Anatomy

The hip is a ball (femoral head) and socket joint (acetabulum).  The surfaces of the joint are covered by articular cartilage.  This allows smooth movements between the two surfaces.   Joint fluid (synovial) is produced which lubricates the joint and permits a wide range of pain free hip movements.  Around the edge of the acetabulum is a lip of tissue called the labrum.  This deepens the socket and improves the stability of the joint.  Muscles surround the hip joint which facilitate movement around the hip.  These muscle groups need to be rehabilitated after any hip operation in order to regain function.

Function

The hip is a very versatile and stable joint which supports the body in both static (standing) and dynamic (moving) postures.  Huge loads are transmitted through the hips which can be up to seven times your body weight during activities such as running.

Common Hip Conditions

Arthritis

There are two main forms of arthritis which affect the hip:

1. Osteoarthritis

This is a very common condition which afflicts a significant proportion of the population.  The lining of the joint (articular cartilage) degenerates so exposing the bone on both sides of the joint.  As the condition progresses spurs of bone can appear around the joint restricting the movement of the hip and causing more pain. Further progression causes bony destruction and an increase in deformity around the hip.  This results in more pain and restricted movement.  The surrounding muscles can be affected resulting in a limp.

2. Rheumatoid Arthritis

This is chronic inflammatory condition which has a strong genetic predisposition.   The bodies own defence system attacks the articular lining of the joint resulting in bone rubbing on bone.  This subsequently causes destruction of the joint with associated pain and stiffness.

Why does osteoarthritis happen?

This is classically divided into primary and secondary osteoarthritis.  In primary osteoarthritis there may be a genetic cause or no obvious cause is found. Secondary arthritis can be caused by previous trauma, developmental conditions such as dysplasia or avascular necrosis.   The latter is where the blood supply to the bone can be disturbed.  These affect the alignment of the joint and damage the articular cartilage thereby increasing the risk of developing osteoarthritis.

Treatment Options

  • Painkillers such as paracetemol/anti-inflammatories/codeine/morphine
  • Weight reduction which decreases the load upon the hip
  • Activity reduction which impact the articular cartilage such as running and impact sports
  • Walking aids
  • Physiotherapy can help maintain stability and muscle bulk around the hip.  This helps support the joint.
  • Steroid injections into the hip joint which offer temporary pain relief

When these measures do not control the symptoms then a viable option would be a total hip replacement.

How do I know when I should have a hip replacement?

As the condition progresses the above treatment options do not relieve the symptoms.  The patient can start getting rest/night pain, sleep is disturbed, difficulty in putting shoes/socks on/getting in the bath and have difficulty doing their day to day activities.

It is at this stage the patient might consider a total hip replacement.

WHAT IS A HIP JOINT INJECTION?

The hip joint can be painful due to arthritis and damage to the surrounding soft tissue structures.

A hip injection can be used to give pain relief and it can also be used to confirm that the pain is indeed coming from the hip and not elsewhere (e.g. back)

How is it performed?

It is performed in a sterile (clean) room

You will be lying on your back and using Xray guidance local anaesthetic is placed around your hip joint.  A fine needle is then passed into your hip joint with the aid of the Xray machine.  The local anaesthetic with steroid is then injected into your hip.

How long will it last?

The injection can give prolonged pain relief which could last up to a year if not longer.  Often the pain returns in which case a further injection can be given or you may be considered for surgical intervention

What are the risks of the procedure?

Every interventional procedure has a risk

  • Infection – rare.
  • Leg numbness and weakness are very rare side effects.
  • Temporary difficulty taking weight through the injected side.
  • Allergy to injected medication.

Risks of the steroid:

  • Facial flushing for a few days.

  • Temporary alteration of your usual menstrual cycle (females).
  • Temporary increase in your sugar levels (diabetics).

What is the post procedure recovery protocol

  • After you have had your procedure, you will need to stay with us for about an hour before you can go home.

  • You will need someone to collect you after the injection.
  • Continue with your pain killing medication and reduce these if you feel you don’t need them
  • Keep a pain diary until you come and see Mr Shahid in 6-8 weeks time

What is a Total Hip Replacement

If you have osteoarthritis of the hip you may be having conservative treatment to improve your symptoms.

These treatments may include:

  • Weight loss
  • Physiotherapy to strengthen the muscles around the knee
  • Painkillers
  • Cortisone Injections
  • Walking aids such as a stick or frame

If after these you as a patient are not satisfied, then surgical procedures may be considered.

A total hip replacement involves replacing the whole of the hip joint.

In the most recent National Joint Register (NJR) it was estimated that there were over 100,000 total hip replacements are performed in the United Kingdom each year.  Sixty percent were female and the average age was 68 for males and 70 for females.

The operation involves removing the head of the femur which permits the insertion of a new femoral stem.

The socket is then cleared and a new socket is implanted.  Thus a new artificial bearing surface is created.

There are various options of fixation with a new hip.  These are broadly divided into uncemented, cemented and hybrid (mix of both) fixation.  This allows the surgeon a range of options to fix your hip depending on the quality of your bone and levels of activity.  These alternative methods of fixation will be discussed with you to ensure you get the most appropriate treatment.

The outcomes following hip replacement surgery are extremely favourable.  Patients are expected to return to an excellent level of function with a good range of movement and excellent pain relief following the procedure.

The Operation

You will either have a general anaesthetic, or a spinal anaesthetic.

The operation will last between 1 and 2 hours.

A cut is made over the side of your hip.

The diseased bone is cut out and the implant is put in its place

These are tested to ensure they work well

The wound is then closed and glued together.  This reduces the need to use clips which can be uncomfortable to remove.

After the operation

Immediately after the operation you will be transferred to the recovery room and then the ward once you are stable.

You will have:

  1. A drip inserted into a vein in your arm that supplies fluids or blood.
  2. 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 Programme

A physiotherapist will visit you on the day of your surgery and begin teaching you how to use your new hip.

It is extremely important that you adhere to this exercise programme and take the necessary precautions with your new hip.

Patients can usually return to work after 6 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

Pain relief

Good pain relief is important and it is better to try and prevent pain before it gets too bad.

Pain relief can be increased, given more often, or given in different combinations. Please ask help from the nurses on the ward if you are in any discomfort.

General home advice

You can expect some pain but not the same sort of pain as you had before the operation. The time it lasts will vary from a few days, to several weeks; everyone is different. It is important to take your painkillers as advised. Swelling and bruising may take up to 6-8 weeks to disappear; for some it can last up to 6 months.

The wound will normally be checked 2 weeks after the operation in Mr Shahid’s clinic.  I use glue instead of clips so there is no need for anything to be removed.  Also I believe it gives a more cosmetic scar.  At this point providing the wound is fine then you can take a shower or bath with the wound covered in a waterproof dressing.

It is important to comply with the physiotherapy advice which will improve your overall outcome after the surgery

Possible Complications

This is a very successful operation, but there are some risks associated with any type of surgery.

Complications can occur as a result of the anaesthetic, the hip replacement itself or as a general result of having major surgery:

What are the complications of total hip replacement ?

Total hip replacement is one of the most reliable procedures performed today.  The results have been extremely favourable.  The complication risk is very small but it is imperative to be aware of these.

The potential complications are:

Infection

Infection is a major concern after any operation.  Fortunately, it is very rare following hip replacement surgery.  Measures are taken to minimize this risk from using antibiotics and meticulous cleaning of the skin prior to the procedure.

If the infection is superficial it may be successfully treated with antibiotics.  However, if the infection is deep in the joint then further surgery may be warranted to clear the infection.

Dislocation

Dislocation occurs when the femoral head dissociates from the socket.  This is relatively rare.  This risk is minimised by ensuring the implant at the time of surgery is in an optimal position and the soft tissue is tensioned appropriately.

Post operatively, it is important to follow the advice from the physiotherapist to minimize any movements which can increase the risk of dislocation.

Thromboembolic disease

Blood clots can develop in the leg can cause undue discomfort and swelling which can impede rehabilitation.

If these clots occur in the lung then these can prove more problematic and worrisome.

In order to minimize these risks I encourage early mobilization and use blood thinning injections for four weeks after the operation.  Furthermore, I insist on patients using thrombo-embolic deterrent stockings (TEDS) for six weeks.

Nerve injury

There are a number of nerves around the hip that are vulnerable during surgery.  Injury can occur due to direct damage or due to placement of the retractors.

Bleeding

Bleeding is a complication of any operation.  In order to minimize this meticulous soft tissue dissection is performed to reduce excessive blood loss.  However, occasionally a blood transfusion may be necessary

Fracture

There is a small risk of fracture. Depending on where the fracture is and the extent of it dictates the immediate treatment.

Leg length inequality

Leg length inequality can occur following surgery.  I measure the legs prior to the procedure on the Xray and use markers during the operation to ensure there is no leg length discrepancy.

Unfortunately there are some particularly complicated conditions in which leg lengthening is more common.  If this is the case then this will be discussed with you prior to the procedure.

Wear/Loosening

Over time the hip can wear out and is likely to occur in any bearing surface over time when one surface articulates against another.

Loosening in the absence of infection (aseptic loosening) is perhaps the most common cause of failure requiring revision hip surgery.

Medical complications

These can include a heart attack, stroke, chest infection and bowel obstruction.  Very rarely there is a risk of death