Hip Arthritis:
The hip joint is a “ball and socket joint.”. It is a very important joint as it allows a great deal of movement but is also weight-bearing. As a result of this, it is often prone to “wearing away.”. This is a simplified reason as to why arthritis occurs.
There are several risk factors for developing hip arthritis:
⦁ Increasing age
⦁ Genetic predisposition (family history)
⦁ Heavy-impact sporting activities
⦁ Complications of hip fracture treatment
⦁ Childhood conditions – hip dysplasia (clicky hips), Perthe’s disease, SUFE
Arthritis can be a very painful condition that may slow your mobility or walking or even stop you from sleeping. The other symptoms of hip arthritis include hip stiffness, difficulty putting on your shoes and socks and excessive pain after sitting for a prolonged period.
A hip replacement is an operation that replaces the severely damaged hip bone with an artificial ball and socket that functions as the natural joint. It is designed to reduce the pain and help you return to your activities.
Failed Hip Replacements
A well-functioning hip replacement may fail over time due to the following reasons. The list is not exhaustive. Mr. Agrawal has experience in dealing with these conditions and would provide you with an independent opinion and discuss any potential treatment options where possible.
⦁ Wearing out-of-joint replacement
⦁ Loosening of the implants
⦁ Instability (hip dislocation)
⦁ Deep infection
⦁ Fractures around the hip replacement (periprosthetic fractures)
⦁ Reaction to metal debris (eg. metal-on-metal hip replacements)
⦁ Unexplained pain
Hip Fractures & Trauma
Fractures of the hip joint most commonly involve a break in the upper portion of the thigh bone (femur), where it attaches to the ball of the hip joint. This region is known as the 'proximal femur' or 'femoral neck'. Hip fractures commonly occur in patients with established reduction in bone density (osteoporosis). In patients with osteoporosis, fractures may be sustained after only relatively minor trauma or simple falls. Hip fractures can also occur in patients with normal bone strength after more severe injury (e.g. motor vehicle accidents) - in this situation hip dislocations, socket fractures, pelvic injury or other injuries unrelated to the hip may also be sustained. The term 'hip fracture' however commonly refers to an isolated fracture of the upper femur.
Osteoporosis is gradual weakening of the bone with a reduction in bone density, leading to an increased risk of fractures. Osteoporosis is a 'silent' condition (causes no symptoms) and takes many years to develop. The risk of developing osteoporosis increases with age, particularly after menopause. Both women and men can develop osteoporosis. There are many treatments for osteoporosis - they are generally most effective if started prior to severe reductions in bone density. Ideally, all patients sustaining a fracture over the age of 50 should have an assessment of bone mineral density (BMD) by DEXA scan.
In most situations where a significant hip fracture has been sustained, surgery is recommended. As many patients with hip fractures also have other health problems, other specialists (eg. Physician, Rehabilitation Consultants) are often asked to assist with various aspects of overall health management. After the surgery, most patients are instructed to full weight bear on the operated hip as desired, however regaining steady and confident walking may take some time. Often admission to a Rehabilitation Unit is useful to help regain confidence and mobility after hip fracture surgery.
Broadly speaking, surgery for hip fractures is divided into two groups - internal fixation or joint replacement.
Internal fixation involves placing the bone back into the correct alignment and holding the position with a combination of metal devices such as plates, screws & rods. The metal devices hold the fracture fragments until the bone unites. Removal is not usually recommended.
Some patterns of hip fracture have an unacceptably high risk of complications if treated with internal fixation. In these situations, joint replacement is recommended. Joint replacements used in hip fracture treatment may be 'half' hip replacements (where only the broken ball is replaced) or Total Hip Replacements (where both the broken ball and socket are replaced). Which joint replacement is recommended depends on a number of factors such as age, general health, activity level and pre-existing joint arthritis.
Avascular Necrosis
Avascular Necrosis (AVN) is a disease where the bone of the femoral head (ball of the hip joint) is damaged by a loss of blood supply. The damaged bone becomes softened and liable to collapse, resulting in deformity of the femoral head and separation of the overlying cartilage. In the late stages of AVN, progressive damage to the hip joint results in early osteoarthritis.
In many situations, no cause is identified (also known as 'Idiopathic AVN'). Known risk factors for developing AVN include the use of corticosteroid medications, high alcohol consumption abuse and hip joint trauma (dislocations and fractures).
This is sometimes a difficult question to answer and depends on several factors. In the early stages of AVN, good medium-term results can be obtained with the use of bisphosphonate (tablet) medications. Once the collapse of the femoral head has occurred, the outcome for the hip joint is less favourable, however, the outlook can still be improved in selected cases with surgical intervention. Hip joints with significant collapse and deformity of the femoral head due to AVN reliably develop early-onset osteoarthritis.
In the early stages of AVN, progression of the disease can be prevented or slowed with the use of bisphosphonate medications (used to improve bone density). Pain associated with AVN can often be significantly improved with a minimally invasive drilling procedure (Forage). After the collapse of the femoral head has occurred, the outcome for the hip joint is less favourable. In some cases, a procedure to protect the softened area of the femoral head by reshaping the upper thigh bone (femoral osteotomy) may be recommended. Ultimately, hip joints with end-stage AVN and associated osteoarthritis are best treated with an artificial joint replacement. In these situations, both hip replacement and hip resurfacing have been shown to be effective.
Acetabular Dysplasia
Acetabular dysplasia is a shallow and abnormally directed hip socket (see Figure). The condition is most commonly associated with a subtle abnormality of the hip joint at birth (congenital hip dislocation) and often remains undetected for many years. Sometimes acetabular dysplasia can develop as the result of other childhood hip conditions such as infection, trauma or Perthes disease.
Hip joints which are abnormally shallow are predisposed to progressive damage to the cartilage, leading to osteoarthritis. Acetabular dysplasia is one of the leading causes of the development of hip joint osteoarthritis, particularly in women.
The hip does not become painful until enough damage has accumulated in the joint. The first symptoms are often mild groin discomfort. Once the joint becomes painful, gradual deterioration of the hip joint can reliably be predicted; however, reducing your activity level may reduce the symptoms.
It is useful to consider dysplasia as a disorder with graded severity, ranging from a very mild (borderline) deformity to very severe joint irregularity. The outcome for dysplasia is significantly influenced by the amount of dysplasia present. Some patients with mild forms of dysplasia may indeed not develop arthritis in the future or have outcomes very similar to patients who do not have dysplasia. For this reason, not all patients with dysplasia require corrective surgical treatment, particularly if only mild deformity is present. In this respect, rather than asking "Do I have dysplasia?" a much more practical question is to ask "How much dysplasia is present?".
This is sometimes a difficult question to answer. Once the hip becomes painful, acetabular dysplasia predictably causes progressive damage to the joint, but the progression can be very slow. Most patients experience ongoing discomfort which gradually worsens over many years, even decades. Patients with very shallow hip joint sockets who have developed symptoms around the age of 20 rarely get beyond their early to mid- thirties without requiring an artificial joint replacement.
This is certainly an option. Artificial joint replacements are a reliable and safe method of treating established osteoarthritis. As joint replacement technology improves we are seeing far more wear resistant bearing surfaces more suitable for use in younger people with hip osteoarthritis. Younger patients managed with artificial joint replacements however do have a much higher likelihood (over their whole lifespan) of requiring increasingly complex re-operations to revise failed artificial joint replacements. In selected patients with acetabular dysplasia, early corrective surgical intervention can slow or prevent the progression of joint damage and improve symptoms.
Trochanteric Bursitis
Trochanteric bursitis is inflammation of a lubricating membrane (bursa) located on the side of the hip. The condition is commonly associated with inflammation & weakness of the tendons attaching at the side of the hip and pelvis region (gluteal tendinopathy). Often the terms "Trochanteric Bursitis" and "Gluteal Tendinopathy" are used interchangeably as most people have elements of both conditions.
While some conditions may predispose to the development of trochanteric bursitis (rheumatoid arthritis, hip joint disorders, tight iliotibial band), most people who develop trochanteric bursitis have no clear precipitating factor apart from deconditioning of the deep "core" postural muscles surrounding the joint. A very significant factor influencing the generation of gluteal tendinitis or trochanteric bursitis in the majority of people relates to factors such as posture, habit and physical conditioning that can be treated by physical therapy and activity modification.
Trochanteric bursitis can affect people of all ages and activity levels but is more common in middle-aged females. Occasionally the condition is observed in association with trauma or surgery around the hip region. In association with trochanteric bursitis, some people may develop degenerative changes or a tear in the adjacent supportive hip tendons.
Trochanteric bursitis typically causes pain distributed to the outer hip region. The pain is often made worse by long walks, stair climbing or prolonged standing. Lying on the affected side often produces discomfort at night. Many people also have weakness of the muscles of the hip, resulting in a limp after long walks or making them feel unsteady when standing on one leg. Most patients with trochanteric bursitis do not recall a specific accident or event to caused their symptoms but rather a gradual onset of increasing discomfort over many weeks or months which fluctuates with activity levels. The pain can sometimes be quite severe and disabling. The condition tends to be chronic (spanning many months or years) and has a high recurrence rate, particularly in women.
The mainstay of treatment is effective and sustained physical therapy and conditioning for improving the functional strength and endurance of the supporting muscles around the hip joint. Muscle conditioning and education are critical for this condition - the recurrence of bursitis pain is common in people who have not obtained satisfactory muscle function with their physical therapy efforts. Tablets and injections for bursitis are used only to assist with physiotherapy efforts - a short course of anti-inflammatory tablets and intermittent corticosteroid injections can be used to provide temporary relief while physiotherapy progresses. Other types of injectable therapies have been described (for example PRP - platelet-rich plasma) and are generally reserved for patients who fail to settle with standard therapies. Non-operative treatments are effective for the majority of patients with trochanteric bursitis, however, the recovery is often slow, taking several months. Patience and persistence are required.
Surgery is usually only considered after other treatments have been conducted properly. Surgery is a safe method of treating trochanteric bursitis and in most cases can be undertaken arthoscopically (key hole surgery). Surgery however is not effective in all people. The tight band of tissue on the side of the hip (iliotibial band) is decompressed and the inflammed bursa removed. Where necessary, repair of a torn or degenerate abductor tendon may also be conducted. As the surgery is often performed by arthroscopic methods, recovery is relatively quick and only an overnight hospital stay is required, however sustained physiotherapy afterwards is still required to achieve good results.
Perthes Disease
Trochanteric bursitis is inflammation of a lubricating membrane (bursa) located on the side of the hip. The condition is commonly associated with inflammation & weakness of the tendons attaching at the side of the hip and pelvis region (gluteal tendinopathy). Often the terms "Trochanteric Bursitis" and "Gluteal Tendinopathy" are used interchangeably as most people have elements of both conditions.
While some conditions may predispose to the development of trochanteric bursitis (rheumatoid arthritis, hip joint disorders, tight iliotibial band), most people who develop trochanteric bursitis have no clear precipitating factor apart from deconditioning of the deep "core" postural muscles surrounding the joint. A very significant factor influencing the generation of gluteal tendinitis or trochanteric bursitis in the majority of people relates to factors such as posture, habit and physical conditioning that can be treated by physical therapy and activity modification.
Trochanteric bursitis can affect people of all ages and activity levels but is more common in middle-aged females. Occasionally the condition is observed in association with trauma or surgery around the hip region. In association with trochanteric bursitis, some people may develop degenerative changes or a tear in the adjacent supportive hip tendons.
This depends on many factors, however the age of the child is perhaps the most important predictor of outcome. Generally, the older the child is when first diagnosed with Perthes disease, the worse the outcome.
This is a difficult question to answer as there are many (often quite conflicting) opinions regarding the best management of Perthes disease in children. Generally speaking, young children developing Perthes have a good chance of having excellent outcomes with observation alone. In older children and adolescents, surgery is sometimes recommended to help assist the joint develop a normal round shape. For younger patients with Perthes disease, I generally recommend referral to a Paediatric Orthopaedic Surgeon for evaluation.
The long term outcome of the hip after Perthes diease depends mostly on the degree of deformity remaining in the joint at the end of skeletal growth (around age 16-18 years). Hip joints with significant irregularity in shape are predisposed to early onset osteoarthritis. Severe deformity due to Perthes disease typically includes a flattened femoral head (ball of the hip joint) and characteristic changes of the upper thigh bone resulting in a stiff hip and short leg.
This depends on the presenting symptoms, shape of the hip joint and how much damage has accumulated within the joint surfaces. Many patients can improve their symptoms without surgery, however as the deformities within the hip are permanent, once the joint has become painful continued slow progression can be predicted. In patients with pain relating to early damage to the hip, joint preserving procedures such as hip arthroscopy (key hole surgery) can reliably improve symptoms, however the underlying hip joint deformities resulting from Perthes cannot usually be corrected with arthroscopy alone. In younger adults with more significant deformity of the hip joint due to previous Perthes disease, a Femoral Osteotomy may be recommended to improve function of the joint, decrease pain and restore leg length. Open Debridement can also be used to reshape the joint. Pelvic osteotomy may also be recommended if the hip joint socket is abnormally shallow as a result of Perthes disease. Ultimately, hip joints with end stage arthritis secondary to Perthes are best treated with an artificial joint replacement. In these situations, both hip replacement and hip resurfacing are effective solutions.
This depends on the presenting symptoms, shape of the hip joint and how much damage has accumulated within the joint surfaces. Many patients can improve their symptoms without surgery, however as the deformities within the hip are permanent, once the joint has become painful continued slow progression can be predicted. In patients with pain relating to early damage to the hip, joint preserving procedures such as hip arthroscopy (key hole surgery) can reliably improve symptoms, however the underlying hip joint deformities resulting from Perthes cannot usually be corrected with arthroscopy alone. In younger adults with more significant deformity of the hip joint due to previous Perthes disease, a Femoral Osteotomy may be recommended to improve function of the joint, decrease pain and restore leg length. Open Debridement can also be used to reshape the joint. Pelvic osteotomy may also be recommended if the hip joint socket is abnormally shallow as a result of Perthes disease. Ultimately, hip joints with end stage arthritis secondary to Perthes are best treated with an artificial joint replacement. In these situations, both hip replacement and hip resurfacing are effective solutions.
Revision Hip Replacement
Total Hip Replacement (THR) involves replacing the damaged and worn hip with an artificial joint (prosthesis). Hip replacements may be manufactured using a combination of materials, including metals, ceramics, wear-resistant polyethylenes and acrylic polymer cement. My recommendations for the type of hip replacement device used and the surgical technique employed for the conduct of your procedure are made after an assessment of your specific requirements.
For people with hip arthritis, joint replacement is an effective and reliable method of providing exceptional pain relief. Hip replacements are very durable, with bearing highly wear-resistant surfaces. The chance of a hip replacement failing before 10 years is less than 5%. Many hip replacement devices last longer than 20 years in greater than 80% of patients.
Hip replacement may be performed using general anaesthetic (put to sleep), regional anaesthetic (epidural or spinal nerve blocks), or a combination of these techniques. Most patients under my care receive a general anaesthetic together with a combination of techniques using long-acting local anaesthetics introduced directly into the wound. Typically these techniques provide good pain relief, allowing patients to walk within 4-6 hours of their procedure.
Choosing an implant is a little like choosing a motor vehicle - there are many hundreds of different models to choose from. Not all people wth osteoarthritis have the same requirements in terms of joint replacement design. The decision regarding what type of joint replacement is best suited to your needs is determined by many factors, including bone anatomy (shape/ size/ density), anticipated activity levels (nature/ volume), the pattern of arthritis wear and your age. In my opinion, selection of the type of hip replacement used should not be a "one size fits all" approach. Prosthesis implant selection is an individualised decision that takes into consideration the specific requirements of the person being treated.
At the time of booking your procedure, I will recommend a preferred implant design to best suit your requirements. When conducting your hip replacement, a large selection of different implants of the chosen design are made available (Figure 1). The multiple options of size, shape and other features within any one implant design allow the construction of literally thousands of combinations to individually enable accurate restoration of leg length, muscle tension, dislocation resistance and joint mechanics.
Typically you are permitted to place your whole body weight onto the hip and walk with assistance within 4-6 hours of your operation. Physiotherapy will be conducted twice daily while in hospital. Prior to discharge, you will be given ample instruction and practice on how to best perform daily functional activities (for example stair climbing and getting into the passenger seat of a car) (Figure 2). Hospital stay is usually 2-3 nights.
Crutches are recommended for comfort for 2 weeks after the procedure and can be discarded when you are confident. Many people like to use a single crutch or cane in the opposite hand for a few weeks longer. Depending on your occupation, you will require 2-6 weeks off work. You can be driven in a car as a passenger immediately on discharge from hospital. Patients managed by anterior approach techniques can drive a car when they feel confident, but no earlier than 2 weeks after their procedure (4 weeks for posterior approach procedures).
Aeroplane travel of less than 6 hours in duration can be undertaken immediately. For regional or interstate patients I recommend staying 1-2 nights longer in hospital (or alternatively staying in a hotel in Brisbane) prior to flying back home. Many patients leave for the airport directly from hospital.
Generally, people who are better prepared for surgery have a lower risk of developing complications and enjoy an easier recovery process. There are many ways in which a patient can better prepare themselves for surgery. The following is a short list of the common recommendations I make in preparation for undertaking surgery (but by no means exhaustive):
- Make an appointment with your physiotherapist for a pre-surgery exercise program ("pre-hab")
- Ask your physiotherapist to show you how to use crutches over stairs
- Reduce of quit smoking (even just for a short time makes a difference)
- Weight loss (consider professional assistance from your GP or weight management centre)
- Well-balanced diet with a reduction in alcohol consumption
- Wash in Phisohex 1% (or chlorhexidine) for 5 days prior to surgery
I typically recommend you continue all your usual medications, with the exception of blood thinning agents or medications that may increase the risk of clot formation (DVT). Please note that many over-the-counter (non-prescription) and complementary/ herbal preparations may also cause strong blood thinning effects. If you have any questions about any particular medication or preparation, please contact the clinic. The following is a list of medications that should usually be ceased before surgery (but not exhaustive):
Warfarin (contact office for instructions)
Plavix/ CoPlavix (contact office for instructions)
Xarelto (contact office for instructions)
Fish Oil/ Omega 3 (cease 3 weeks prior)
Supplements - Ginko, Ginseng, Garlic (cease 3 weeks prior)
Hormone Replacement Therapy (HRT) (cease 3 weeks prior)
Oral Contraceptive Pill (OCP) (cease 3 weeks prior)
Please note: Aspirin 100mg tablets, taken on advice from your doctor, for the management of a known heart condition or after stroke SHOULD BE CONTINUED.
For people who require greater than 2-3 nights of hospital admission, a rehabilitation unit admission at St Andrew's War Memorial Hospital. Alteratively a rehabilitation unit closer to your home can be arranged with advance notice. Most people do not require rehabilitation unit services, but they can be easily arranged if required.
Hip replacement surgery is very safe, and serious complications are uncommon. Serious wound infection occurs in less than 1%. Dislocation occurs in less than 1% of people managed by direct anterior approach hip replacement (3% for posterior approach). Clots can form in the veins of the leg (deep venous thrombosis 'DVT'), which on rare occasions may dislodge and travel to the lungs causing breathing difficulty. Many patients with hip arthritis have a short leg on the affected side, which is corrected during surgery. Occasionally it is not possible to make the leg lengths equal, particularly if a very large length discrepancy is present before surgery. I will discuss the risks of the procedure with you in detail before the operation.
Once you have recovered, there are very few restrictions on activity after hip joint replacement. Impact pursuits such as running cannot be performed for 6 months after surgery. Activities such as walking, cycling, skiing, tennis & tennis may be conducted without limitation. Your suitability for returning to running activities depends on the nature and volume of the sport you are undertaking and the type of prosthetic implant selected. Some activities may place the joint replacement at risk (for example extremes of joint flexion and rotation in some advanced yoga postures) - if you are unsure please check with us before re-commencing
I usually recommend lifetime surveillance of your hip joint replacement is conducted by intermittent X-ray evaluation and clinical review. A standard surveillance program typically involves clinical assessment every 5 years.
Hip replacement
Revision hip replacement is a 're-do' or 'second' artificial hip replacement, performed because of failure of the previous hip replacement procedure for any reason.
The most common reason for requiring revision of a hip replacement is the gradual loosening of the grip between the bone and the prosthetic implants. This is a condition known as "Aseptic Loosening". Aseptic loosening usually occurs slowly over many years, with the artificial hip joint becoming increasingly painful over time. Typically the bone adjacent to the implant will have erosions due to the effect of wear debris. As hip replacement technology is constantly improving, with more durable bearing materials and better fixation methods, aseptic loosening is becoming less common and occurring much later stage after the original operation.
Other reasons for requiring a revision hip replacement include infection, dislocation or fracture of the bone surrounding the implants. Implant material failures such as metal stem or ceramic bearing fractures are exceedingly rare.
Revision hip replacement procedures are very variable, as the nature of the operation depends on the problem causing the failure of the original implant.
In general, revision hip replacements are technically more demanding than 'first-time' replacements and are associated with a higher risk of complications and longer recovery times. Revision hip replacement often involves the removal of failed implant(s) and insertion of new prosthetic components. Not all implants necessarily require removal - some portions may be retained if the strength of bone contact is maintained and no wearing of the retained components is observed. In addition, as a result of the gradual loosening process over time, bone quality may be compromised and bone grafting may be required. Typically an artificial bone graft or donor bone is obtained for use in these situations.
For infection of a hip replacement, a 'two-stage' revision may be recommended. This is where the old implants are removed and the final implants are inserted in a second procedure only after the infection has been definitively eradicated.
As revision hip replacements are technically demanding, not all surgeons perform these procedures. In these situations, surgeons will often refer for ongoing care by a colleague who performs these procedures on a more frequent basis. If you have been asked to see A/Prof Weinrauch for this reason, it does not indicate that your original surgeon is uninterested in your care - in fact, quite the opposite !.
Before undertaking revision hip replacement, I will discuss the recommended procedure with you in detail.