In health, the hip joint surfaces are perfectly smooth, allowing almost friction-free movement. Osteoarthritis causes the articular cartilage joint lining to become worn-away. Often there is no obvious cause for this (termed "primary osteoarthritis"). This tends to occurs around middle age in people with a strong family history of arthritis. Secondary osteoarthritis occurs if disease conditions (such as dysplasia or Perthes disease) result in abnormal anatomy and increased mechanical loading to the joint. If osteoarthritis becomes severe, the bone surfaces rub directly against each other causing an uncomfortable grinding sensation. Pain is usually felt in the groin and thigh. There may be stiffness and a sensation of instability. Walking, exercise and deep flexion tend to aggravate symptoms. For some people, activity modification, pain killers and weight-loss may help, whilst for others, a total hip replacement will be more effective.
Healthy hips require a good blood supply. If this is disrupted, the bone may soften and die, causing collapse of the femoral head. This typically causes very severe pain with weight-bearing. There are many causes for this condition including exposure to steroids, trauma, high intake of alcohol and certain blood disorders (including sickle cell disease). In about 25% of cases, no obvious cause can be found. X-rays may appear normal in the early stages of the disease though the diagnosis can be reliably made using MRI scanning. If the condition is not advanced, avoidance of risk factors together with surgical procedures to restore the blood supply can be helpful. If the damage to the bone within the femoral head is advanced, replacement of the hip may be needed.
The femoral neck region (the upper part of the thigh bone just below the hip) is susceptible to fracture in patients who have weakened bone due to osteoporosis. This form of "broken hip" is usually seen in elderly female patients. Surgery is invariably required to either fix the fracture back into place or to replace the joint. Although less common, fractures in this region may also occur in young and fit people in association with physical training. So called "Stress fractures" of the femoral neck may present with progressive pain associated with a high level of physical activity (such as training for a marathon). Importantly, a simple X-ray may miss the diagnosis and a MRI is usually needed.
It is now recognised that certain variations of normal hip development can cause impingement between the outside of the hip socket and the femoral neck. Pain is initially felt when the hip is deeply flexed and the leg is brought in across the body. With time, stiffness may progress and damage to the joint itself can occur. Hip impingement may cause a tear at the cartilage rim of the socket (the "labrum") and with time may also result in wear of the joint surface.
Hip dysplasia refers to a broad spectrum of developmental abnormalities of that may cause hip pain. At one extreme is a situation whereby the femoral head develops outside of the socket (congenital hip dislocation). This results in shortening of the leg and an obvious limp. Thanks to screening of newborn children, this condition is now uncommon. A less severe form of dysplasia results in a shallow pelvic socket. The resulting abnormal loading of the joint may cause pain and osteoarthritis. Because the abnormalities may be subtle, the diagnosis is sometimes missed. Surgery to form a more normal socket can reduce the chance of the joint wearing-out early
Pain in the buttock and upper thigh is often due to inflammation of the large muscles that stabilise the hip and straighten the leg. There may also be inflammation at the tip of the thigh bone where the the tendons of these muscles inset. Often pain is felt when lying on the painful side. Sometimes symptoms come on after a change in exercise regimen or following trauma. A range of treatments include rest, anti-inflammatory medications, stretches, injections and shock-wave therapy.
For many people, occasional use of a simple pain-killer such as paracetamol may be all that is needed to keep their symptoms under control. Non-steroidal anti-inflammatories (such as ibuprofen) are often more effective but can have significant side-effects. Stronger pain killers containing opiates can become addictive and are best avoided. Dietary supplements such as glucosamine tend to not make any difference. Although not part of mainstream medicine, many patients report finding turmeric helpful.
Often patients seek help when their hip pain makes maintaining their active lifestyle difficult. There is however good evidence that regular low-impact exercise such as cycling, swimming or pilates can help maintain hip flexibility and stave-of surgery. If on a bike, set the seat high with the handle-bars not too far forward. Swimmers may find breast-stroke uncomfortable but crawl tends to be well tolerated. Higher impact sports like road running or squash can irritate the hips; moving over to racquetball or an inclined treadmill can help.
If the hip is very worn and painful, treatment with a physiotherapist will not cure the problem. However, working with a therapist will help build core strength, making some activities of daily living easier. This will also facilitate your recovery if surgery is eventually needed. For other hip conditions such trochanteric pain syndrome, physical therapy represents the mainstay of treatment.
Most people find the prospect of using a walking stick fairly unattractive (though if you do consider using one, it is more helpful in the opposite hand). A pair of Nordic hiking poles can be an effective way of taking the load off painful joints when takling more challenging terrain. Well cushioned trainers usually help whilst heels can aggravate.
This form of non-invasive treatment is used to treat chronic soft-tissue inflammation. Although the mechanism of action is not well understood, the mechanical pulses are thought to stimulate healing. This treatment can be used trochanteric pain (at the side of the hip), as well as other conditions such as tennis elbow, patella tendonitis and plantar fasciitis. The results are not instant and treatment may be uncomfortable.
Injections can be used in the trochanteric area, around the major hip tendons or into the joint itself. Often ultrasound or X-ray is used to locate the exact spot. If the cause of pain is uncertain, injections of local anaesthetic alone may be used to clarify the diagnosis. More commonly, injections will include steroids and/or joint lubrication gel (viscoelastic supplementation).
Many hundreds of combinations of hip replacement components are currently in use and certainly no single prosthesis is the best choice in every situation. Whilst much emphasis is often placed on the type of implant, the most critical success factors are; i) precise pre-operative planning of implant positioning and dimensions; ii) meticulous surgical technique to deliver the planned reconstruction.
For every individual, the surgeon must make their recommendation taking into account the patients age, their anticipated activity level and their specific bone characteristics (strength, size and shape). The surgical strategy is then exactly defined by making a series of planning measurements using either X-rays or CT scans.
The stem can be anchored to the bone either using polymethyl methacrylate cement or a porous surface treatment that bone grows onto. Whilst hip replacements were traditionally fixed with cement, over the last decade, uncemented stems has become more popular, especially for younger patients. The attraction of uncemented implants is that a potentially life-long bond with the patients bone can be formed. Uncemented stems, are also particularly suited to minimally invasive surgical techniques and may incorporate "bone conserving" designs. Cemented stems have demonstrated excellent longevity and a lower risk of fracture during surgery. When the bone is weak (osteoporosis), it may be sensible to use cement.
Arguments as to which form of implant fixation is superior have raged for decades. However, highly reproducible outcomes are consistently observed when using both cemented and uncemented implants provided that the "best in class" prostheses are used. In the U.K, the clinical evidence showing the long-term reliability of hip replacements is rated by the "Orthopaedic Data Evaluation Panel" (ODEP). Currently the highest ODEP rating is 13A*, indicating that robust clinical data exists beyond 13 years with a revision rate <5% after the first decade. For the majority of cases, Mr Bartlett uses exclusively implants with the best clinical track-record (including "13A*" rated "Taperlock", "Corail" and "CPT"). Occasionally, conventional prostheses do not match the patients anatomy well and in such circumstances a bespoke implant may preferable (e.g Symbios custom-made hip prosthesis).
The patients pelvic socket (acetabulum) is resurfaced using the cup. This is either fixed with cement or "uncemented" (fixed with bone on-growth). Sometimes, screws are also passed into the pelvic bone to help attach uncemented cups.
Whilst cemented cups are made from a single block of plastic, uncemented cups are formed from titanium and allow the insertion of metal, plastic, or ceramic liners. All cups are fundamentally the same shape (hemispherical) and typically vary in diameter from 48-56mm. My practice has moved exclusively to uncemented cups as this affords greater versatility during surgery and allows for potentially easier/ bone saving revision surgery if this is required.
Movement occurs between the surface of the ball head and the shell liner ("the bearing"). The ball is made from either a metal or ceramic and the socket may be either plastic, metal or ceramic. During the early days of hip surgery, the polyethylene used in the cups would tend to wear-out after 10-15 years, necessitating revision surgery. Thankfully, modern hip replacement materials are far less susceptible to wear.
The extraordinarily low levels of wear seen with ceramic on ceramic bearings make this combination attractive for very active patients. Recent refinements to the material properties of polyethylene (high cross-linking and vitamin E enrichment) are set to further improve the already excellent longevity of ceramic-on-poly' bearings.
Occasionally, when there is an increased risk of dislocation, a very large plastic head may be used (a "dual mobility" bearing).
METAL-ON-METAL BEARINGS ARE NOT USED IN ANY FORM WITHIN MR BARTLETTS PRACTICE.
taking you step by step through how to best prepare for total hip replacement surgery
Of the >70,000 total hip replacements performed in England and Wales last year over 90% were to treat hip pain due to osteoarthritis. Conditions such as avascular necrosis, trauma, dysplasia, and inflammatory arthritis are more common in younger people.
People vary in their attitudes to pain, disability and surgery. There is no set level of pain that a patient needs to reach to be "bad enough" to justify surgery. The decision has to take into account the individual persons age, activity aspirations and medical fitness. Most people who go on to have surgery would describe their pain and difficulties because of the hip as being severe.
Losing weight usually helps though this is difficult! Non-impact exercise such as swimming or Pilates is a more effective way of keeping mobile and delaying surgery. Avoid deep hip flexion or twisting however.
Paracetamol is a safe and useful pain-killer when symptoms are mild. Non-Steroidal Anti-Inflammatories (NSAIDs) such as ibuprofen or Optiates like Tramadol are more effective but are associated with troublesome side-effects. Sometimes a hip injection is appropriate.
For the very elderly this operation can significantly improve the quality of life and allow on-going independence. Although the risks are increased when operating on patients aged in their 80s and 90s, the surgery generally remains safe. Elderly patients will usually need longer to recover in hospital (typically 4-6 days rather than 1-3) and should expect a slower rehabilitation. Extra support at home or a brief period in a residential facility is often sensible.
A hip replacement will provide excellent and long-lasting pain relief and this must not be denied to young adults.
Historically, people were often told to only expect 10-15 years from their new hips. Thanks to great improvements in the materials used, replacements can now be expected to last for many decades. Whilst the risk of needing a further operation is higher for young patients, for many their hip replacement will be a once in a lifetime operation!
Surgery is performed with either general or spinal anaesthetic. Our preference is usually to recommend a "spinal" as this provides excellent pain relief after the operation and avoids the "hang-over" sometimes associated with a general anaesthetic. The spinal anaesthetic is combined with intravenous sedation so that the patient is aware of very little during surgery. We will always take into account your preferences and offer you the choice.
Total hip replacement surgery is considered safe and reliable. Whilst enormous efforts are taken to eliminate risk, complications can occur and these may be serious. Risks include bleeding, nerve injury, fracture, dislocation, leg-length inequality, thrombosis, infection, embolism, revision surgery, pain, and death. Whilst it is necessary for a surgeon to discuss these risks with their patients, it must be remembered that the vast majority of patients go through surgery without any difficulties
Usually about 60 minutes.
Perhaps the greatest improvement to hip surgery over the last decade has been the radical improvement to post-operative pain control. Although no surgery can be completely pain-free, most people have little or no discomfort for the first 24 hours. After that, there is usually a moderate ache at the side of the hip. This is discomfort is usually managed with a combination of tablets and minimal use of opiates.
Blood transfusion is now rarely needed after hip replacement surgery (used about 1 in 20 cases). This is thanks to improvements in anaesthetic methods, medications that help to limit bleeding (tranexamic acid) and less invasive surgical approaches. People with anaemia are more likely to need a blood transfusion though this condition can usually be corrected before surgery.
Recovery is time is quite variable. A fit and motivated patient may only need 24 hours in hospital. A more elderly and frail patient might be in for 3-5 days and need significant help for the first few weeks.
Before leaving hospital, your physiotherapists will have provided you with an exercise program. In the first two post-operative weeks you should aim to get up and walk for 10 minutes or so every hour during the day. We will schedule a few sessions of physiotherapy also. You will be provided with pain killers, TED stockings and tablets to thin the blood (anticoagulants to be taken for four weeks).
The wound is at the side of the hip and is typically between 8-20cm in length. Mr Bartlett uses dissolvable internal stitches and skin glue so there is no need for removal of skin clips or stitches. A waterproof dressing allows regular showering. After two weeks, the wound is checked in clinic and usually no further dressings are needed.
Crutches are usually needed for the first 2-4 weeks after surgery. I normally expect patients to manage to "walk the block" by about 10-14 days. Painkillers are usually needed during the first couple of weeks. Most people are about "3/4" recovered by 6 weeks, at this time it is reasonable to think about driving. The amount of time off work depends on the nature of the job and the commute but many people feel they need at least two months away from the office.
Many patients under-estimate the recovery period after joint replacement. Although the post-operative pain is relatively short-lived, it takes time to recover endurance and get back to being fully active. During the first couple of months some care is needed to minimise the risk of dislocation. When fully recovered, it is ok to enjoy sports like skiing, swimming, tennis, hiking, horse-riding and biking. Some sports including squash, water-skiing, marathon running and parachuting are best avoided
It is normal to feel tired during the first few weeks after surgery. During this period, the hip may feel sore,stiff and a little weak. The leg will be a little swollen and there may be significant bruising at the back of the thigh down to the knee.
It is not normal to have severe pain in the hip, wound redness/ leaking, calf pain/ swelling, breathlessness, or a fever. You should let Mr Bartlett or an emergency Doctor know immediately if you develop such symptoms.
Yes. You should expect to undergo an additional check and allow a few minutes of extra time for this. Security staff are well used to dealing with people with prostheses; an explanatory medical note is not required.
Whilst it is anticipated that revision hip replacement surgery will be required less often required in the future, approximately 8,000 procedures are still performed in England and Wales each year. Broadly speaking, the risk of requiring a revision procedure within the first decade after surgery is one in twenty.
In the past, it was common for the replacement parts to simply "wear-out" or even break. Thankfully these problems are now rarely seen. Revision surgery may be required for the treatment of infection, dislocation, fracture or if the implant becomes loose. Sometimes surgery is needed to correct the treatment of hip fractures. More recently, some people suffering from allergic reactions to Cobalt and Chromium ions released from the now discontinued "metal-on-metal" hip replacements have also needed further surgery.
Revision hip replacement surgery can vary greatly in complexity. The principal aims are to provide a dependable and anatomical reconstruction whilst preserving bone-stock and muscle function. Sometimes all that is required is a change of one component such as a worn liner or re-orientation of a component. Conversely, if there is a deep infection or significant bone loss in the femur or acetabulum (pelvic socket), reconstructive surgery can be extremely technically demanding.
Surgery will take between about 1 hour for a simple procedure to up to four or five hours for a more complex reconstruction. Generally, the risks of complications (such as bleeding, infection, fracture & dislocation) are increased and recovery is slower compared to a "first-time" total hip replacement. This underlines the critical importance of careful patient preparation, surgical experience and meticulous planning.