What is Arthritis?
Arthritis is a condition that can affect any joint in the body.
A simple joint forms between the ends of 2 bones and is the structure that allows movement – ie The Hip joint is where the Pelvis bone (containing the socket) interfaces with the Femur/Thigh bone (the top end of which forms the ball).
The joint surface is a specialized layer of gristle like tissue 2-3 mm thick that sits on the end of the bone. The scientific name for this layer is articular cartilage. This tissue acts like a shock absorber and reduces load on the bone beneath. It also has a very low friction characteristics which allows the surfaces to glide easily over each other.
Arthritis is where there is loss (partial or complete) of this joint surface layer. This loss is usually progressive and ultimately leads to a situation where the bone is exposed or uncovered resulting in “bone on bone” contact – this is the situation in an advanced or end stage arthritis. A good analogy for arthritis is a car tyre where the tread has worn down.
The main symptom associated with arthritis is pain. The exact cause of pain in arthritis is uncertain and probably multifactorial. Bone is a very sensitive tissue with lots of nerve endings – a broken bone is usually very painful. When the bone is not properly protected by a damaged joint surface, the bone is subject to more load and stress, which can cause pain. The wear debris created by joint surface damage floats around the joint and irritates and inflames the lining tissue of the joint (synovial lining) which also can be a contributory cause for pain.
Osteoarthritis of the Hip
Osteoarthritis of the hip, like all forms of arthritis, is due to a loss of the cushioning joint surface tissue (articular cartilage) that covers the ends of the bones of the joint – the femoral head (ball) and the acetabulum of the pelvis (socket). This is a progressive condition and the natural history is one of slow deterioration – as the articular cartilage loss increases, so usually do the symptoms. When the articular cartilage layers are worn away completely, the joint articulates with “bone on bone” surfaces – this is usually very painful (as the bone has lots of nerve endings) and constitutes an advanced osteoarthritis. Osteoarthritis differs from inflammatory arthritis in that the articular cartilage loss is due to “wear and tear” (a degenerative process – osteoarthritis is also known as degenerative arthritis) rather than due to an inflammatory process.
Inflammatory Arthritis of the Hip
Inflammatory Arthritis of the hip, like all forms of arthritis, is due to a loss of the cushioning joint surface tissue (articular cartilage) that covers the ends of the bones of the joint – the femoral head (ball) and the acetabulum of the pelvis (socket). The end result is the same as that of osteoarthritis – with progressive loss of articular cartilage, ultimately leading to a “bone on bone” arthritis situation.
Avascular Necrosis of the Femoral Head
Avascular Necrosis (AVN) of the hip occurs when the blood supply to the bone of the femoral head (the ball part of the hip joint) is disrupted. This typically leads to death of the bone cells (osteocytes) in a localized area of the top of the femoral head/ball leading to collapse of the affected bone and its associated joint surface. This irreversible damage generally leads to a progressive arthritis (often quite rapid) of the hip with pain, stiffness and loss of function for walking, bending etc.
Transient Idiopathic Osteoporosis of the Hip
Transient Idiopathic Osteoporosis (TIO) is an unusual condition that most commonly affects the hip joint but can affect other joints such as the knee in particular. Unlike normal osteoporsis which untreated is a progressive, irreversible condition, TIO is, as its name implies, a condition that is transient and resolves itself after a period of time, usually several months up to a year. Idiopathic refers to the fact that we don’t understand why this condition occurs and osteoporosis is a condition where the mineral content and volume of the bone reduces making it weak and susceptible to fracture. TIO of the hip generally affects both men and women between the ages of 45 and 75 but can also occur in women in the later stages of pregnancy.
Trochanteric Pain Syndrome
Trochanteric Pain Syndrome (TPS) refers to conditions that lead to pain over the greater trochanter of the upper femur (thigh bone) – this is the bony prominence on the outside of the hip. Most commonly this involves inflammation of one of the bursae (bursitis) of the hip but other tissues in the area can be affected. The bone of the trochanter itself can be a source of pain (fractures, local bone lesions), the gluteal tendons which insert into the trochanter (tendinopathy, tendon tears, calcific tendinopathy) and the fascial tissue of the outside of the thigh – the fascia lata/iliotibial band complex – (fascial tightness, “snapping” hip). TPS can result from a problem with one of these tissues or can be due to multiple local tissue pathologies acting in concert.
A bursa is a filmy sac of tissue that contains a tiny amount of fluid. It acts as a cushion that protects the bone from excessive pressure from overlying moving soft tissues. Bursa are present in the body wherever there are bony prominences close to joints – over the front of the knee (pre-patellar bursa), over the point of the elbow (olecranon bursa) and over the side of the shoulder (subdeltoid bursa). On the outside of the hip, there are 2 bursae – the superficial trochanteric bursa which protects the bone from the fascia lata/iliotibial band and the deeper subgluteal bursa which lies between the gluteal tendons and the bone. The term “trochanteric bursitis” refers to inflammation of one or both of these 2 lateral hip bursae.
The cause of trochanteric bursitis is idiopathic in most cases – this means there is no identifiable reason. Idiopathic trochanteric bursitis occurs most commonly in females (? Increased pelvic width compared with males), in older age groups (50 -75 years – associated with degenerative soft tissue changes) and there is unquestionably an association with obesity (increased soft tissue load with weight bearing activity). Tightness of the fascia lata/iliotibial band complex can be identified in many patients with this condition. Trochanteric bursitis can occur after trauma to the outside of the hip (a fall or direct blow) or after lying on the side of the hip for a prolonged period. Inflammatory conditions such as rheumatoid arthritis can cause local bursal inflammation. Bone spurs on the trochanter and calcium deposits in the bursa itself can lead to bursitis. Bursitis can follow hip surgery, particularly hip replacement and hip fracture fixation.
Gluteal tendon abnormalities can cause trochanteric pain, but rarely in isolation. The gluteus medius tendon attaches to the superficial surface of the greater trochanter whereas the gluteus minimus tendon attaches to the deep surface. The gluteus maximus tendon inserts into the upper part of the femur and is not usually implicated in TPS. Tendon tears can be a result of an acute injury (generally younger athletic individuals) but much more commonly are part of a degenerative process that occurs with ageing. Internal degeneration of intact tendons (tendinopathy) can be present and degenerative tendon tears are very common in individuals above the age of fifty – only a small proportion of these are actually painful – probably a result of an associated bursitis or impingement (abnormal contact or pinching) against the overlying fascial tissue.
Snapping hip is generally a condition that affects young and generally athletic/active females. It is caused by the fascia lata/iliotibial band, which is a large sheet of fibrous tissue on the outside of the leg, snapping or audibly rubbing against the greater trochanter with repeated flexion and extension of the hip. This snapping may or may not be painful. The bursa can be caught in between and become inflamed as part of a “friction” type syndrome.
Trochanteric Pain Syndrome is characterised by pain over the lateral aspect or “point” of the hip. It can radiate sometimes along the outer aspect of the thigh or into the buttock. It is usually dull and aching but the outside of the hip can be quite tender to touch. Generally this causes most trouble at night when lying on the affected side – which is either not possible at all or only for a very short time. Some individuals find they are unable to lie on the opposite side for any period – this position will also cause pain to arise in the affected hip. This nocturnal pain can cause major disruption to sleep and is often the main driving reason for seeking treatment. Pain can be present with sitting, particularly when driving for significant distances. When bad, pain can be present even with walking, stair climbing or any activities involving repetitive hip flexion and extension.
Examination of an individual with suspected TPS should include an observation of gait, palpation over affected site for the extent of tenderness, assessment of the range of motion of the hip (noting painful positions) and the strength of the various muscle groups supporting the hip, particularly the gluteal muscles. A test for fascial tightness is very helpful and this maneouvre will often reproduce pain typical of TPS. Snapping of the fascia over the greater trochanter can often be demonstrated by the individual, if present.
Radiological investigations are very helpful in determining the tissues involved and their pathologies in each case of TPS. Plain xrays are important for ruling out hip joint disease but also show any irregularities on the external surface of the greater trochanter, together with calcific deposits in the adjacent soft tissues and any local bone lesions within the trochanter itself. Ultrasound is a popular investigation but does have significant limitations. It may reveal fluid in the trochanteric bursa and can demonstrate tendon pathology, but its diagnostic accuracy is variable. MRI is the investigation of choice as it can show all forms of pathology in both the soft and bony tissues of the trochanteric region as well as the hip joint itself.
The natural history of TPS, even if untreated, is usually one of slow resolution over a period of months to years. The treatment of TPS may change slightly depending on the diagnosis as to the cause/pathology present, but in general follows some basic principles. In almost every case, conservative or non-operative treatment is the appropriate first line management. It may seem obvious, but avoidance of situations that cause pain is essential – continuing with painful activity will never allow this condition to settle. This usually means adopting a comfortable sleeping position at night – avoiding lying on the affected side, putting a pillow between the legs if lying on the opposite side or lying on the back to avoid direct pressure on the painful area. Correction of associated underlying conditions – weight loss in obese individuals and rheumatological review/treatment of established generalized inflammatory disorders when present (eg. rheumatoid arthritis) is very important. Local physical treatment in the form of stretches to the fascia lata/ilio-tibial band complex and gentle eccentric gluteal and core strengthening can be very helpful, particularly when able to be undertaken comfortably. Instruction from a therapist regarding the use of a foam roller or similar device over the trochanter and fascia can complement an exercise program. Analgesic medication and local heat can reduce the pain of TPS. Non-steroidal anti-inflammatory drugs (NSAIDs) can be useful in inflammatory tendon/bursal conditions. Cortisone injections into the trochanteric and subgluteal bursae (under ultrasound control to ensure accuracy of delivery) are often more effective than NSAIDs and don’t generally have the same potential for side effects. Reducing pain in this way to enable satisfactory participation in a stretching/strengthening exercise program can be one of the keys to successful treatment. Sometimes multiple cortisone injections are required, spread out over a period of time. Injections of autologous blood (patients own blood) or platelet rich plasma may be indicated in TPS where tendinopathy/tendon tears seem to be the predominant pathology.
Surgical treatment of TPS is rarely required or indicated. Surgery unfortunately is not always successful and it is impossible to predict the outcome pre-operatively. Recovery is generally slow and often involves a period of non-weight bearing on crutches followed by an extensive rehab/physiotherapy program together with a lot of patience. Despite undertaking all the correct steps, a proportion of individuals with TPS undergoing surgery will still continue to have pain and functional limitation. If surgery is to be undertaken, identification of all the pathologies involved and addressing each of these with the operative procedure is important. Surgery clearly carries some risk – infection, deep vein thrombosis, nerve or vessel damage and anaesthetic complications are possible – and is always absolutely a last resort attempt at symptom improvement in most cases of TPS.
Loose Body of the Hip
The hip, like any other joint in the body, can be affected by loose bodies. These loose bodies may be cartilaginous or bony, but are most often a combination of both – these are referred to as osteochondral (osteo = a bony core and chondral = a cartilage surface) loose bodies.
There are a number of conditions that can lead to loose bodies forming within the hip joint. Traumatic dislocations of the hip can be associated with fractures of either the femoral head (ball) but more commonly of the edge of the acetabulum (socket) and as a result small fracture fragments can break off the joint surface and become loose and potentially trapped in the joint.
Osteoarthritis can be a cause of loose bodies – presumably osteophytes (bony spurs around the margins of the joint) break off and can become loose inside the hip. A somewhat unusual condition called osteochondritis dissecans can affect the joint surface and underlying bone of the femoral head (ball) of the hip. In its advanced stages a small part of the surface can detach and float free in the hip. In a condition called synovial osteochondromatosis – multiple and sometimes hundreds of small loose bodies can arise like “mushrooms” from the synovial lining of the hip and are shed into the joint.
Loose bodies can vary in size from tiny to very large and their size tends to dictate what kinds of problems they can cause. Small loose bodies may cause no trouble at all, mid size ones tend to float/move around inside the joint and can get stuck from time to time causing intermittent locking or jamming of the hip. Very large loose bodies frequently can’t move around freely in the joint but in some circumstances can restrict movement in a similar way to hip impingement conditions.
Symptomatic loose bodies of the hip are best treated by removal – either by open operation (for very large loose bodies) or by arthroscopic (minimally invasive) means in most cases. It is also important to treat any joint surface defect associated with the origin of the loose body. Definitive treatment of loose bodies associated with synovial osteochondromatosis is almost impossible because new bodies will tend to form again with time. Synovectomy of the hip may address this problem but it is difficult to remove all synovial tissue from the hip because of its complex joint geometry.
Labral Tear of the Hip
The acetabular labrum is a fibrocartilaginous structure that sits around the rim of the socket of the hip. It is triangular in cross-section. It is very similar tissue in structure to the glenoid labrum of the shoulder and the meniscus (“cartilage”) of the knee and is colloquially known as the “cartilage” of the hip.
Similar to the meniscus of the knee (which has been extensively studied), the labrum of the hip performs a number of important functions for the joint. It is almost certainly involved in some way in load transmission across the surfaces of the hip and assists with the flow of lubricating synovial fluid throughout the joint. The labrum acts as a “seal” and deepens the joint – important for stability and contains proprioceptive receptors that allow impulses to be sent to the brain regarding the position of the joint and its attached leg, which is important for balance, co-ordination and injury prevention.
The labrum of the hip (again similar to the knee meniscus) has only a limited capacity for repair when damaged. The base of the labrum where it is attached to the bone of the hip socket (the acetabulum) has a blood supply that comes directly from the bone itself. Injury or tears to the labrum in this vascular zone have some capacity for healing. Unfortunately the free edge of the labrum has a very limited or poor blood supply and damage to this portion of the labrum generally results in tears that have no significant capacity to heal by themselves. The site of damage of the labrum clearly has significant implications with regard to how they are treated.
Labral tears of the hip fall into 2 main categories.
The first of these is the “acute” tear – which generally occurs in younger individuals pursuing athletic activities. In this group, there is frequently a significant injury or incident involving forced rotation or hyperabduction (“doing the splits”) of the hip. There may be a noise or sensation of damage felt within the hip or groin followed by immediate onset of pain. A proportion of these types of labral injury involve the vascular zone.
The second is the “degenerative” tear – which tends to occur in individuals over the age of 35 years and usually without a preceding injury or incident. The internal structure of the labrum “dries out” as we age – losing elasticity and flexibility – and as a result it is prone to small surface splits or damage that with time and “normal” use can progress to a significant tear. Many of these tears are asymptomatic – they cause no problems at all, even though they can be seen on investigations like an MRI scan. We know that degenerative tears of the labrum become more frequent with age and that a high percentage of the population over 65 years of age have them. If a degenerative tear of the labrum creates an unstable segment or “flap” that can move around abnormally or get caught between the ball and the edge of the socket – it can create pain inside the hip.
Labral tears of the hip cause pain and this is classically felt deep over the anterolateral aspect of the groin in what is called the “C” sign – so described because of the classical hand position used when showing the position and distribution if the pain (see figure).
This pain location corresponds with most tears (around 90-95%) of the labrum being at the front (anterior) or top (superior) of the hip. Tears of the labrum at the back of the hip (posterior) are unusual but may cause pain felt deep in the buttock. Pain is felt with significant physical activity (running & sport), often with changing direction or certain rotational movements of the leg and often when the hip is repeatedly flexed particularly under load (squats, cycling in an aerodynamic position etc.) Tears can cause clicking with various movements of the hip. This kind of clicking is usually painful. Clicking in the hip however can be due to a number of different causes, most of which are innocent. If a labral tear is of sufficient size it can cause mechanical symptoms – catching, jamming, locking or a sensation that something goes in and out of place inside the joint.
Plain xrays are a good first investigation in anyone with suspected hip pain/pathology, even though xrays are most frequently normal or may show some degenerative joint changes. The best investigation for diagnosing a labral tear is undoubtedly an MRI scan with or without intrarticular gadolinium (a contrast agent injected into the joint). In a lot of cases tears can be seen directly by the scan but sometimes only small fluid collections are seen on the external surface of the labrum – these collections are called paralabral cysts and are a strong indication that a labral tear is present. A labral sulcus – a groove or pit seen between the labrum and its attachment to the edge of the acetabulum (seen in about 35% of hips) is often mistakenly reported as a “tear” on MRI.
It should be noted that labral tears can co-exist with other hip pathology – particularly hip impingement in younger individuals and osteoarthritis in older patients – and these other pathological entities need to be considered when investigating and mapping out a treatment plan.
Not all labral tears require treatment. Assymptomatic (non painful) tears identified on MRI scan and tears associated with significant osteoarthritis do not require any specific treatment. Symptomatic (painful) tears without mechanical symptoms can be managed in some individuals without surgery, by a combination of avoidance or modification of exacerbating activity (ie altering cycling position), physiotherapy techniques to correct muscle imbalances that are often present and the use of analgesic and anti-inflammatory medication for pain relief. Conservative treatment may be indicated initially in “acute” tears where there is some prospect of spontaneous healing. Surgery in the form of hip arthroscopy is indicated in patients with painful tears unresponsive to non-operative treatment or tears with clear mechanical symptoms. Arthroscopic treatment generally involves resection of the torn segment of the labrum and smoothing of the remaining labral surface but repair of the labrum can be undertaken in cases of detachment or vascular zone tears in an otherwise healthy labrum – this unfortunately is not a common situation. As a general rule “acute” tears in healthy labral tissue tend to respond best to surgical treatment, whereas the outcome in “degenerative” tears is more variable.
FemoroAcetabular Impingement (FAI)
FAI is a complex condition that was first described about 15 years ago. Looking back now it is clear that FAI in one form or another has probably been around for hundreds, if not thousands of years.
FemoroAcetabular Impingement refers to a condition of the hip where there is abnormal contact (impingement = pinching or conflict) between the ball of the hip (femoral head) and the edge of the socket (acetabulum). This results in local damage to the tissues on the outer margin of the socket – the labrum and the adjacent socket joint surface. These damaged tissues cause hip pain and the abnormal contact between ball and socket generally leads to some restriction of hip movement. The damage created by this abnormal contact situation can become progressively larger and more severe and in theory, in some people if this is unchecked over many years, it may lead to arthritis. It is believed that a number of cases of primary osteoarthritis of the hip where the cause is unknown (idiopathic) could be due to FAI. Whilst a number of these cases of osteoarthritis display features on xray that could be consistent with FAI (anecdotal observation), at present no longitudinal scientific studies (following a group of people over many years and observing what happens to the hip) can prove this link.
Snapping Hip Syndrome is characterized by an audible and sometimes visible “snapping” or “cracking” sensation of the hip that generally occurs when the leg is moved in a certain way.
The most common reason for snapping hip is movement of the fascia of the outside of the leg (the fascia lata/iliotibial band complex, which extends from the side of the pelvis to the outside of the knee) over the bony prominence on the outside of the hip (known as the greater trochanter). This most frequently occurs in young athletic females who perform activities that involve repetitive flexion and extension of the hip (eg dancing/cycling). The snapping can usually be demonstrated by the afflicted individual and can usually be seen on the outside of the upper thigh. The snapping sensation is usually not painful but if the trochanteric bursa becomes inflamed as a result of friction between the fascia and the bone of the trochanter, then pain can result (see Trochanteric Pain Syndrome).
Most cases of snapping hip require no specific treatment other than reassurance that the condition is not serious and will not lead to hip joint disease in the future. If the snapping is annoying but not painful, modification of exacerbating activities combined with a program of physiotherapy for fascial stretches, gluteal strengthening and instruction regarding the use of a foam roller or similar device can be helpful. If pain is a significant issue then this can be combatted by use of analgesics, anti-inflammatories and sometimes an injection of local anaesthetic and cortisone into the trochanteric bursa.
Surgery is rarely required but is occasionally indicated in resistant painful cases. It is important to have plain xrays and probably an MRI scan to rule out local bony or soft tissue pathology in the region of the trochanter. Surgery involves release or lengthening of the fascia lata/iliotibial band which is usually very tight together with removal of any bony projections from the greater trochanter.
The second most common cause of snapping hip syndrome is a condition called coxa saltans interna. This condition is caused by the main hip flexor tendon (iliopsoas tendon) contacting the front of the socket of the hip or a bony part of the pelvis called the iliopectineal eminence. This creates snapping felt at the front of the hip or deep in the groin (as opposed to the outside of the hip), again generally with hip flexion or sometimes rotation. This snapping can be painless or painful. Other causes of snapping at the front of the hip include part of the quadriceps (the rectus femoris tendon) contacting the ball (femoral head) of the hip joint and tears of the cartilage (labrum) of the hip joint. A dynamic ultrasound investigation may enable the “snapping” structure to be identified. Treatment of snapping psoas tendon follows the same basic principles as for snapping fascia lata/iliotibial band with non-operative treatment being the mainstay and surgical release reserved for rare cases unresponsive to physical therapies.
Meralgia Paraesthetica (MP) is an unusual condition that is characterized by a burning pain and sensory abnormalities (tingling and/or numbness) affecting the outer side of the thigh.
It is caused by pressure on/compression of a nerve – the lateral cutaneous nerve of the thigh (LCNT)(also known as the lateral femoral cutaneous nerve) – as it crosses from the lower abdomen into the upper thigh. It travels through a small tunnel on the outer aspect of the inguinal ligament – a fibrous band structure that runs from the bump at the front of the pelvis above the hip (the anterior superior iliac spine) to the inner part of the groin (pubic bone). Meralgia is classically caused when the LCNT is squashed as it travels through this tunnel. As this nerve is a sensory nerve only – compression causes pain and sensation disturbance but doesn’t cause any muscle weakness/paralysis.
Meralgia paraesthetica classically occurs in middle age (40-60 years) and in both males and females. In most cases there is no identifiable cause of this condition but there are definite associations with obesity and diabetes. Direct pressure on the front of the pelvis from tight clothing (jeans and belts), seat belts in cars, tool belts and pregnancy can be implicated at times.
The main symptom in MP is burning pain over the outer aspect of the thigh, along the line of the LCNT. This is usually constant and doesn’t change with rest or activity but may be aggravated by direct pressure over the front of the pelvis.
There may be sensitivity of the skin of the thigh to light touch and sometimes tapping over the course of the nerve where it crosses the inguinal ligament can produce pain and tingling in the thigh.
MP is largely a clinical diagnosis – there are no definitive tests for this condition, although nerve conduction studies can be helpful if positive.
Treatment in the first instance usually involves an injection of local anaesthetic and cortisone delivered around the nerve as it runs through the inguinal ligament. This is generally best done by a radiologist using ultrasound to localize the nerve. This injection can be helpful in confirming the diagnosis if it eliminates the pain of MP in the first few hours whilst the local anaesthetic is working. In many patients a single injection is all that is required but sometimes its effect wears off after resolution of symptoms for weeks or months. It can be repeated if helpful initially for a reasonable period. Weight reduction, optimal control of diabetes and attention to tight clothing and seat belts etc. should be addressed if appropriate.
Surgical decompression of the nerve may be indicated in cases unresponsive or recurrent with conservative treatment. Surgery involves dividing the tissue of the roof of the tunnel, releasing pressure on the nerve as it travels through the inguinal ligament. In cases where the condition has been present for a long time, surgical decompression of the LCNT may not relieve the condition completely and numbness/tingling may persist.
Stress Fracture of the Femoral Neck
Stress fracture of the hip is an unusual condition that generally occurs in athletic individuals who begin or significantly increase running/other impact activity. The fracture itself usually occurs in the femoral neck at the base of the ball of the hip joint. Sometimes the fracture can occur in the bone of the pelvis adjacent to the hip and rarely in the femoral head (the ball of the hip joint). A stress fracture begins as a tiny microscopic crack in the bone which slowly increases in size with loading activity such as running. This is different to an acute fracture where there is a single incident or event (ie falling over) that causes the fracture. A stress fracture is like getting a piece of coathanger wire and bending it back and forth – eventually if this cycling continues the wire will break.
Most individuals with a stress fracture of the hip notice pain in the groin which comes on with running and activity. This pain tends to settle quickly with rest initially and recurs when attempting running again. If running is continued despite the pain then often the condition reaches a point where the pain doesn’t completely settle with rest and in some cases can be present continuously. Stress fractures occur in many bones in the body but the bones of the foot (at the extremity of a weight bearing limb) are most commonly affected.
Sometimes stress fractures can be seen and diagnosed on plain xrays but frequently scanning (CT or MRI or Nuclear Medicine) is required to be certain.
Treatment of stress fracture generally requires reversal of the reason the fracture has developed in the first place – too much activity needs to be replaced by REST of the injured limb/joint. Bone generally takes 6-8 weeks to heal and this is the period of time where crutches and non-weight bearing are required. This period can be followed by a period of progressive partial weight bearing (still with crutches) and hopefully crutches can be discarded at approx. 12 weeks. A graduated running program can be started once walking is comfortable with the aim of slowly progressing distance and possibly speed over a period of 3 months. If pain recurs at any stage in this process then activity is reduced again until the pain settles. Occasionally stress fractures of the femoral neck require surgery – these types of fracture have a particular pattern on CT/MRI scan.
A variation on the typical stress fracture of the hip is the kind of fracture seen in the upper femur which can occur secondary to osteomalacia (VitaminD deficiency), parathyroid disease and with the use of bisphosphonate drugs for the treatment of osteoporosis.
Arthroscopy of the hip
Hip Arthroscopy is a minimally invasive operative procedure which allows the treatment of a range of hip joint conditions. It can be used to treat labral (hip cartilage) tears, local areas of joint surface damage, remove loose bodies and undertake simple treatment of early arthritis conditions.
About the surgery
The procedure is usually performed as a “day case” – admitted the day of surgery and discharged from hospital a few hours after surgery. The procedure is normally performed under a general anaesthetic (GA) and for this reason fasting from food/fluid is required before surgery. You will be notified when to stop eating/drinking. You will need to be picked up from hospital by a relative or friend as you will not be able to drive home.
Hip Arthroscopy involves introduction of a small telescope into the hip joint. In order to achieve this the bones of the joint – the ball (femoral head) and socket (pelvic acetabulum) are separated by a small distance. This is done by injecting air and fluid into the hip joint under x-ray control and then applying traction to the foot through a special boot. Two small stab incisions (approximately 5mm in length) are then made over the side of the hip to facilitate firstly the introduction of the joint telescope and then a series of working micro-instruments can be inserted through the second incision. These instruments enable the surgeon to undertake appropriate corrective action relevant to the pathological conditions that may be present.
At the end of the procedure local anaesthetic is normally injected into the hip to minimise pain post operatively and the small incisions are closed with stitches and steristrips. A waterproof dressing is then placed over the area. Your surgeon will normally come and speak with you regarding the procedure before being discharged home. Sometimes the wound will be redressed in the day surgery area before being discharged – particularly if there has been any significant fluid leakage beneath the original dressing.
After the surgery
When you are discharged from hospital you should have a set of photographs from your procedure, some painkillers which will probably be required for a few days, a pair of crutches and a sheet of instructions for your physiotherapist. It is often easier to hire crutches from a local pharmacy or supplier – these are easier to return compared with hospital supplied crutches. Please bring these with you on the day of your surgery. It is not generally recommended to start physiotherapy until after post operative review by your surgeon at 10 – 14 days. If you need a certificate for work/study, please ask your surgeon on the day.
Once you get home it is generally recommended that you mainly rest for the first couple of days. It is normal to feel discomfort and sometimes swelling locally in the groin and thigh. Please use painkillers and ice for this especially in the first 48 hours. Small amounts of bleeding beneath the dressing are very common and not a cause for concern. It is advisable to use crutches to assist with walking and weight bearing activity in the first 5 – 7 days. It is usually okay to put some weight on your operative leg over this period and proceed to full weight bearing after about a week. It is also not advisable to drive in the first 2 – 3 days after surgery. After a couple of quiet days at home you may increase activity slowly as comfort permits. There are no specific exercises to follow at this point – you may move the hip/leg freely provided it is comfortable. Avoid excessive walking, prolonged standing, squatting or deep bending and any significant rotational movements of the leg. Your surgeon will advise you if there are any changes to these basic post-operative guidelines. Should you have any concerns, consult your surgeon or general practitioner.
The post operative visit is usually at 10 – 14 days after surgery. At this time your dressing and stitches will be removed and the surgical wounds inspected. Your surgeon will normally discuss with you the surgical findings and procedure, going over your surgical photographs. At this stage it is normally recommended that you start a hip rehab program under the guidance of a physiotherapist who can tailor the program to your particular condition. Heavy impact activity and sport is usually avoided in the first 6 -8 weeks but gentle low impact activity such as stationary cycling and swimming/hydrotherapy are okay once your surgical wounds are well healed. Rehab usually consists of progressively regaining range of movement of the hip, strengthening exercises to the hip girdle muscles but also to your core muscles (lower abdominals and spine) and some proprioceptive exercises (a combination of balance and coordination work).
Risks and complications
As with any operation there are potential risks and complications that can occur. Fortunately these are infrequent and hip arthroscopy is generally regarded as a relatively low risk procedure – however should a significant complication occur you could be worse off than before the procedure. There is a very small risk associated with any form of anaesthesia. Should you have any concerns in this regard, please speak to your anaesthetist who will see you before surgery. There is a small risk of infection developing in the hip and a small risk of deep vein thrombosis (blood clot) developing in the leg – the risks of both are less than 0.5 percent. There is risk of permanent damage to vessel or nerve around the hip – around 1 in 1000 cases. Short lived numbness around the hip, genitals and in the lower leg is slightly more common and if present usually lasts a few days before resolving. Unfortunately there is no procedure (hip arthroscopy included) that fixes all problems and there is a chance that you may continue to experience problems with the hip after surgery of this or any type. Occasionally a hip joint may be very stiff and if the joint cannot be separated satisfactorily, there is a small chance that the surgery will not be able to be undertaken. Despite these potential problems associated with hip arthroscopy, in most cases the surgery results in significant improvements in pain and function.
Recovery following surgery is quite variable and dependant on individual factors, the original hip condition and it’s treatment and your body’s response to exercise / physiotherapy. Your surgeon and physiotherapist should be able to guide you in this regard.
Post Operative Care Information
Hip Arthroscopy is usually undertaken making 2 or 3 small stab incisions on the outer part of the hip. These incisions are closed with stitches and steristrips and a waterproof dressing is then placed over the area. Sometimes the wound will be redressed in the day surgery area before being discharged home – particularly if there has been any significant fluid leakage beneath the original dressing. Small amounts of bleeding under the dressing are very common and not a cause for concern. You may shower with this dressing on but don’t immerse in a pool or bath. If a significant amount of moisture accumulates under the dressing it will need to be changed – otherwise leave dressing intact until seen by your surgeon at the post operative visit. Occasionally the dressing will fall off after 8 – 10 days – just keep the area dry or if concerned get your local doctor to redress this for you.
At the end of the procedure local anaesthetic is normally injected into the hip joint to minimise pain post operatively. This will wear off after a few hours and you may need to use ice packs locally and take the painkillers prescribed to you at this stage. These are often required in the first 48 hours or so but this varies from one individual to another. Short lived numbness around the hip, genitals or lower leg is uncommon but if present will usually resolve after a few days.
It is advisable to rest in the first 2 – 3 days quietly at home. Over this period you may get up and weight bear on the operated leg as comfort permits using crutches for short periods. Crutches are usually required for 5 – 7 days and you may fully weight bear after this time if comfortable. Occasionally you will need to protect weight bearing for a longer period – your surgeon will advise you if this is required.
You may move the hip / leg freely provided it is comfortable but avoid hyperflexing the hip, deep squatting or significant twisting of the operated leg in at least the first 2 weeks.
It is not advisable to drive in the first 2 – 3 days after surgery or whilst you are taking pain medication. If you can comfortably operate the accelerator/brake/clutch without pain, you may drive at your discretion.
You may return to work as soon as pain is tolerable. Generally if a job does not require prolonged standing and walking, you may return after about a week. Work of a more physical nature may necessitate a longer absence.
Physiotherapy is not usually recommended until after review by your surgeon at 10 – 14 days.
Follow Up Visit:
This has been made for you at the time of booking your surgery and is detailed on the sheet attached to the booking information you have been sent out.
Your surgeon will advise you if there are any changes to these basic post operative guidelines. Should you have any concerns, consult with your surgeon or general practitioner.
Arthroplasty of the hip
Total Hip Replacement (THR) is a surgical procedure that is arguably the most effective in all of medicine. In the right individual it can dramatically change a persons life providing improvements in pain relief and quality of life in a very cost effective way. 34,000 hip replacements were performed in Australia in 2010 and this number is increasing slowly each year.
THR is potentially indicated when the normal surfaces of a hip joint have been damaged irretrievably. The common causes for this are:
(1) Osteoarthritis – a degenerative “wear and tear” condition seen generally in adults over the age of 50 years. The cartilage cushioning layer on the surface of the ball and socket of the hip wear away leaving “bone on bone” contact causing pain and stiffness.
(2) Inflammatory Arthritis (eg Rheumatoid Arthritis) – an auto-immune disease where the synovial lining of the joint becomes chronically inflamed and the cartilage surfaces of the hip joint become progressively destroyed.
(3) Avascular Necrosis of the Hip – an unusual condition where the blood supply to the ball of the joint fails leading to collapse of the bone directly beneath the joint surface. This leads to destruction of the smooth joint surface of the ball.
(4) Fracture of the Hip – very occasionally the fracture is such that hip replacement is indicated.