What is hip osteoarthritis?

The hip joint is a ball and socket joint and has a protective cartilage cushion which helps to evenly distribute forces throughout the hip joint. By far the commonest type of arthritis to affect the hip is osteoarthritis which is a degenerative condition which often results from progressive wear of the hip.

What can cause it?

Osteoarthritis is often due to age-related wear of the cartilage in the hip. It may have an associated family history/genetic component, or secondary to a condition such as osteonecrosis, previous trauma, childhood hip disorders or a previous infection of the hip.

It can also be secondary to a systemic condition such as diabetes and rheumatoid arthritis. A history of heavy lifting or repetitive loading of the hip can also cause osteoarthritis. Being overweight is also a risk factor.

What are the symptoms and signs?

Symptoms can comprise a broad spectrum which can range from an intermittent mild activity-related groin ache through to more significant constant pain involving the groin, buttock, lower back and the ipsilateral knee joint. The pain from an arthritic hip rarely radiates beyond the knee joint. If there is radiation beyond the knee joint towards the foot one would certainly have to exclude a spinogenic cause. As the disease process progresses, one’s analgesic requirements often increase and mobilisation distance decreases.

Hobbies and activities of daily living, such as donning your own shoes and socks, bath transfer and performing one’s own pedicure gradually become more and more compromised as one’s quality of life diminishes. There may be associated symptoms such as clicking, grinding or giving way.

Objective signs in the office may include: an associated limp or a waddle as the patient walks; on the couch there is often a significant reduction in the range of motion of the hip joint and as the disease process progresses the hip can become quite irritable with pain being reproduced with even a small amount of internal rotation. The soft tissue envelope along with the nerve and vascular supply of the limb is always routinely assessed.

What investigations may be required?

Investigations help confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning.

Plain radiograph (x-ray)

Plain radiographs are a quick and effective way of confirming arthritis in a joint. In the early stages when there is inflammation with no damage to the joint they may be normal. Most people, however, present when there is some structural damage.

X-rays are taken centred on the hip from both the front and the side. On occasion, further tests, including an ESR/CRP to exclude significant infection or inflammation, are performed but often the diagnosis of hip osteoarthritis is readily made from x-rays alone.

The following are features of arthritis on a plain radiograph:

  • Decreased joint space
  • Subchondral sclerosis
  • Subchondral cysts
  • Osteophytes
  • Deformity

MRI

In situations where other soft tissue conditions are suspected an MRI scan of the hip joint can also be very useful. MRI provides excellent high definition static images.

MRI is particularly useful in assessing:

  • Cartilage loss
  • Reactive bone changes
  • Effusion
  • Synovitis
  • Ligament damage
  • Tendon pathology (tenosynovitis, tendon tears)
  • Any other pathology

Can the problem get worse?

The problem certainly can progress and therefore the condition must be carefully monitored both clinically and radiologically.

Potential complications

It should be borne in mind that complications may result from a condition with or without surgery. Complications of non-operative treatment include: worsening pain, increased stiffness, increasing deformity, adjacent joint disease, pain elsewhere, for example in knee, hip or lower back (due to abnormal gait and compensatory mechanisms). Complications can occur with any type of surgery.

Potential general complications: risks and complications of anaesthesia, bleeding, infection, blood clots, failure to fully correct a deformity, the need for further surgery, persistent pain, complex regional pain syndrome and wound healing problems, genito-urinary and cardiovascular complications.

Potential complications which are specific to the surgery mentioned above include:

Nerve damage/foot drop, intraoperative fracture, stiffness, instability/dislocation, loosening, wear, leg length discrepancy, the need for revision surgery, non-resolution of symptoms and partial resolution of symptoms.

If develop sudden onset of chest pain, breathlessness/ breathing changes or sweating please call 999 immediately since this could be an undetected clot which has travelled to the lungs. This is an emergency and requires immediate treatment. This is a very rare complication.

Treatment

There is no one treatment that has a reliably successful, quick and easy cure for arthritis. Therefore researchers and doctors are constantly looking for new and better ways of treating arthritis.

Many treatments have come into fashion and then gone away over the years once results had shown that the initial promise was premature and misplaced.

At The London Hip and Knee Clinic we do not promote or discourage new treatment options for arthritis. We would, however, advise a cautious approach to relatively untested treatment modalities with little or no evidence to back their use. Patients undergo these treatments at their own risk.

Non-surgical management

These include activity modification, painkillers, physiotherapy, the use of a walking stick, hip joint steroid injection.

Non-operative management for hip osteoarthritis aims at relieving pain and return to full activity whenever possible. It is likely to be most effective in the early stages of the condition.

It should always be the first line of treatment. Options include:

Activity modification. A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities with lots of turning and twisting.

Non steroidal anti-inflammatories. The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with hip arthritis by reducing inflammation in the joint.

Analgesics. The use of paracetamol and other painkillers to help reduce pain levels.

Physiotherapy. Physiotherapy works by strengthening muscles around not only the joint but the whole kinetic chain. Results are variable with arthritis and depend really on the severity of the disease. In a very stiff and damaged joint, physiotherapy may make your symptoms worse. Your surgeon will guide you.

Walking aids. The use of a walking stick or cane to reduce the forces going across the damaged joint.

Weight loss. Can relieve the pressure on painful damaged joints.

Dietary supplements. These are increasingly popular with people who have arthritis. The cartilage found in joints, normally contains glucosamine and chondroitin. It is thought that taking supplements of these natural ingredients may help to improve the health of damaged cartilage.

Research has provided mixed results but on the whole suggests that glucosamine sulphate is more likely to be helpful than glucosamine hydrochloride. If you notice no improvement in your symptoms after 3 months then you should probably discontinue it. If you do find it improves your symptoms then you should continue taking the supplements. There is no extra benefit in taking glucosamine and chondroitin.

Remember that supplements also have side effects and it is advisable to discuss with your GP before starting any new treatment.

Surgical treatment

There is no doubt a total hip replacement is the operation of the century. It is one of the top three interventions that can be performed in any branch of medicine including cataract surgery and renal transplantation surgery.

Furthermore, the hip replacement patient demographic is changing. People are now living longer and, as a consequence, more and more people are wearing out their native hip joints and are requiring intervention in the form of hip replacement surgery.

However, on the other end of the spectrum, we are seeing a rise in the number of younger patients requiring joint replacement surgery. The exact cause of this rise is unknown. Is the unhealthy lifestyle created by modern living causing us to wear out our joints quicker through intense fitness regimes?

Total hip replacement involves surgically removing the worn down cartilage and neighbouring bone and replacing it with artificial components. Significant biotechnological advances have now led to the formation of state-of-the-art hip replacement designs.

These often involve press fitted biological fixation into the host bone along with ceramic on ceramic/ highly cross-linked polyethylene bearing surfaces. These high-performance designs have revolutionised the treatment of end-stage arthritis in all age groups.

Whatever your age, it is important to remember that you do not need to suffer constant pain and misery as a result of hip arthritis. Total hip replacement design has become significantly advanced and it is now one of the most successful operations performed with excellent outcomes.

Postoperative period and recovery

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.

After your operation, a routine enhanced programme of recovery will commence. The main parallel work streams of this programme are as follows:

Physiotherapy

Mobilisation is commenced on Day One. Gradually there is an increase in the frequency of transfers in and out of bed. This then progresses onto stairs and mobilisation to the toilet/shower and back.

Before discharge, the patient is well rehearsed in the exercise routines and is competent in negotiating stairs. It is extremely important to remain well motivated and perform your exercises after discharge to fully optimise the range of motion of the new hip. For six weeks you may be on crutches and one should avoid unnecessary twisting by keeping both legs parallel during transfers.

Occupational therapy

Will focus more on activities of daily living, functional transfers and adaptation of the home environment.

Pain control

During the operation, spinal anaesthesia with local infiltration of anaesthetic around the hip is used. After the operation regular oral medication is then used. Ask for extra if required. Before discharge required prescriptions are provided.

Wound care

It is perfectly ok to experience an ooze from the wound especially as one mobilises. Your dressing may require changing. Before discharge, the wound should be dry and arrangements will be in place for staple removal by your practice nurse.

Nutrition, fluids and excretion

Immediately after the operation intravenous (directly into the veins) fluids are given. Medications such as routine antibiotics are also given via this route. Urine output is carefully monitored. A bedside commode may be needed during the first postoperative day.

Normal diet is introduced as soon as possible. The urine catheter is removed once mobile. Bowel habit should also return to normal before discharge.

Personal hygiene

On the first morning after the operation ablutions are performed at the bedside. Showering is then gradually introduced – at first with assistance and then independently.

What is an Anterior Cruciate Ligament Injury?

The Anterior Cruciate Ligament (ACL) is a very important stabiliser of the knee joint. Ligaments connect bone to bone, providing stability. An ACL injury results when this important ligament is damaged. It is the most commonly injured ligament in the knee.

What can cause it?

The classically described injury mechanism involves an indirect valgus (knee bent inwards) force coupled with a twist of the knee.

What are the symptoms and signs?

In the acute stage pain is a factor, however, this rapidly settles and the main symptoms are a feeling of instability or loss of confidence in the knee following repeated episodes of giving way.

There is often an instantaneous swelling of the knee following the injury. There may even be an audible ‘pop’ or ‘click’ heard at the time.

In summary symptoms following an anterior cruciate ligament injury include:

  • Pain
  • Popping sensation at the time of the injury
  • Swelling
  • Bruising
  • Limp

Once the acute swelling and bruising have settled, a thorough clinical examination is performed including the following special tests:

  • Lachman’s test
  • Anterior drawer +/- a pivot shift

Your knee surgeon Mr. Mann will also examine you to rule out or confirm the presence of any associated injury such as:

  • Focal meniscal injury
  • Osteochondral damage
  • Medial collateral ligament injury
  • Lateral collateral ligament injury
  • Posterior cruciate injury
  • Posterolateral corner injury
Can the problem get worse?

In isolated anterior cruciate ligament ruptures the natural history is often quite difficult to predict.

Some patients’ symptoms do settle with a dedicated course of ACL rehabilitation physiotherapy, which is directed towards neuromuscular optimisation of the knee joint.

A recent Scandinavian cohort/observational study, published in the British Medical Journal, showed that a significant proportion of patients do settle with just physiotherapy alone.

Non-surgical management

Acute phase

We recommend the PRICE regime:
Protection – minimise the risk of re-injury, for moderate to severe sprains, the use of crutches is recommended as well as the use of a knee brace
Rest – by avoiding walking on the knee while it remains painful and swollen (at least 48 hrs)
Ice – apply immediately or as soon as possible following the injury to minimise swelling (make sure ice is wrapped in a towel and you apply until area becomes numb, remove and discontinue the ice at this stage, continued application following numbing may result in tissue damage)
Compression – bandages and dressings help immobilise the injured knee, reducing pain and swelling
Elevation – of the knee to at least heart level to help minimise swelling and aid soft tissue healing

During the initial stages of this injury, it is often difficult to perform a meaningful clinical examination as the knee is too painful. Your surgeon will guide you according to the grade of your ligament injury.

Rehabilitation phase

Effective rehabilitation is critical to ensuring full recovery: resolution of painful symptoms, swelling and restoration of stability. It is also important as it will prevent the risk of chronic knee instability. Using an experienced physiotherapist can help with your recovery and rehabilitation.

The different stages of rehabilitation include:
Stage 1 –  this involves resting, protecting the knee and reducing the swelling (week 1)
Stage 2 – this involves restoring the range of motion, strength, flexibility and most importantly proprioception exercises of the knee (week 2-3)
Stage 3 – at this stage return to activities that do not require twisting or turning, and commence pool based exercises
Stage 4 – return to activities that require sharp, sudden turns (cutting activities) such as tennis and football (weeks to months)

Section

FAQs

When can I stop using a walking stick?

This depends on the postoperative weight-bearing status. Sometimes protected weight bearing is required for six weeks after the operation. It can take a while before the muscles around the hip regain full control. Therefore normally you will be seen at six weeks after the operation before being advised to wean off any walking aids.

Why am I still not sleeping well?

During the first six weeks after the operation, very few people sleep throughout the night. Often you are sleeping on your back which is an unnatural position for some. When you eventually start sleeping on your side you may find it easier to place a pillow between your legs.

How far can I walk?

Following a routine primary total hip replacement, you should be able to walk the same distance as before the hip became symptomatic. Ensure that you don’t become tired, breathless or dizzy.

Will security alarms at airports be set off by my new joint replacement?

Stainless steel replacements will set off the alarms. It may require you to have a word with the security staff to explain the situation. Titanium replacements usually go undetected.