Hip arthritis consultant explains latest treatments - Do I need hip surgery?

Contents

• Introduction
• How do you know if you are at risk of hip arthritis?
• How is the hip joint affected?
• Hip preservation surgery
• Latest reported outcomes
• Summary
• Patients with arthritis

Introduction

Historically most surgery of the hip joint in the adult has been for the treatment of hip arthritis.  However, the cause and development (pathophysiology) of hip arthritis is now far better understood and treatment emphasis is now shifting away from total hip replacement towards the prevention and/or delay of hip arthritis. Until we find the ultimate cure we will need to continue to replace diseased and worn out hips. However, the important questions are: – Will early surgical procedures delay the need for a total hip replacement?  When or if a hip replacement becomes necessary, which is the best type of hip replacement, and what is the best procedure?

Hip surgery for the prevention of arthritis can be performed arthroscopically (keyhole) or by open surgery. The rehabilitation and return to pre-injury level of activity is often prolonged (4-9 months) and therefore patients should be aware of the need for appropriate counseling prior to surgery. This is a detail that can be easily overlooked and is important because both patient and surgeon need to be realistic about the outcome.

There are potential risks and complications from both procedures and these must be weighed against the patient’s symptoms, own set of personal circumstances as well as the disease status (pathology). If arthritis is already present, then it is too late to perform hip preservation surgery, so seek advice early if you have hip pain.  

How do you know if you are at risk of hip arthritis?

Patients may have no symptoms.  If however you experience pain around the hip, which is worse on sudden rotary movement and is associated with a sensation of the hip feeling unstable or ‘catching’, then you may have hip arthritis.  Susceptible individuals are those who partake in activities which require deep hip flexion, sudden rotary movements or a combination of both, such as athletes or gardeners.

The proper investigation of these symptoms by your Orthopaedic Consultant will normally require an examination of the hip and include x-rays, CT scan or MRI & Arthrogram (dye injection in the hip), as is deemed appropriate.

How is the hip joint affected?

There will always be a mechanical weakness where two moving parts meet. The connecting structures between the ball (femoral head) and socket (acetabulum & labrum) become damaged over time, which makes the underlying cartilage (articular cartilage) also susceptible to trauma. As the articular cartilage is injured, the underlying bone becomes exposed and then this undergoes changes.  This final process is arthritis. Hence surgery is initially geared at preventing further damage and repairing existing damage with the aim of delaying the onset of further arthritis. The trauma can occur as a result of a single significant event or from the repetitive trauma caused by a misshapen femoral head or acetabulum coming into contact with each other.

Hip preservation surgery

The choice of treatment will largely depend on the degree of symptoms, the range of movement of the joint and the presence or absence of arthritis. 

Physiotherapy will be advised if appropriate.  If not, the surgical options are either ‘arthroscopic’ or ‘open’ surgery, both of which are geared towards reshaping the deformed femoral head or the acetabulum, as well as treating damage to the labrum and articular cartilage. The gold standard for treatment of this condition is Open surgery. The literature however suggests that Arthroscopic treatment outcomes are comparable.  The benefit of Arthroscopic treatment is that there is less tissue trauma and hence there is faster recovery.  

As a patient, ensure you are clear on the expected benefit from surgery and the expected timescale for recovery prior to proceeding with any particular procedure. 

As with most treatments, complications can occur and these include:-

• Inability to treat the underlying pathology, so no change in symptoms
• Infection (less than 2% risk)
• Deep vein thrombosis and pulmonary embolism (less than 2% risk)
• Neurovascular complications (less than 10% risk)
• Fracture (less than 10% risk)
• Joint stiffness
• Joint Instability

There are potential risks and complications from both procedures and these must be weighed against the patient’s symptoms and pathology. If arthritis is already present, then it is too late to perform hip preservation surgery, so seek advice early if you have hip pain.  

Latest reported outcomes

As these are relatively new procedures, there are no results yet giving the long term outcome and success of the procedures described above.  However, early to mid-term results look promising.

Arthroscopic procedures are as favourable as open procedures for the treatment of Labral tears and may prove to be the more beneficial of the two procedures.

Summary

Lesions of the acetabular labrum can lead to arthritis.  Early diagnosis and treatment may however prolong the lifespan of the hip joint.  Hence it is important that early advice is sought for painful hip conditions.

Advice for patients with arthritis

For those patients whose disease has already advanced and hence whose only choice is a hip replacement, the decision on the type of procedure and prosthesis is often confusing.  This is because so many components are available, with little to choose between them.  The choice often comes down to surgeon preference and experience.

My advice is:-

1. The best results come from a surgeon performing a procedure with which they are best experienced, using a prosthesis with which they are familiar.
2. For patients younger than 65 years of age (though older patients do sometimes also qualify), a prosthesis that does not use cement for its fixation appears to give the best results.
3. For the older patient, the cup prosthesis, ( i.e the part that is inserted in the pelvis and articulates with the head of the prosthesis in the femur), can be inserted successfully with or without cement.
4. Prostheses that are composed only of metal, release metal ions in the body that may cause harm to an unborn child. (no evidence of this occurring to date however.) Hence women of child bearing age need to discuss this option with their surgeon prior to proceeding with the operation.
5. The larger the head part of the prosthesis, the smaller the chance of dislocation.  However, head size is determined by the size of the pelvic acetabulum.  Hence women usually have smaller head sizes inserted than men.
6. There is little to choose between a ceramic acetabular liner and ceramic femoral head, a strengthened polyethylene acetabular liner and ceramic head or a strengthened polyethylene acetabular liner and metal femoral head, with regards to the time the prosthesis will last before it wears out.
7. If your limb which has the arthritis is much shorter than your other leg, then a prosthesis with a stem that goes into your femur, is better at correcting this than one which just sits on top of your femur.  The one that sits on your femur is known as a Hip Resurfacing prosthesis, of which the Birmingham Hip Replacement is one type.  This is comprised completely of metal and is matched with a metal acetabular cup.
8. Having a stable prosthesis is the primary goal of hip replacement surgery.  However if this can be combined with less muscle cutting, less pain and a faster recovery, then this would be ideal.  Enquire whether your surgeon offers minimally invasive surgery.

The key advice then is: Seek advice early with respect to hip pain. Choose your surgeon carefully. Be confident of their ability to perform the procedure offered. Be clear on the procedure offered and the reasons for doing so.

For further information on the author of this article, Consultant Orthopaedic Surgeon, Miss Samantha Tross, please click here.