What is Hip Replacement? A Review of Total Hip Arthroplasty, Hip Resurfacing, and Minimally-Invasive Hip Surgery.
Edited By: Seth S. Leopold, M.D.
Last updated Friday, January 12, 2007
Figure 3 - If you have ever eaten a drumstick, you have seen cartilage; it is the white (or slightly yellow) smooth surface capping the end of the bone. Figure 4 - This is a normal X-ray of the hip; the black line between the ball and socket parts of the joint is the normal cartilage, which is "see through" on an X-ray. Figure 5 - Joint with normal hip cartilage Figure 6 - Joint with arthritic hip cartilage Figure 7 - Hip pain in the lower back and/or buttocks area is often from spinal stenosis (spine arthritis), rather than from the hip joint itself. Figure 8 - Hip pain over the outside of the hip is often from bursitis, which not related to arthritis of the joint at all. Review of the conditionWhat are some general characteristics of hip arthritis? What are its usual manifestations? Arthritis simply means “inflammation of a joint,” and itself is a
very general term. Many of the more than 100 different conditions that
cause joint inflammation also go on to cause permanent destruction of
the weight-bearing surface of the hip, which is called cartilage.
If you have ever eaten a drumstick, you have seen cartilage: it is
the white (or slightly yellow) smooth surface capping the end of the
bone (see figures 3 and 4). The surface of normal human cartilage is
much more slippery than a hockey puck sliding on ice.
In contrast, arthritic cartilage may be cracked, thinned, or worn
completely through to the bone. (see figures 5 and 6). If a doctor has
told you that you have “bone-on-bone,” he or she means that the
cartilage has completely worn away. Damaged cartilage (and certainly a
bone-on-bone situation) does not glide well. As a result, a severely
arthritic joint may be stiff, and it may feel like it grinds, catches
or locks with attempts at motion.
However, the main symptom most people with hip arthritis have is
pain. The pain typically is worse with activities or weight-bearing,
and is sometimes relieved by rest.
About 80 percent of patients with hip arthritis will have some pain
in the groin or the front of the thigh; other typical pain patterns
include pain in the back of the thigh, the side of the thigh, or the
buttock. Sometimes, with hip arthritis doesn’t cause hip pain at all
because the symptoms show up as knee pain. Some patients with hip
arthritis limp while walking, sometimes with a “lurching” gait towards
the arthritic side.
What are the different types of hip arthritis? Although there are many types of arthritis (over 100, in fact),
fewer than a handful of conditions account for over 95 percent of hip
replacements performed. Some of these are:
- Osteoarthritis:
Sometimes called degenerative joint disease (DJD), or “wear-and-tear”
arthritis, osteoarthritis is localized to the joint itself, and does
not have any systemic (whole body) manifestations. We know that most
young patients (under age 50) with osteoarthritis of the hips have this
condition as a result of one of several childhood hip conditions--but
by the time the symptoms show up in adulthood, the condition is treated
as it would be for anybody with hip osteoarthritis.
- Post-traumatic arthritis: After a severe fracture of the pelvis or
a dislocation of the hip, the joint surface cartilage may suffer
damage--either because of direct trauma or because of a loss of joint
congruity (the good fit between the ball and the socket)--leading to
pain and stiffness.
- Rheumatoid arthritis:
This is a condition in which the body’s own cells attack joint surface
cartilage. It may affect any joint in the body. The result of this is
stiffness, swelling, and pain. The symptoms may vary over the course of
the day, and may wax and wane. There are many types of rheumatoid
arthritis, including some that affect children and young adults. Most
patients with rheumatoid arthritis should be followed by a special kind
of physician, called a rheumatologist, since there are so many new and
successful medical therapies that can help control this disease. There
are a large number of types of arthritis that are somewhat similar to
rheumatoid arthritis; as a group, these are called “inflammatory
arthritis,” and they include conditions like systemic lupus erythematosis (SLE, or lupus), psoriatic arthritis, and others.
- Avascular necrosis (or osteonecrosis)
of the Femoral Head: This is not exactly a type of arthritis, but
rather a condition in which the circulation to the “ball” of the “ball
and socket” part of the hip joint becomes impaired. This causes the
bone in a portion of the ball (called the femoral head) to die and
collapse. The process can be quite painful. In addition, the femoral
head loses its round shape and flattens. Since the hip depends on a
symmetric and congruent fit of the ball into the socket, the resulting
poor “fit” causes further stiffness and pain, and leads to loss of the
remaining joint surface cartilage (arthritis).
What else might be confused with or similar to hip arthritis? How can these be distinguished from the condition? Many conditions cause pain in the area of the hip, and most are not related to the hip joint at all. Some of these are:
- Spinal stenosis (or spinal arthritis): This condition commonly
causes pain in the lower back that radiates to the buttocks (see figure
7). It may cause symptoms on both sides or just one. Many patients with
this find that walking slightly stooped forward, as with a shopping
cart, causes some relief of pain. Your orthopaedic surgeon can easily
tell this from hip arthritis with a good physical examination and some
basic X-rays.
- Bursitis
of the hip (greater trochanteric bursitis): Patients with this
condition often have pain and tenderness over the “point” of the
hip--the prominence on the outside of the thigh about 3 to 4 inches
below the beltline (see figure 8). This condition may keep one from
sleeping comfortably on that side. Bursitis is not in the hip joint at
all, but rather is an inflammation of a structure called a “bursa,”
which is a fluid-filled sac between next to the femur (thigh bone) that
helps tendons to glide smoothly over the bone. Again, an orthopaedic
surgeon can readily distinguish this from hip arthritis with a good
physical examination.
- Non-orthopaedic conditions: Many diverse conditions can cause pain
in the hips, thighs or buttocks. Peripheral vascular disease (hardening
of the arteries) can sometimes cause buttock or leg pain that is worse
with activities or walking. Referred pain from intra-pelvic conditions
in women (such as ovarian cysts) can cause pain in the groin and mimic
hip joint symptoms, as can inguinal (groin) hernias. A good family
doctor can make sure none of these conditions are present using simple
physical examination techniques.
How common is hip arthritis (statistics, demographics, risk factors)? According to the most recent statistics from the U.S. Centers for Disease Control and Prevention, nearly 70 million Americans suffer from some form of arthritis or chronic joint symptoms. The Arthritis Foundation recently called arthritis the number one cause of disability in this country.
Not every person with arthritis has symptoms in the hip; however, it
is the second most commonly-affected large joint (after the knee), and
causes a disproportionate amount of disability to those patients who
are affected. It is safe to say that the number of people in this
country who experience symptoms from arthritis of the hip is on the
order of several million, or more.
According to the American Academy of Orthopaedic Surgeons,
nearly 300,000 people had some type of hip replacement in 1997 (the
last year in which statistics were available), of which nearly 200,000
were performed for arthritis. The remainder were performed for hip
fractures or tumors. Again, that number represents a small proportion
of people who suffer with hip arthritis and who do not undergo surgery.
Risk factors
Some types of arthritis are hereditary, although the patterns of
inheritance are not well-understood for all types of arthritis. Obesity
(excessive body weight) has been associated with arthritis of the knee,
but interestingly, the data are not clear about whether it also causes
arthritis of the hip. One arthritis-like condition, called avascular necrosis (or osteonecrosis)
of the femoral head, is associated with a variety of risk factors,
including: excessive alcohol use, use of medical steroids like
prednisone (which are different from body-building steroids), some
medical conditions including sickle-cell anemia, severe hip trauma,
unusual occupational exposures including deep-sea tunnel digging, and
abnormalities of blood clotting. How is hip arthritis diagnosed? What tests or exams may be used? History and physical examination
An orthopaedic surgeon will begin the evaluation with a thorough
history and physical exam. Based on the results of these steps, (s)he
may order plain X-rays.
X-rays
If you have arthritis of the hip, it will be evident on routine
X-rays of the joint. X-rays taken with you standing up are more helpful
than those taken with you lying down, as the way your joint functions
under load (i.e. standing) provides important clues about the severity
of the arthritis to your physician.
Other tests
If your orthopaedic surgeon suspects a problem with the hip joint,
but does not identify the source of the problem on plain X-rays, (s)he
may decide to order another test, such as a Magnetic Resonance Imaging
(MRI) study or a bone scan. These are more commonly ordered in the
evaluation of conditions that are related to arthritis--such as avascular necrosis (osteonecrosis)--but are not always treated using the same techniques.
Can medications help hip arthritis? It is important to distinguish broadly between two types of arthritis: inflammatory arthritis (including rheumatoid arthritis, lupus, and others) and non-inflammatory arthritis (such as osteoarthritis).
Although there is some level of inflammation present in all types of
arthritis, conditions that fall into the category of true inflammatory
arthritis are often very well managed with a variety of medications,
and more treatments are coming out all the time. Individuals with rheumatoid arthritis
and related conditions need to be evaluated and followed by a physician
who specializes in those kinds of treatments, called a rheumatologist.
Excellent non-surgical treatments are available for these patients;
those treatments can delay (or avoid) the need for surgery, and also
help prevent the disease from affecting other joints.
So-called non-inflammatory conditions, including osteoarthritis
(sometimes called degenerative joint disease), also sometimes respond
to oral medications (either painkillers like Tylenol, or non-steroidal
anti-inflammatory drugs like aspirin, ibuprofen, celebrex, or vioxx)
but in many cases, symptoms persist despite that type of treatment.
It is important to avoid using narcotics (such as Tylenol #3,
vicoden, percocet, or oxycodone) since they are have many side effects,
are habit-forming, and make it harder to achieve pain-control safely
and effectively after surgery, should that become necessary. Narcotics
are designed for people with short-term pain (like after a car accident
or surgery), or for people with chronic pain who are not surgical
candidates. People who feel they need narcotics to achieve pain control
should consider seeing a joint replacement surgeon (an orthopaedic
surgeon with experience in hip replacements) to see whether surgery is
a better option. Can exercises help hip arthritis? There is little evidence to suggest that hip arthritis can be
prevented or caused by exercises or activities. There is no evidence
that, once arthritis is present in a hip joint, any exercises will
alter its course.
However, exercise and general physical fitness have numerous other
health benefits. Certainly, people who are physically fit are more
resilient and, in general, are more able to overcome the problems
associated with this condition. Physically fit people also tend to
recover more quickly from surgery, should that eventually be necessary
to treat the hip arthritis. Specifically, how is hip arthritis improved by total hip arthroplasty, hip resurfacing, and minimally-invasive hip surgery? Regardless of how the hip replacement is performed--either through a
traditional incision, or through one of the recently-developed
less-invasive incisions--the goals and possible benefits are the same:
relief of pain, and restoration of function.
The large majority (more than 90 percent) of hip replacement
patients experience substantial or complete relief of pain once they
have recovered from the procedure. The large majority walk without a
limp. It is quite likely that you know someone with a hip replacement
who walks so well that you don’t know (s)he even had surgery!
Frequently, the stiffness from arthritis also is relieved by the
surgery. Very often, the distance one can walk will improve as well,
because of diminished pain and stiffness.
Many patients with hip arthritis who also have low back pain can
achieve a good amount of improvement after hip replacement surgery, but
this is not as consistently achieved as relief of the hip pain itself.
The reason for this improvement, when it occurs, is that stiff hips can
transmit extra loads to the lower back. When the stiffness is relieved
by hip replacement, the hip once again can “carry its share” of the
burden, and some back pain is relieved. Surgery for hip arthritis at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call the Bone & Joint Surgery Center at 206-598-3354 or Eastside Specialty Clinic at 425-646-7777 to make an appointment.
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