Common hip joint problems

19. August 2014

Orthopaedics resident of East-Tallinn Central Hospital Dmitri Kulak says that osteoarthritis (OA) is a disease of the joints that in addition to the cartilage also affects the bone under the cartilage, ligaments in joints and muscles next to the joint. It is a complex disease. It is the third most common chronic disease. 20-30% of people over the age of 70 suffer from it.

Osteoarthritis can be either primary or secondary. Primary osteoarthritis is idiopathic and its exact causes remain unclear. The causes of secondary osteoarthritis are numerous, e.g. anatomic peculiarities of the femoral head and neck, trauma or inflammatory joint diseases such as rheumatoid arthritis.

The average arthritis patient is over 55 years old, complaining of hip pain that may radiate to the groin, buttocks, thighs and often to the knees. Turning the leg inward from the hip joint may be difficult or painful and the pain often radiates to the knee. The hip joint is stiff and sitting, standing or moving normally is difficult. The pain is strong in the morning and there is exertion pain.

Osteoarthritis is like a closed circle – as the cartilage wears away an aseptic infection appears in the joint from time to time, and in response to this the muscle produces large quantities of joint fluid, which increases the pressure inside the joint, disturbing the metabolism in the cartilage, which in turn damages the cartilage.

The signs of osteoarthritis include limping, stiff joints, pain that affects daily life, limbs that are often shorter and increased pain after exertion. Conservative treatment includes making changes in daily life and losing weight to reduce the burden on the joints. Also, losing weight makes future surgery easier in case it proves to be necessary and the patient will also recover easier and faster after surgery.

Physiotherapy is certainly very important, both before and after surgery, as it helps maintain the mobility of the joint and muscle performance. Crutches, sticks and mobility walkers are recommended. Different painkillers or NSAIDs (non-steroidal anti-inflammatory drugs) can also be used. Corticosteroid injections in the hip joint are often used in the case of advanced arthritis, but these injections can only be given by orthopaedists.

Surgical treatment of advanced osteoarthritis of the hip means replacing the joint with an endoprosthesis (hip replacement), whereby the femoral head with the damaged cartilage is taken out and the damaged cartilage and bone tissue up to the healthy bone are removed from the acetabulum. The femoral canal is then prepared and a test prosthesis is inserted to observe mobility. It must be guaranteed that the mobility of the prosthesis and joint is good and the prosthesis does not become dislocated. Only then is the real prosthesis inserted.

The purpose of a hip replacement is to reduce pain and to restore joint function to the pre-operative level. Hip replacement is one of the most common surgical procedures in orthopaedics and produces excellent results which are evidenced by clinical research and studies of the survival of implants. Contemporary technology has improved the bearing surface of the prostheses and they can also be used on younger patients without having to change it several times during the patient’s life. The average lifespan of a prosthesis is 15-20 years. Every subsequent instance of hip replacement surgery is always more risky and difficult, and the patient usually needs more time to recover than after the first surgery.

Endoprostheses have different bearing surfaces: ceramic, metal and plastic. Plastic-on-metal bearing surfaces are currently preferred due to their cost-effectiveness. They are very durable and are used in 85% of cases.

The patient and the orthopaedist must make the decision about a hip replacement together – it cannot be decided by one party alone. It is generally recommended when the pain disturbs the patient’s life so much that they cannot function normally and conservative treatment is no longer effective. However, the patient’s own hip is still their own hip and replacement surgery should not be done too early. If pain is the only main symptom, then the mobility achieved with the prosthesis may not be as good as that of the patient’s own hip.

Like any other surgical procedure, hip replacement may also have complications. For example, dislocation or luxation of the endoprosthesis, difference in the length of the legs, deep-vein thrombosis, fractures, infections or implant migration. Hip replacement puts certain restrictions on the patient for life, e.g. they have to avoid sitting in a position where the thigh is bent more than 90 degrees from the hip joint, and one leg cannot be crossed over the other. The patient may not bend down directly: they must squat first to pick up things off the floor or ground. In general, patients get used to these restrictions very well.

Can hip osteoarthritis be prevented?

Ten years ago the answer would have been a resounding ‘no’, but now specialists believe that it can be prevented in certain cases. This concerns the femoroacetabular impingement (FAI) that younger people can suffer from. It occurs in people aged 20-50 and comes with a feeling of discomfort and pain in the groin, the area of the greater trochanter and the buttocks. Physical exertion, sporting activities and changes in the nature of work increase complaints. Joint mobility is restricted. The impingement can be identified with an objective examination or tests if the patient reacts in a certain manner to certain leg positions when lying down – for example, if the pelvis also moves during the internal rotation of the hip, internal rotation is less than 20 degrees or there is pain in the groin.

Treatment of FAI. Surgical treatment includes hip arthroscopy, mini-open decompression, surgical dislocation of the hip and corrective osteotomy of the hip. Physiotherapy does not help in most cases. Timely surgical treatment of FAI is very effective in alleviating pain and improving the patient’s quality of life. It slows down and reduces the progress of cartilage damage and the emergence of osteoarthritis.

Hip dysplasia is a developmental disease occurring in ca 1/1000 babies where the front upper edge of the acetabulum is not properly developed – it is low and the angle of the acetabulum is abnormal. Anterior lateral overload and rupture of acetabular labrum are developing. Advanced arthritis develops over time. Discovering hip dysplasia in babies and treating it correctly help the joint develop into a fully functional hip and there are generally no problems in an older age.

A patient suffering from dysplasia who comes to see an orthopaedist is usually a youngish woman who feels discomfort when walking; there is sharp pain in the groin; the hip may become locked; one of the legs is weaker; there is exertion pain etc. Treatment can be conservative and surgical. The latter is used if conservative treatment with NSAIDs or lifestyle changes is unsuccessful, the patient is still young enough and there is no osteoarthritis.


Source: Meditsiiniuudised Online