The hip is the joint that connects the pelvis to the thigh. It supports body weight and helps walking.
What are the parts of the hip joint?
The femur is the bone located inside the thigh. In the hip joint, the upper part of the femur (femoral head), is articulated into a pelvic cavity called the acetabulum.
The two surfaces of the joint, which are tangent, are covered by a relatively soft tissue, called cartilage, which allows them to slide together, easily and painlessly. The joint is stabilized by a sac (synovial sac), surrounded by a fluid (synovial fluid), which serves as a lubricant, facilitating movement, just like a lubricant in a machine’s gears.
Around the joint there are several muscles and tendons that connect them to the bones. The muscles move the hip and knee. These muscles are especially strong as they help balance the body and walking. They need to work together perfectly for the person to be able to walk normally.
When treatment is required?
The soft surface (cartilage), which covers the bones in your hip joint, can be worn. In the medical language, we are talking about hip arthritis. Because of cartilage wear, bone areas come into direct contact. The bone surfaces are roughened and friction is caused when the joint is moving.
The sliding of the femoral head into the acetabulum becomes difficult. Gradually, the bone is deformed. Bone protrusions (osteophytes) are created, which further limit the mobility of the joint. The development of arthritis is unpredictable: it can be confined to one area of the joint and spread gradually or it may affect the entire sliding surface within a few months. The causes of arthritis are varied: age, increased weight, a fall, problems in joint structure, susceptibility due to heredity, certain diseases (inflammatory diseases), etc.
What are the symptoms?
Your hip is in pain. The pain usually is located on the groin area, on the lateral side of the body and can sometimes be reflected on the knee. The joint becomes stiff, making your movements difficult. The discomfort can get worse to the point that it prevents you from walking. With the development of arthritis, the muscles that move your joints are weakened, because they do not function properly. You are not walking normally, which often causes problems in the knee, spine, other hip, etc.
What exams do I need?
To determine the seriousness of your condition, your doctor will rely on evidence such as:
- the frequency of taking medication to relieve pain,
- the difficulty in walking, its deteriorating progress or the need to walk with the use of a walking cane,
- the distance you can travel without aching, the difficulty in putting your shoes on on,
- the difficulties you face in your daily and social life, etc.
Radiology is the technique that uses X-rays to examine the bones inside the body. But it cannot be used to assess the status of the articular cartilage. The significant decrease in the “gap” between the femoral head and the cavity of the pelvis in which it is articulated indicates that the thickness of the cartilage between the bones decreases.
Radiographs show progressive bone deformities and the appearance of small protrusions (osteophytes).
Sometimes, more sophisticated techniques, such as computed tomography and magnetic resonance imaging, are needed to allow us to better assess the condition of the cartilage and muscles.
Medications allow to relief joint pain and irritation (inflammation). Some new medicines (chondroprotective drugs) protect the cartilage and delay the development of arthritis. Physiotherapy is recommended to address inflammation, maintain flexibility of the joint and strengthen your muscles.
The effectiveness of chondrocytes is great at the onset of the disease. Their results appear to be decreasing subsequently. Medicines and physiotherapy temporarily relieve the patient, but do not prevent the development of arthritis.
When do I need surgery?
If the results of conservative treatment are not satisfactory, your doctor will recommend surgery. After a certain level of pain and stiffness, your nerves require surgery. This stage varies depending on the condition of each patient. Talking to your doctor, who will assess your age, your health, your lifestyle and other parameters will help you make that decision.
If cartilage damage is relatively limited, the surgeon may decide to maintain the joint. The surgeon cuts the bone and relocates it so that the degenerated parts of the bone are not strained (osteotomy). On the contrary, when the surfaces are irreparably damaged, the surgeon removes the damaged areas and replaces them with artificial parts (implants), which ensure the smooth operation of the joint. This procedure, presented here, is called total hip arthroplasty.
None of the above treatments are ideal.
Conservative treatment, although significantly delaying arthritis, does not prevent it from developing. Many years after an osteotomy, prosthesis may be required. The implants can wear out, reduce the joint’s stability and need replacement.
What are the risks without treatment?
Without treatment, joint pain and stiffness worsen. Difficulties in your movements increase and can even make walking impossible. It is a serious problem, especially for the elderly, who lose the ability to self-serve (autonomy). Hip dysfunction can sometimes affect the function of the other hip, knee, back, etc. If other joints are damaged, the condition becomes complicated (progressive arthritis). In any case, your physician is responsible for assessing the risks of lack of treatment. Feel free to talk to your doctor.
The total hip replacement suggested by the orthopedist
The surgeon suggests replacing the worn areas of your joint with artificial parts (implants). In the medical language, this is called total hip arthroplasty.
It makes sense that good fitness contributes to a successful outcome. For this, you are advised to lose weight, if necessary, and maintain flexibility and strength of your muscles and joints with appropriate exercises, following medical advice. You should resolve any blood circulation problem (varicose veins), before scheduling a total hip arthroplasty. Otherwise, there is a risk that the veins may clog (deep vein thrombosis). To reduce the risk of microbes being introduced into the operated area (infection), any existing infection (skin, teeth, etc.) should be excluded. Before surgery, contact your anesthesiologist, who will recommend the appropriate anesthesia method for you and give you instructions to follow.
During the procedure, either you are completely asleep (general anesthesia) or your lower body is numbed by an injection in the epidural space of your spine (epidural anesthesia).
The operation is performed in an operating room, subject to strict hygiene and safety rules. Hygiene rules are very important in bone surgery, so the medical team takes special precautions. In most cases, you lie on your back or sideways. The position, however, may vary depending on the technique your surgeon applies. There are various techniques that your surgeon is called upon to choose, depending on your case and the practices he or she employs. During surgery, the surgeon needs to adjust and possibly perform additional actions that lengthen the surgical operation without, however, making it more difficult or dangerous.
The surgical procedure
Usually, the surgeon makes an incision on the lateral surface of the hip. The size of the incision varies depending on the technique (about 10 to 20 cm). The joint is deep and the surgeon needs to have perfect eye contact to intervene. After incision on the skin, the surgeon removes and / or detaches the muscles and tendons. Then, the synovial sac, which surrounds the joint, is opened. This procedure is very accurate and minimizes the risk of damage to nerves, blood vessels or muscles.
The basic operation
The surgeon cuts, according to previous calculations, the upper part of the femur (femoral head) with the damaged cartilage and removes it. With special tools, he then creates a tunnel inside the thigh to place the first part of the prosthesis. If the cavity in the pelvis (acetabulum) is severely damaged by arthritis, the surgeon also prepares the bone, by removing the cartilage with special tools of various sizes. The bone must be adjusted perfectly to the parts of the prosthesis. For this reason, the surgeon tests various implants. This ensures that they are held in the bone, in the proper direction, so that the risk of dislocation, etc. is minimized. He then places the final implant and fastens it. If only the femoral head is replaced, the prosthetic part consists of a stem, which is inserted into the femur. The strain is attached to a spherical part (head of the prosthesis).
In medical language, we are talking about femoral head implant.
When all parts need to be replaced (total hip arthroplasty), the surgeon adds a cup-shaped prosthetic part (the “cup”), secured to the acetabulum. The fixing is done with or without the use of special cement, without affecting the result. The choice of method depends on the type of prosthesis, the quality of your bones, your age, etc. Then the surgeon joins the two parts of the prosthesis and ensures that they are firmly held in all positions. Finally, he puts back in place all the elements surrounding the joint (synovial sac, muscles, etc.).
Is there a need for blood transfusion?
It is normal to have bleeding during surgery. Blood loss can be compensated:
- either by donated blood (standard blood transfusion),
- or by your blood, collected before surgery and then re-administered, to make up for the loss (autologous transfusion),
- or by collecting blood that is lost during surgery and re-administered after a cleansing process (self-transfusion system).
Combined surgical interventions
Your surgeon may take additional steps to improve the function of the prosthesis and minimize the risk of dislocation.
It is normal for the operated area to produce liquids (blood, etc.). If necessary, your surgeon will insert a thin tube (drainage system) to drain the fluids after surgery. In order to close the incision, your doctor uses stitches, clips or some other suturing system that is fixed or gradually absorbed by the body (absorbable material). The final form of scarring depends on the condition of your skin, the forces it bears or your exposure to the sun, which should be avoided after surgery.
The duration of surgery
The duration of surgery varies; however, its prolonged duration does not imply any complication, as it depends on several factors (method, number of combinations, etc.). Usually, it takes from 1 to 2 hours. You also need to consider preparation time, recovery time, etc.
Every patient perceives pain differently. It can be intense during the first two to three days. However, it is controlled with appropriate treatment. It is likely the first times you get up and start walking, to experience pain, because the joint is stressed. If the pain is severe, however, do not hesitate to talk to your treating physician. There is always a solution.
The problem of arthritis was addressed. The prosthetic head is fitted in the acetabulum (in the case of femoral head prosthesis) or in the prosthetic cup (in total hip arthroplasty) and functions like the normal joint.
Usually, you can get out of bed the next day, but you need to remain seated. You can start walking right away, in most cases, but you have to wait two to three days for the doctor to remove the drainage system, change gauzes, etc. You may walk with the help of a walking stroller.
Painkillers will be administered to reduce pain, as well as medication to make the blood more fluid, which prevents the formation of blood clots in the veins of the lower extremity (venous thrombosis). You may also use special bandages or socks to aid blood circulation (venous stasis). You should have regular blood tests. The fluid drainage system is usually removed within the next two days and the sutures or clips after about ten to twenty days. The exercises for restoring your joint movements (physiotherapy) usually begin the next day of surgery and last for several months.
It depends on the hospital in which you are hospitalized and mainly on your situation and your overall health status. Generally, you return home after about five to ten days. You may also be admitted to a physiotherapy center for three weeks or more (up to six weeks).
You must strictly follow your doctor’s instructions. It is important to be consistent in your post-surgery visits to the doctor and to undergo screening tests (e.g. X-rays) if necessary. In this way, the surgeon monitors the healing progress of the hip and adjusts the physiotherapy accordingly. You usually visit your doctor after three months, then six months, one year and after several years (three, five, seven years), to check the stability of the bone prosthesis.
The pain associated with arthritis recedes immediately after surgery. However, if you have to exert stress on your joint in the weeks following surgery, painkillers may be helpful. The scar of the incision, muscles and tendons can cause slight pain for some months (post-operative pain).
The replacement of painful – due to friction – areas allows the joint to function smoothly. You can soon walk again. The effect of surgery is often impressing. At best, you forget that the prosthetic joint is there at all! You must, however, avoid specific movements that increase the risk of dislocation.
A rest period of two to three months is recommended. You can quickly get back to your daily activities, avoiding heavy movement (usually approximately ten days later). Your movements must be carefully handled, especially when climbing or descending stairs. You may need to adjust the conditions in your home (carpet care, bathroom handles, etc.). Returning to your professional activities takes place six weeks to four months after surgery, once your hip is firm and does not trigger pain. However, it depends on your profession. In some cases, you need to adjust your business activities accordingly. Protect your hip.
Adapt your activities; avoid violent sports and strenuous work, so you can reap the benefits of the intervention for longer. Do not hesitate to ask your surgeon for any questions you may have about the dangers of any activity.
Treatment to prevent deep venous thrombosis (anticoagulants) takes several weeks. Your surgeon will judge when treatment is no longer necessary. Physiotherapy under the guidance of a specialist (physiotherapist) takes several months, until the result is satisfactory. The program of physiotherapy (at a physiotherapy center, home, etc.) varies, depending on your case, the type of intent and the procedure your surgeon follows.
The medical team takes all the necessary precautions to limit complications, but problems can always arise. We mention here only the most common or the most serious among those that this operation may present. For the usual risks of each procedure, look for the leaflet “The Risks of Surgery”. The risks associated with anesthesia are listed in the relevant form.
Blood vessels and nerves, located near the joint, can be injured during surgery (especially if there is any sensitivity) resulting in:
- significant blood loss (bleeding), or formation of blood clots (hematoma),
- risk of paralysis or loss of sensation in some parts of the lower extremity, if nerve injury is not restored.
Fortunately, this case is extremely rare and your surgeon is experienced in techniques to assist in your recovery. In the preparation of the pelvic cavity (acetabulum), in which the femoral head is fitted, injury to adjacent blood vessels can also occur. It is rare, but in this case, an abdominal incision has to be made to stop bleeding. If you need blood transfusions, there is always the fear of transmitting certain diseases (AIDS, Hepatitis). Don’t worry, as all products used are subject to strict examinations to avoid this risk.
The acetabulum and femoral bone can be broken (fracture). So they need to be restored.
If your bones are particularly fragile, if you suffer from osteoporosis (bone disease), or if you are elderly, there is, in theory, an increased risk of fracture during or after surgery. Your surgeon, however, adapts his technique to the condition of your bones to reduce this risk.
Infection of the treated area by bacteria is extremely rare, but is a serious complication and sometimes requires the removal of the prosthesis. In some cases it is impossible to replace the prosthetic parts. The infection can cause stiff joints, or can reach the bone and become permanent (chronic infection). Fortunately, this case is extremely rare. To avoid this risk, you should not be ill (carrier of infectious bacteria) before, during or after surgery, because they usually end up infecting the implant, even after many years. A minor tooth problem, a skin infection, etc., can be a significant risk. For this reason, a few days of preventive antibiotic treatment is necessary.
Consult your doctor for any questions or doubts you have. The risk of developing blood clots (thrombosis) in the veins of the lower limb (thrombophlebitis) or in the lungs (pulmonary embolism) is significant. For this reason, your doctor will usually take the necessary precautions (anticoagulants, special socks, etc.).
Some people have a poor blood circulation system, which increases this risk. The stitches in areas set to the muscles, tendons or other elements that the surgeon has intervened on can break. If the materials placed move after surgery, they may injure blood vessels, nerves, or other articular components. The two legs may be uneven after surgery. The surgeon tries to prevent this problem with similar manipulations, but it is not always possible. In some cases (e.g. when the pelvic structure is unusual or the muscles surrounding the joint are relaxed and deficient), this difference between the legs is necessary. Sometimes, a new bone is created in the joint (ossification), which restricts hip movements. Especially in the first months, the two parts of the prosthesis can be dislocated. For this reason, the patient learns to avoid specific movements.
The prosthesis can break, injuring the bone or not. This case, however, is extremely rare. Over time and irrespective of how it is fixed, the prosthesis may lose its stability in the bone (relaxation). This causes new pain and difficulties in movements. Sometimes, the materials of the prosthesis need to be replaced. Some of these complications require additional actions or a new intervention. Do not worry. Your surgeon is well aware of these problems and will act accordingly to prevent them. Depending on your state of health, you are more or less exposed to some of these risks.
If you observe anything abnormal post-operatively, such as pain, discoloration, a strange sensation, etc. do not hesitate to speak with your surgeon, even if your discomfort seems minor. He is responsible for helping you, as he knows exactly your situation. If you are injured (fall, accident, dislocation, etc.) and are transferred to the emergency room, inform the medical team that you have had hip arthroplasty. You may need to have a radiograph to re-examine your hip prostheses. Ideally, your surgeon should examine you as soon as possible as he/she should evaluate the results of the X-ray.
Patients feel that their lives are changing as they quickly return to activities they abstained from, due to pain and arthritis.
It is a common surgical operation, but it does include some risks that you need to consider before deciding to proceed.