Osteoarthritis of the Hip and Hip Replacement Surgery

What is osteoarthritis of the hip?

The hip joint is a large ball- and socket joint, consisting of the top of the femur (thigh bone) and the socket (acetabulum) of the pelvis bone. A normal hip joint has smooth cartilage surfaces allowing pain-free range of motion. When the joint is diseased or damaged, the bone under the cartilage becomes exposed. This leads to arthritis, causing pain, stiffness, and limping.

Common causes of hip arthritis are:

  • Osteoarthritis is the most common form, because of age-related wear and tear.
  • Inflammatory arthritis like rheumatoid arthritis causing inflammation in the lining of the joint and eventual joint damage.
  • Avascular necrosis where blood supply to the hip becomes interrupted, leading to death of the femoral head with collapse, can be caused by dislocation of the hip, chronic cortisone use or chronic alcohol abuse.
  • Post-traumatic or injury related arthritis after motor vehicle accidents, sport injuries etc.
  • Congenital conditions where the socket does not develop fully, called hip dysplasia – this leads to early onset arthritis.

How is hip arthritis diagnosed?

Symptoms of hip arthritis include:

Pain: Pain in and around the hip as well as groin pain is common. Pain may radiate to the knee. Pain after activities like walking. Pain gets worse with time and eventually you can have pain at rest.

Night pain: Pain laying on your hip and night pain is very common.

Stiffness: It is common to lose range of motion in hip arthritis. You might have difficulty putting on your shoes and socks or clipping your toenails.

Weakness: You might have trouble lifting your leg up when getting into a car.

A complete history and physical examination will be done – this includes assessing range of motion, leg length measurement, strength test, and neurovascular examination of the leg.

You might need to have further tests done to confirm the arthritis.

These tests may include:

  • X-ray of the hip.
  • CT (Computed tomography) scan.
  • Magnetic resonance imaging (MRI) of the hip.

 

Treatment of Hip Arthritis:

Treatment of hip arthritis depends on the type of arthritis, the stage of the arthritis, the severity of the pain as well as your age.

Treatment for early osteoarthritis consists of the following:

  • Range of motion exercises to keep the hip as mobile and as flexible as possible. These are low impact exercises like hydrotherapy, swimming and cycling. A physiotherapist may help you with this in the early stages.
  • Modification of activities – this is to try and avoid activities that cause pain and discomfort in your hip. This might be something like, reducing the number of times you play sport, like tennis or golf.
  • Cold and heat packs. Cold is normally very good after activities and heat packs can be used before exercises.
  • Weight loss.
  • Medication to treat arthritis may help but they do have potential complications. Oftentimes initial treatment will be with paracetamol. You might also benefit from anti-inflammatory medication. This should be used with caution and only when needed.
  • Injection of cortisone. This is normally done with ultrasound control and in combination with a local anaesthetic. This can help to reduce inflammation and pain in the hip for some time. Cortisone injections can increase the risk of infection with total hip replacements and should be avoided for about 6 months before surgery.
  • Injection of hyaluronic acid: It is also called viscosupplementation. It is the injection of synthetic joint fluid that can give pain relief for a period. It has been used in arthritis treatment for a long time.
  • Walking aids like a wheelie walker, cane, or walking frame.

 

Surgery to treat arthritis of the hip is normally indicated when the treatments above fail, and your quality of life starts to suffer because of the arthritis.

This includes:

  • Difficulty to do simple daily tasks like getting dressed or climbing stairs and walking.
  • Inability to get a good night’s rest because of night pain and interruption of sleep.
  • Inability to participate in activities that you enjoy for instance playing sports, e.g., gholf, tennis, running, etc.

 

The decision to proceed with hip replacement surgery should be taken only after discussion of the procedure with your surgeon. Once you have all the relevant information, you can make an informed decision about proceeding with your hip replacement.

Types of Surgery:

The type of surgery depends on the severity of the arthritis as well as the age of the patient.

Hip Arthroscopy:

With this type of surgery, a small camera is placed inside the hip joint and instruments placed through small incisions to clean out or debride the joint. This type of surgery is normally done in patients with very early arthritis. Although this gives pain relief for some time, the surgery is not a permanent solution and not a procedure done by Dr. Pretorius.

Total Hip Replacement:

A total hip replacement is a major surgical procedure. During this procedure the damaged joint is replaced a by an artificial (prosthetic) joint. During a total hip replacement, both the ball (femur head) and the socket (acetabulum) are replaced with a prosthetic joint. This may be fixed with cement (in poor quality bone) of without cement (tight fitting prosthesis that are textured for bone to grow onto)

Approach: 3 common approaches are used to replace the hip joint:

  • Anterior Approach: From the front – Dr. Pretorius’ preference.
  • Lateral Approach: From the side – can cause limping.

  • Posterior Approach: From the back – most used approach but it has a slightly higher dislocation rate.

The approach used will be discussed with you. Not every approach is suitable for everybody, and this will depend on your age, body mass index and hip anatomy.

General risks of surgery:

  • General anaesthetic is given in addition to a spinal block, where a needle is placed in your back after a local anaesthetic injection. This will numb the area below your waist. Unexpected death from an anaesthetic is very rare.
  • Antibiotics are routinely used during surgery to prevent infection – some patients may have an allergic reaction or anaphylaxis.
  • Often a catheter is inserted to drain your bladder, that can increase the risk of a bladder or urinary tract infection.
  • Wound infection.
  • Bleeding in the wound with formation of a haematoma (big collection of blood).
  • Pain / numbness around the incision.
  • Allergies to antiseptic solutions used to clean the surgical site.
  • Allergies to sutures and / or dressings.
  • Deep vein thrombosis – there is always a risk of DVT with surgery of the lower limb.
  • Nausea and vomiting after surgery.

Specific Risks with Hip Replacement Surgery:

  • Infection in the hip joint that can either happen right after operation or later on, if an infection causes bacteria in your blood. Please check before having dental- or other surgery.
  • Injury to nerves – very rare. With the anterior approach the nerve that supply feeling to the outer thigh may be damaged. This will normally recover over time.
  • Injury to blood vessels.
  • Blot clots in legs (as mentioned previously) and sometimes in lungs.
  • Constipation from pain medication.
  • Fractures of the femur or pelvis.
  • Dislocation of the hip – about 2 – 3%, especially early after surgery.
  • Difference in leg lengths – the leg on the arthritic side is normally slightly shorter. When doing the hip replacement every attempt is made to get leg lengths equal. If the hip is not stable (dislocating) on the table, the leg must be lengthened to make it stable.
  • Ongoing swelling in the leg.
  • Ongoing pain and stiffness.
  • Loosening of the prosthesis (bone / cement) or failure of bone to grow onto the prosthesis. Loosening happens gradually over time and is more likely towards the end of the hip replacement’s ‘lifespan’ (20 – 25 years).
  • Bone formation in the soft tissue around the hip – this is called heterotrophic ossification and can lead to significant stiffness

Recovery after Total Hip Replacement:

Following your total hip replacement, you will wake up in the recovery room. The nurses in the recovery room will monitor your recovery by regularly checking your vital signs (pulse, blood pressure, oxygen levels, etc.), consciousness- and pain levels.

Once you get to the ward, an ice pack may be applied to your hip to help for pain and swelling.

Once the spinal anaesthetic has worn off, a physiotherapist will get you to stand up next to the bed. This might happen on the same day as your surgery depending on what time your operation finished. You will be encouraged to start mobilising as much as possible.

If an indwelling catheter has been inserted into the bladder, this will be removed the next day.

As soon as you can demonstrate that you are able to walk with crutches and able to climb stairs, you will be able to go home. This is normally between 3 – 4 days after surgery.

Some elderly patients might have trouble going straight home, especially if they live alone. Arrangements can be made for a transfer to a rehabilitation unit after surgery, if this is covered by their health fund.

When you get home, you will need to continue with elevation of the leg, application of ice packs for 30 minutes 4 – 6 times a day. You will need to continue to use 2 crutches for about 4 weeks and then one crutch for 2 weeks. (Use one crutch in opposite hand). You will be discharged home with strong pain medication. Try to use stronger pain medication only if the more regular pain medication like paracetamol, is not effective.

It is important to keep the surgical area clean and dry and to keep the wound dressings intact.

You will be supplied with a follow-up date for the removal of sutures and a wound review.

A physiotherapist will see you in hospital and will supply you with some initial exercises. It is important for you to book an appointment with a physiotherapist of your choice, to continue with your rehabilitation in the months following your surgery.

During recovery, it is important to follow the advice below, especially in the first 6 weeks:

  • With the anterior approach (incision in front), avoid turning away from the operated hip. Always turn towards the replaced hip.
  • Avoid sitting on low chairs.
  • Try not to cross your legs.
  • Use an elevated toilet seat.
  • Please use nonslip socks.
  • Use slippers or slip-on shoes and avoid having to tie your own shoelaces.
  • It is important to avoid falls: Stairs and the bathroom are especially hazardous places.
  • Driving an automatic light vehicle is allowed after 2 weeks with a left hip replacement and 6 weeks with a right hip replacement.

Recovery after surgery is different for every patient. The rehabilitation process is as important as the surgery. Your motivation and effort are really important to ensure an effective recovery and a satisfactory outcome.

Please contact the surgery immediately if you have any of the following:

  • Any redness, swelling, bleeding or drainage from your incision site.
  • Any fever or chills.
  • Any increase in pain around the incision site.
  • Any pain in your calve or thigh with increased swelling in the leg.
  • Loss of movement or change in leg lengths.
  • Any other concerns you may have.

 

Please find links to some useful information regarding hip osteoarthritis and hip replacement surgery:

 

Total Hip Replacement