Degenerative Joint Disease- Hip (osteoarthritis)
Osteoarthritis or Degenerative Joint Disease is the most common type of arthritis that occurs most commonly in hips, knees, ankles, and foot joints. Osteoarthritis is also known as “wear and tear arthritis” since the cartilage simply wears out. When cartilage wears away, bone rubs on bone causing severe pain and disability.
Pain is the most frequent symptom for patients with hip osteoarthritis. The pain from hip arthritis is usually described as being in the groin or thigh. The pain is frequently worsened with activity and relieved by rest. It may occur at night and, in severe cases, prevent sleep. Patients with hip arthritis also tend to have stiffness and often limp when they walk. They may have difficulty going up and down stairs and putting on their shoes and socks.
The most frequent reason for osteoarthritis is genetic, since the durability of each individual’s cartilage is based on genes. If your parents have arthritis, you may also be at risk of suffering from degenerative joint disease. In addition, osteoarthritis may be a result of a past trauma, metabolic conditions like gout, previous surgery, or may be a result of your own anatomy.
Less invasive or minimally invasive surgery involves a smaller incision than the traditional techniques. However, there is a misconception that the length of the incision is the key determinant of the quality of the result and the speed of the postoperative recovery. In reality the speed of postoperative recovery depends very little upon the length of the incision, but rather is determined by multiple factors including the extent of the arthritis being treated, the quality of the surgical technique, and postoperative pain management and rehabilitation protocols. Perhaps one of the most important features of my hip replacement program involve optimized pain management protocols for rapid recovery, independent of the surgical approachused.
In minimally invasive hip replacement surgery, the incisions used are smaller than in years past and no muscle are detached or cutted. While minimally invasive techniques are utilized it is important to realize that there is some trauma to the tissues in all cases.
Less invasive surgery includes unique pre- and post-operative pathways for anesthesia, nursing care and rehabilitation. These have facilitated the early discharge protocols that get our patients home soon after surgery. While some patients are hospitalized for 2-3 days, many now are discharged one day after surgery, if desired.
You should have a clear understanding of the goals of your joint replacement surgery before you proceed. A discussion of joint replacement surgery should include a review of the technique that your surgeon suggests. If your surgeon offers minimally invasive or small incision surgery, ask about potential short-and long-term risks and benefits of this type of surgery. Review his or her specific results for contemporary and minimally invasive surgery in relation to fracture, infection, blood clot, nerve injury and dislocation rates. Complications appear to be more common when the surgeon has less experience with this type of surgery. Inquire about his or her qualifications, competence and proficiency with the technique. Understanding the usual post-operative course, including hospitalization, blood loss, rehabilitation and return to work is important.
Arthritis simply refers to the inflammation of a joint that causes pain, swelling, stiffness, instability and often deformity. Severe hip arthritis and hip pain can interfere with a person’s activities and can limit his or her lifestyle. If you are experiencing hip pain caused by hip arthritis, it is important to know that there are treatments available.
There are multiple types of arthritis that can affect a joint. The most common ones that are seen are osteoarthritis (degenerative joint disease), rheumatoid arthritis, psoriatic arthritis, and lupus. Rheumatoid, psoriatic, and lupus arthritis are often associated with other conditions that may require treatment from a rheumatologist or other medical doctor.
Osteoarthritis or Degenerative Joint Disease is the most common type of arthritis that occurs most commonly in hips, knees, ankles, and foot joints. Osteoarthritis is also known as “wear and tear arthritis” since the cartilage simply wears out. When cartilage wears away, the bone is subjected to higher degrees of stress, which causes pain, stiffness and disability. If the arthritis is severe and all of the cartilage wears away, the bones can actually rub together, causing what some people refer to as “bone on bone arthritis”.
If you are currently experiencing mild to severe hip pain, you should schedule an appointment. Doctors diagnose arthritis with a medical history, physical exam and x-rays of the hip.
Most patients go home within few days after total hip replacement surgery. Your discharge may be as early as the day of surgery, or may rarely be prolonged for other reasons.
No surgery is painless, and hip replacement surgery is no exception. However, postoperative pain from hip replacement surgery is very manageable. Despite their surgical pain, it is not unusual for patients to state that they feel immediate relief after surgery from the deep preoperative arthritic pain. While the experience of pain is unique to each individual, most patients manage the immediate postoperative pain from hip replacement without difficulty.
Most patients getting hip replacement surgery undergo spinal anesthesia with sedation, so they are not awake during the surgery. This type of anesthesia has many benefits, not the least of which is the continuation of pain relief for several hours after surgery. Additionally, spinal anesthesia has been demonstrated in studies to have other benefits, such as decreased surgical blood loss and a decreased risk of developing lower extremity blood clots when compared with general anesthesia. The muscle relaxation provided by spinal anesthesia also makes performing the surgery easier and therefore may be less traumatic for the patient.
After surgery, patients are treated with other pain medicine, mostly taken by mouth. While it may seem surprising, often the postoperative pain from hip replacement can be managed simply with oral pain medicine. This spares patients from the side effects of stronger intravenous medicines. If it is felt that intravenous medicine is needed, patients are usually provided with occasional injections depending on the level of pain. These types of pain control are generally provided until the day after surgery. After this, most pain medicine is provided in pill form as needed. Patients are often discharged with a prescription of the pills that worked for them during their hospital stay.
Patients can also help relieve their pain with means other than pain medicine. For example, applying ice and elevation to the hip area after therapy can go a long way toward controlling the swelling that often causes discomfort after such activity. On the other hand, when patients have discomfort from stiffness, usually doing some exercises will help relieve this pain more than any medicine will.
When the hip joint has worn down to the point when it no longer does its job, an artificial hip (called a prosthesis) made of metal, plastic and ceramic can take its place. The surgery to implant the prosthesis is termed a total hip replacement. While the idea of getting an artificial hip joint may be frightening to some, it is one of the safest and most effective surgical procedures. Patients rank total hip replacements as one of the most satisfying surgeries in the human body.Hip and knee replacement are among the most common and successful orthopaedic surgeries. The indications for these surgeries are well established and their overall success documented by extensive research. Substantial pain relief and improvement in function is expected for most patients for 15 years or more after surgery.
Minimally invasive and small incision hip replacement surgery is merely a variation of traditional joint replacement surgery encompassing an array of modifications to the original technique. The patient can be discharged one day after surgery and some can go home on the day of surgery, if desired.
The most apparent benefit of total hip replacement is dramatic pain relief. Almost all patients have complete, or near complete, relief of arthritic hip pain. As the pain lessens, function often improves. After having hip replacement, most patients have great results, including better range of motion, less pain, better balance and stability, and less limping.
Total hip replacement replaces the original ball and socket joint. The hip socket (acetabulum) is replaced with an artificial cup and liner, and the upper thigh bone is replaced with an artificial stem and new ball (femoral head). It is an excellent procedure designed to improve pain relief, motion and function.
Possible surgical complications of the hip include: loosening, wear or breakage of the prosthesis, hip dislocation, infection, pain, stiffness, limp, leg length inequality, delayed healing of bone and soft tissues, and extra (heterotopic) bone formation. Other rare complications include fracture of the femur or acetabulum, nerve and blood vessel (vascular) injury.
Medical complications can include: thrombophlebitis, pulmonary embolism, blood clots in the legs, bleeding, urological complications, and very rarely even death. Other rare complications, which can be encountered with any surgery, include cardiac, gastrointestinal, kidney and lung problems.
While inflammation of the leg veins (phlebitis) is not rare, the occurrence of symptomatic blood clots has been greatly reduced with the use of compression devices on your legs in the hospital and blood thinning medications such as aspirin. Early mobilization (walking and moving one’s foot up and down) are extremely important for helping to reduce the development of blood clots.
Long-term complications such as wear, stiffness or loosening of the parts relate as much to patient behavior as to surgical success. In the instances where one of these complications occurs, they can often be corrected with revision surgery.
If you are scheduled for an x-ray at Rothman Orthopaedic Institute, please arrive at least 15 minutes before your scheduled appointment.
If you are bringing x-ray films to your appointment, they must be current to be of value for your appointment with the doctor (no older than three to four months). If you have older films, please bring them in for comparison.
If you are bringing Bone Scans, CAT scans, or MRI films of the hip or knee please bring a copy of the written report as well.
Please bring any recent (no older than three to four months) laboratory blood work related to your joint replacement such as an Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP).
If you have had your total hip or knee aspirated (“tapped”) please bring the laboratory results from this procedure.
For revision surgery, your doctor needs this information to order replacement parts which will match up with the implant that you currently have in place. For conversion surgery (converting previous surgery, such as fixation of a hip fracture, to a total joint replacement), this information allows us to have the necessary tools available to remove the hardware in place.
Total hip replacement is recommended for patients with arthritis that results in severe pain and limited function. Pain cannot be measured, and the degree of pain sufficient to warrant surgery should be decided by the patient and doctor together. Age (young or old) is rarely an issue anymore. It is important for patients to work with their medical and orthopaedic physicians to be in the healthiest possible condition before undergoing surgery.
In a simultaneous procedure both hips are replaced in one operation, on the same day under one anesthesia. This means that there is one hospitalization and one recovery period. Certain patients are at higher risk for medical complications if they undergo simultaneous bilateral hip replacement surgery. Your physician will discuss with you the relative merits and safety of simultaneous BTHR.
The staged procedure means that both hip replacements take place as two separate surgical events. Surgeries are planned to be performed several monthsapart one from the other, requiring two hospital stays, two episodes of anesthesia and two rehabilitation periods. The time between surgeries may vary depending upon your individual medical condition but most surgeons will want you torecover about 3 months from the first surgery before you undergo the second surgery.
The most common reason for a Bilateral Total Hip Replacement is severe arthritis that is causing pain and stiffness in both hips interfering with activities of daily living and significantly reducing one’s quality of life. Stiffness can be significant making simple tasks such as putting on your shoes and socks very difficult. Pain is usually worsened with weight bearing activities, such as standing and walking. Arthritis of the hip is a progressive condition that usually worsens with time.
The ideal candidate for a simultaneous total hip replacement would be a younger, healthier, non-obese individual with stiffness, pain, and limitation of activities that significantly reduces one’s quality of life.
The advantages of having a simultaneous hip replacement in the properly selected patient include: only one surgical event, one episode of anesthesia,shorter overall hospital stay and the ability to rehabilitate both new hipreplacements at the same time.
The advantages of having a Staged procedure includes lower stress level for the cardiovascular system (heart and lungs) as well as a lower risk of requiring blood transfusion after surgery. In general, elderly and/or obese patients and those with serious medical issues are best treated with a staged procedure. Your surgeon will help you decide what the best choice is for you.
This procedure is not encouraged in older or obese patients with substantial health conditions, such as heart, lung, and/or vascular disorders. These patients would be at increased risk for significant perioperative complications.
The simultaneous procedure may require a longer hospitalization and a more intense period of rehabilitation. While most patients who receive simultaneous BTHR can go home after surgery, some patients may have to go to a rehabilitation facility.
Evidence is emerging that subtle abnormalities around the hip, resulting in femoroacetabular impingement (FAI), may be a contributing factor in some instances to osteoarthritis in the young patient. FAI is the abnormal contact or friction between the femoral neck/head (ball) and the acetabular margin (socket), causing tearing of the labrum and avulsion of the underlying cartilage region, continued deterioration, and eventual onset of arthritis.
Nonsurgical treatment typically fails to control symptoms.
Surgical management involves dislocation of the hip (while preserving the blood supply to the femoral head) and femoroacetabular osteoplasty. Encouraging results have been reported following femoroacetabular osteoplasty and arthroscopic treatment of femoroacetabular impingement.
The labrum is a pad of fibrocartilage deep in the hip joint. The hip is a ball-in-socket joint with the ball from the thigh bone (femur) and the socket from the pelvis (acetabulum). The labrum is a pad of cartilage that lies between the femoral head (ball) and the acetabulum (socket). It acts as a stabilizer and a shock absorber in the hip. Labral tears are common in athletes. When tears in the labrum occur, patients can experience pain deep in the hip joint. There are many different causes for tears. When a labral tear is symptomatic and patients have failed non-surgical measures such as physical therapy, activity modification and medication, it may be repaired arthroscopically.
There are three types of snapping hip: internal (iliopsoas tendon or hip flexor), intra-articular (loose bodies), and external (IT band). In most patients the snapping is merely an annoyance, but it can lead to pain and dysfunction, especially with athletic activities. When non-surgical measures have failed, these conditions can be treated arthroscopically.
The synovium is the lining of our joints. When this lining gets irritated, it can become inflamed, which may cause hip pain. The synovitis is typically secondary to an intrinsic hip problem (labral tear, FAI, arthritis) but may be due to a primary disease of the synovium (inflammatory arthritis). When indicated, the synovium can be resected arthroscopically.
Hip arthroscopy is a unique, minimally invasive outpatient technique that uses fiber-optic cameras and small instruments to treat painful hip conditions that were traditionally repaired through larger open incisions. It can allow for a quicker recovery period, less scarring, and a return to pre-injury activity levels which make it an ideal technique for athletes and those under the age of 55. There are many conditions that can be treated arthroscopically when indicated.
Indications for hip arthroscopy include: labral tears, loose bodies, hip impingement (FAI), snapping hip, articular cartilage injuries, synovitis, and hip pain. Relative contra-indications for hip arthroscopy include pre-existing arthritis, obesity, infection, and regional pain syndromes (e.g. RSD, fibromyalgia).
Candidates for hip arthroscopy include:
Athletes with hip pain associated
with labral tears +/- FAI
Athletes with snapping hip syndrome
Pre-arthritic patients with hip pain
and labral tears +/- FAI
Pre-arthritic patients with hip pain
associated with synovitis
Hip arthroscopy is not a common technique, so your surgeons experience is an important factor to consider.
Repeat (also called “revision”) surgery is different than first time (also called “primary”) total hip replacement. During revision surgery, some or all of the original components may need to be removed and new components put in their place. Revision hip replacement is more complex than primary replacement.
You will arrive the morning of your surgery and get prepared for surgery. You will be taken to the preoperative holding area where your surgeon or member of the team will mark the correct operative location. You will meet the anesthesia team and nurses who will be involved in your operation.
After surgery, you will recover in the post-anesthesia care unit (PACU) as your anesthesia wears off. You will then be transferred to your room. Once your anesthesia wears off, physical therapy will assist in getting you out of bed and you will begin to walk. Once you can walk, eat normal food and have your pain controlled, you can leave the hospital.
On average, patients stay for 0-3 nights after total hip revision surgery. Your discharge may be as early as the day of surgery, or may be prolonged, depending on the complexity of your revision.
No surgery is painless, and revision hip replacement surgery is no exception. However, pain after revision hip surgery should be manageable.
Most patients getting revision hip replacement surgery undergo spinal anesthesia with sedation, so they are not awake during the surgery. This type of anesthesia has many benefits, not the least of which is the continuation of pain relief for several hours after surgery. Additionally, spinal anesthesia has been demonstrated in studies to have other benefits, such as decreased blood loss and a decreased risk of developing blood clots when compared with general anesthesia. The muscle relaxation provided by spinal anesthesia also makes performing the surgery easier and therefore may be less traumatic for the patient. Occasionally, if the revision surgery is expected to be lengthy or complex, general anesthesia (i.e. using a breathing tube) is necessary. General anesthesia is also a safe and effective means of anesthesia during hip surgery.
After surgery, patients are typically treated with oral pain medication. This spares the patient from the side effects of stronger IV medicine. If needed, IV medications may be used as well. Patients are often discharged with a prescription for the pain pills that worked for them during their hospital stay.
Patients can also help relieve their pain with means other than pain medicine. For example, applying ice and elevation to the operated leg after therapy can go a long way toward controlling the swelling that often causes discomfort after such activity. Maintaining activity can also help prevent stiffness and swelling, which can also lead to pain.
Many patients express concerns about taking pain medicine after surgery, particularly with respect to narcotic addiction. While it is possible to become addicted to narcotic pain medication, this is rare when the medicine is taken appropriately after surgery. Postoperatively, patients have a good reason to have pain and it is okay to take pain medicine as directed by your surgeon at this time. It often takes less narcotic medication to control a person’s pain when the medicine is taken appropriately – that is, when the patient begins to experience some discomfort. In the early postoperative period, patients should not try to “hold off” on taking pain medicine because they think the pain will calm down in time. These patients who “hold off” until their pain becomes too severe often need more narcotic medications to control their pain than they otherwise would have needed if they had taken their pain medicine earlier. This increases the chance that they may experience a side effect of the pain medications.
Side effects of pain medicine and anesthesia include nausea, constipation, and sometimes a tired feeling. Having these side effects does not mean that a patient is allergic to the medication. If a patient has a problem with these side effects, often the medication can be adjusted, or a different medication tried in order to minimize these effects. Please call your surgeon’s office if you are having any issues with your medications.
The 1st office visit after surgery is typically 2-6 weeks from the date of surgery. If you have staples or visible sutures, the 1st office visit after surgery is often 2 weeks from the date of surgery.
Approximately 2 weeks after your surgical date, the staples or sutures will be removed. Some patients will have no visible staples or sutures and therefore will not need to have anything removed.
If you have a specialized dressing that looks like a large band-aid, you may shower with the dressing in place. The dressing should be removed 5-7 days from the day of surgery. If you have a gauze dressing and tape on your hip, it will most likely be removed before you are discharged from the hospital. If not, it can be removed 2 days after surgery and the area should be kept clean and dry.
These blood thinners are prescribed for up to 2-6 weeks post-operatively. If you are prescribed aspirin, you will take it once or twice a day for 4 weeks, as directed by your surgeon. If you are on warfarin (Coumadin), you will need your blood to be drawn twice weekly to ensure that you are taking an appropriate level of the medication. Your primary medical doctor who cleared you for surgery will typically arrange for monitoring your warfarin by blood labs and will communicate with you the dose you should take. If not your PCP, then often your cardiologist will be guiding you with respect to your Coumadin dosing. Sometimes, other medications are used to reduce the risk of blood clots and you should follow your physician’s directions when taking these medications.
Yes, for three to six months. To decrease swelling, elevate your leg and apply ice for 20 minutes at a time (3-4 times a day).
Yes, it is normal to feel numbness around the incision.
It is common to have bruising on the skin. It is from the normal accumulation of blood after your surgery.
Please do exercises as instructed by your surgeon. Remember that if you are using your hip to do things (e.g. walking around), you are actually doing physical therapy for your hip. You may have been given a link for an on-line physical therapy program called “Force Therapeutics” that will help guide you on which exercises are appropriate after your total hip replacement.
This varies with each patient. Patients often use a walker or crutches initially after surgery. Some patients may have restricted weight-bearing after revision surgery while others will not. Your surgeon will tell you about your weight-bearing status after your surgery.
Restrictions in range-of-motion or “hip precautions” after revision surgery are common for a time period after surgery. Some patients may not have hip precautions while others may. Your surgeon will tell you about hip precautions after your surgery.
Yes, we encourage you to do so.
Yes, you may ride in a car, however, you must be off all pain medications prior to driving. It is a patient’s responsibility to determine their own safety. Patients must be able to operate their car safely.
Yes, you may ride in an airplane. Be sure to get up and move around at frequent intervals to prevent blood clot formation. You may find it more comfortable to sit in an aisle seat.
The ultimate success of the operation should be the same in both the simultaneous and staged procedures. Your surgeon is the best source to help you decide what’s best for you.
Revision total hip replacements have higher risks compared to primary total hip replacements. There are higher risks of nerve and blood vessel injuries, increased risks of clots to the legs and lungs, and there is a higher risk of infection since another surgical procedure is being performed. Revision total hip replacement patients may undergo subsequent revision surgery. While inflammation of the leg veins (phlebitis) is not rare, the occurrence of symptomatic blood clots has been greatly reduced with the use of compression devices in the hospital and blood thinning medications such as aspirin. Early mobilization (walking and moving one’s foot up and down) are extremely important for helping to reduce the development of blood clots. Other complications include dislocation, infection, wear, stiffness or loosening of the parts. In the instances where one of these complications occurs, they may need to be corrected with another revision surgery.
The disadvantages of having a Staged procedure is that it requires two hospital stays, two episodes of anesthesia and delays full return to work from disability as compared to simultaneous hip replacement.
Avascular necrosis (AVN), also known as osteonecrosis, is a disease that results in death of bone. This bone death occurs in a part of the femoral head (the ball at the top of the thigh bone that sits in your hip socket).
Symptoms of avascular necrosis can be variable and often times there is no pain at first. The most common symptom is hip pain, typically in the groin region. In the earliest stages of the disease plain x-rays are often normal. A magnetic resonance image (MRI) study can allows us to detect avascular necrosis earlier than x-rays.
The causes of avascular necrosis are not completely understood, but it appears to be related to an interruption in blood flow to the femoral ball. Here are some possible reasons:
Non-operative management may consist of protective weight-bearing (namely, partial weight-bearing with crutches) for six weeks then re-evaluation. Non-steroidal anti-inflammatory medications or acetaminophen may help relieve some pain. Other medication options include medications that help moderate bone loss. However, even with protective weight bearing and medication there is a risk of the hip getting worse.
Trochanteric bursitis is the more common clinical syndrome in that regional pathology. Local injections of corticosteroid are still the mean modality of theconservative treatment but are not sufficient to avoid recurrence or chronicity which may lead to tendon tears.
Muscle strains in the hip area occur when a stretched muscle is forced to contract suddenly. A fall or direct blow to the muscle, or overstretching and overuse can tear muscle fibers, resulting in a strain. The risk of muscle strain increases with prior injury to the area, improper warm up before exercising or attempting to do too much too quickly. Strains may be mild, moderate or severe, depending on the extent of the injury.
Tendonitis (also known as tendinitis) is a general term used to describe inflammation associated with a tendon. Tendons connect muscles to bone, and inflammation of these rope-like tissues is the most common cause of soft-tissue pain. Tendonitis differs from arthritis, which refers to inflammation of a joint. The onset of tendonitis can usually be attributed to overuse of the associated area. With age, repetitive motion can injure the tendon where it attaches to the bone, promoting an inflammatory response by the body. This inflammation can cause “pain on motion,” swelling, warmth, tenderness, and redness. This latter symptom is called “erythema” and refers to the dilation of small surface blood vessels, capillaries as a result of the inflammatory process.
A wide variety of conservative treatment options:
Surgical treatment:
Surgical refixation of gluteus medius tendon
Transfer of the anterior portion of the gluteus maximus
Conservative, or non-surgical, treatment is effective in the early stages of arthritis. Conservative care includes weight loss, activity modification, anti-inflammatory medication or shots.
There are many causes for hip pain. They generally can be broken down into primary hip problems, secondary hip problems, and referred pain. Primary hip pain can be secondary to labral tears, FAI, snapping hip, synovitis, arthritis, loose bodies, or other causes. Secondary hip problems include instability (connective tissue disorder, dysplasia), bursitis, piriformis syndrome among other causes. Referred pain can be from the low back, SI joint, muscular imbalance, among other causes. Treatment of hip pain depends on the primary cause.
Swelling and heat (inflammation) of the joint lining called synovium causes a release of enzymes which soften and eventually destroy the cartilage. Rheumatoid arthritis, Lupus and Psoriatic Arthritis are inflammatory in nature.
Osteoporosis is a bone disease that happens when your body loses bone, doesn’t make enough bone, or both. This causes your bones to become weak and can cause you to break a bone with only a minor injury, or possibly even from a sneeze.
Normal bone looks like a honeycomb. When you have osteoporosis the holes of the honeycomb become larger, making the bone weaker. Weaker bones increase your risk for a fracture.
You don’t feel your bones getting weak, so you may not find out you have osteoporosis until after you’ve broken a bone. One in two women and up to one in four men age 50 and older will break a bone because of osteoporosis. Osteoporosis Care
It is important once you have a fragility fracture, a fracture that happens with little to no trauma, that you see a healthcare provider to determine if you have osteoporosis. Your healthcare provider may order a DEXA scan. This is a special x-ray that measures your bone density to see if you have osteoporosis.
Your healthcare provider may also order blood work to make sure there are no other reasons why you could have osteoporosis.
Your healthcare provider will see you back in the office to discuss your results. Based off your results, your provider will come up with a treatment plan. This may include physical therapy, medication, and lifestyle changes.
Reducing your fall risk can help lower your chances of sustaining a fragility fracture. Here are somepotentialways to minimizeyourrisk:
Turn inside and outside lights on when you leave so it is well-lit when you come home.
Additionally, you may reduce your risk of osteoporosis by following these suggestions:
