is faster
- Hospital stays are shorter: For traditional hip replacement, hospital stays average four to five days. Many patients need extensive rehabilitation afterward. With less invasive procedures, the hospital stay may be as short as one or two days. Some patients can go home the day of surgery.
Reproduced with permission Fischer S., (interim ed): Your Orthopaedic Connection. Rosemont, Illinois. Copyright American Academy of Orthopaedic Surgeons.
