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Anatomy of the Normal Hip Joint
The hip joint is located where the thigh bone (femur) meets the pelvic bone. It is a “ball and socket” joint. The upper end of the femur is formed into a round ball (the “head” of the femur). A cavity in the pelvic bone forms the socket (acetabulum). The ball is normally held in the socket by very powerful ligaments that form a complete sleeve around the joint (the joint capsule). The capsule has a delicate lining (the synovium). The head of the femur is covered with a layer of smooth cartilage which is a fairly soft, white substance about 1/8 inch thick. The socket is also lined with cartilage (also about 1/8 inch thick). The cartilage cushions the joint, and allows the bones to move on each other with very little friction. An x-ray of the hip joint usually shows a “space” between the ball and the socket because the cartilage does not show up on x-rays. In the normal hip this “joint space” is approximately 1/4 inch wide and fairly even in outline.
The most prominent symptom of hip arthritis is pain. Most patients think that their hip is in the region of the buttocks and are surprised to learn that true hip pain is most commonly experienced in the groin. Groin pain of hip arthritis is sometimes misdiagnosed at first as a hernia or a “groin pull The pain can radiate down the front of the thigh for a few inches as well. Occasionally it goes all the way down the thigh to the knee (“referred pain”). This is because the hip and knee have an overlapping nerve supply. In fact, in some patients with hip disease, knee pain may be the only symptom!
Back pain is even more frequently confused with hip pain. Pain in the buttocks, across the low back and down the back of the thigh usually comes from the spine. It usually indicates a pinched nerve in the lower spine. Patients with a pinched nerve will also often have numbness or tingling in the leg. To complicate matters, some patients with an arthritic hip may also have a pinched nerve from a back disorder. It is important in such cases to determine which problem is causing most of the pain: the hip or the back. If your problem is mainly in your back, you may still be left with most of your pain after going through a hip replacement, and you will not be very happy with the result! If most of your pain is from the hip, a hip replacement may have the added benefit of improving your back condition as well, since the stiffness of an arthritic hip can aggravate a back problem.
Most patients with significant hip disease have a limp and one leg may feel shorter than the other. Bone-on-bone contact occasionally causes the patient to feel or hear the hip creaking during walking. As the disease progresses, the hip becomes stiff and less movement is possible. This may make
it difficult for you to clip your toe nails or to tie your shoe laces, and may also limit your ability to spread your legs. Quite often the first step or two after prolonged sitting may be especially painful. Eventually you may have to “take a break” to ease the pain after walking only short distances. The distance you can walk will gradually decrease until you can only take one or two steps at a time. The three common causes of pain around the hip are arthritis, bursitis, or a pinched nerve in the lower back (the commonest cause). The groin pain of hip arthritis is sometimes misdiagnosed at first as a hernia.
Should you limit your activities?
If you have hip arthritis, the more you walk the more the hip will hurt. In time, running, tennis, golf and eventually even walking may become impossible. You can minimize the pain by simply cutting back on activities which seem to aggravate the hip. Whenever possible, use an elevator (or an escalator) instead of stairs, and avoid long walks that leave you in pain. However, “saving the joint” by becoming totally sedentary will not slow down the arthritis. Therefore it is recommended that you remain as active as your pain will comfortably allow. A reported study in the Annals of Internal Medicine, in 1992 suggests that people with hip arthritis who force themselves to remain active may do better in the long run than those who “baby” themselves. Also, being totally sedentary leads to a loss of muscle and bone strength.
The best all-around exercise for you is swimming.
The water relieves the stress on your hip as you “walk” about in the shallow end of the pool. Dr. Huddleston can prescribe a program of “pool therapy” for you. Bicycling (stationary or mobile) is also well tolerated. If you do not have access to an exercise bike or pool, then walk as much as you can tolerate without causing yourself excessive pain.
A cane has been known since pre-biblical times to be an effective pain-reliever for hip arthritis.
Unfortunately most people today are too vain to use one! Two important facts about canes: 1). Hold the cane in the opposite hand (yes, the opposite hand) from the side with the hip problem and 2). The cane should be the correct height. Any medical supply company that sells you a cane will adjust it to the correct length.
Weight loss will probably decrease your pain if you are greatly overweight.
One pound of weight loss equals 3 pounds in stress reduction on the hip during normal gait! But weight reduction alone is unlikely to completely relieve the pain. Obesity also makes the hip operation more difficult, and complications occur more frequently in overweight people. It can be very difficult to lose weight when you are not very active because of your hip pain. Do the best you can!
Cortisone injection into the hip joint can be very effective if the cortisone is injected accurately into the joint.
It quite frequently gives good relief for six months or so. It is a deep joint, and a long needle must be used with x-ray guidance for the needle. It is therefore not often done as an office procedure. Cortisone occasionally gives remarkable results, with even up to a year of relief in quite severe arthritis. You never how well it will work until you actually try it. Bursitis of the hip (another common cause of “hip pain”) is easily (and effectively) treated with cortisone injections given in the office.
Non-Steroidal Anti-Inflammatory Drugs NSAIDs (Pronounced EN-seds)
Non-Steroidal Anti-Inflammatory Drugs NSAIDs (Pronounced EN-seds), are a group of drugs which decrease the inflammation (pain and swelling) in arthritic joints. The pain relief from NSAIDs can be quite amazing. Although they are commonly referred to as “arthritis pills”, none of them will in any way influence the outcome of the arthritis. There are many NSAIDs available, and newer ones are constantly being brought onto the market. The “newest” one is not necessarily the most effective. Most people respond better to one NSAID than to another, and you may have to try several before the “right” one can be found for you. They all have potentially serious side effects and should only be taken under medical supervision. Most can only be obtained by prescription and are expensive. Common over-the-counter NSAIDS are ibuprofen.
Always take NSAIDs with food or antacids, or with a full glass of water. These medications have potentially serious side effects, and should only be taken under close medical supervision.
Hip Replacement Surgery
The modern Hip Replacement (also known as Hip Arthroplasty) was invented in 1962 by Sir John Charnley, an orthopedic surgeon working in a small country hospital in England. His work has been one of the great triumphs of Twentieth Century surgery.
The arthritic femoral head (i.e., the femoral head) is removed, and replaced with a metal ball. The ball has a metal stem which is anchored into the hollow space inside the femur bone with bone cement. The worn out socket is replaced with a plastic socket.
The painful parts of the arthritic hip are thereby completely replaced with metal and plastic surfaces. The plastic socket has a very low frictional resistance, and a very low wear rate against the metal ball. Hip replacement was first performed in the United States around 1969.
Many hundreds of thousands of hip replacements have been performed in the U.S. since then. Hip surgery has become safe and is extremely successful.
When should you have Hip Replacement Surgery?
If your symptoms are mainly from an arthritic hip, and you are physically fit enough to undergo surgery, when should you consider having your hip replaced? Hip arthritis is not a life-threatening condition: the procedure is “elective.” There are possible complications associated with hip replacement surgery. The decision to have the operation is a highly personal matter, and only you can make that decision. If you are confined to a wheelchair and in constant pain, it is a decision that will be quite easy for you to make, even though the operation (any operation) involves taking a certain amount of risk. If your disability is great enough, the potential benefits are worth the risk. If your arthritis is responding to conservative measures, and you can still walk long distances without a cane, you don’t need a hip replacement.
Here are some facts to help you make your decision:
- Once you have hip arthritis it will never get better. It won’t even stay the same. It will generally progress as time goes by. There are no exercises, diets, vitamins, or minerals (except, perhaps, chondroitin sulfate) which will make any difference. Copper bracelets will definitely not make any difference!
- The rate of further deterioration varies greatly from person to person. The pain may become unbearable within six months for one person, yet drag on at a tolerable level for several years in another person who has the same degree of arthritis.
- You will never need a hip replacement if you are willing to live with the pain.
- You may believe that it is better to delay having the operation in hope that the technology of hip replacement will improve with time. However, the rate of progress in this area is extremely slow, so this is something to consider only if you are very young, or your arthritis is mild and you can easily live with your symptoms.
- More than 98% of patients who have a hip replacement operation have no major complications which leave them in any way dissatisfied with their replacement.
- The main arguments against waiting too long are:
- The longer your arthritis forces you to “sit around” the softer your bones become,and the weaker your muscles.
- If your pain and disability are not responding to conservative measures, and you realize that you are going to have to have the operation sooner or later anyway, you may reasonably conclude that there is no point in waiting. Why put it off for another year or two when you could have spent that time enjoying your life free of pain!
Newer Developments in Hip Replacement
The major problems with standard hip replacements are: wearing out of plastic sockets, loosening of the bond between the implant and bone (either cemented or un-cemented). In time the cement can crack, directly resulting in loosening.
Secondly, the body reacts to minute fragments of cement, plastic or metal, and attempts to remove them, but unfortunately the process also removes bone adjacent to the particles, leaving the bone structurally weakened. If the implant loosens, a second surgery may become necessary to reattach it. There has been much research into the loosening problem. It was widely believed that the solution was to eliminate the cement. This led to the development of the Cementless Hip Replacement in which the surface of the metal parts is porous, and looks like coral. Bone can grow into the metal pores and bond the implant to the bone without the use of cement.
Major recent developments have been the introduction about eight years ago, of cross-linked polyethylene for manufacture of plastic sockets, and the introduction of metal-on-metal hip replacements, in which both the ball and socket are made of metal. Both developments greatly increase the lifespan of a hip replacement, but both have their own potential problems. Plastic sockets are mainly used in older patients.
Surface Replacement came into vogue in the 1980’s. It had a metal cap and a plastic socket. It was off the American market within four years because of the high failure rate of this combination. Dr. McMinn, in Birmingham, successfully re-designed it ten years ago, with a metal socket against a metal cap. The FDA cleared the Birmingham Surface Replacement for use in America in 2006. It is highly recommended for younger patients. Dr. Mark is an expert on Surface Replacement.
The most recent important new developments have been minimally invasive hip replacement, and pain management for hip replacement.
Hip resurfacing is an old idea that has been re-engineered as an exciting new alternative to conventional total hip replacement. It has only recently been approved by the Food and Drug Administration for use in the United States.
The Birmingham Surface Replacement is recommended for active, young adults, ideally male patients not over 60, and females not over 50 years of age. These age limits can be raised for very active people with outstanding bone quality.
Most surgeons allow Surface Hip Replacement patients unrestricted activity after the initial healing period, including marathon running, basketball, football, racquetball and singles tennis. Some surgeons believe that a Surface Replacement is intrinsically more durable because the stresses around it are different than those around a regular hip replacement. There is no direct scientific evidence yet that that is so. A well-performed Surface Replacement should last for many years regardless of activity. And should it fail, it is an easy operation (for surgeon an patient) to convert it to a regular hip replacement. This is the main reason Surface Replacement is recommended for younger patients who wish to live a lifestyle that allows for extreme sports activity.
The patient-experience with Surface Replacement is more or less identical to total hip replacement as described above. However, the BSR is a technically much more demanding operation for the surgeon than regular hip replacement.. It is harder to work on the socket because the intact ball of the hip is in the way. The incision must be longer than for standard hip replacement. If the alignment of he cap is less than perfect notching of the “neck” of the hipbone can occur, setting the stage for fracture of the “neck” of the femur bone. About 2% of surface replacement patients suffer fracture of the neck within the first year after surgery