The most common form of arthritis affecting the hip is osteoarthritis, which describes a disease process where the once smooth articular cartilage becomes rough and pitted. Normal articular cartilage is smooth and extremely slippery, allowing for motion of the joint with minimal friction. Healthy cartilage also functions as a shock absorber. In hip osteoarthritis, the articular cartilage of your femoral head and acetabular socket thins, frays and pits. With advanced disease, the underlying cortical bone is exposed, and your joint bearing becomes bone-on-bone. This rubbing of roughened surfaces and exposed bone causes pain, joint swelling, grating and reduced range of motion in the joint.
There are many causes of hip arthritis, though most have no known single causative factor. Specific causes include hip joint infection, inflammatory arthritis and following trauma to the hip. For the common osteoarthritic hip, muscle weakness can lead to instability in the hip and altered load bearing of the joint. Weaker muscles also function as poorer shock absorbers in protecting the hip, leading to increased forces across the joint. Over time this can lead to increased wear, and eventually the symptoms of osteoarthritis.
Many risk factors are known for the development of hip osteoarthritis and include:
- Increased age
- Being overweight
- Muscle weakness and loss of general conditioning
- Previous injury to the joint
- Inherited cartilage disorders
- Family history
- Malformed hip joints, such as from childhood hip disorders like hip dysplasia and a slipped capital epiphysis.
Early intervention and control of the risk factors can limit the progression of the disease, and in many can remove the need for surgical intervention. In those where the symptoms begin to impact on quality of life, surgery in the form of a joint replacement can restore your mobility and reduce your pain, allowing you to do the things in life you love.
What symptoms will I have if I am developing hip arthritis?
The common symptoms for all types of arthritis are pain, joint weakness and a feeling of instability, and a decreased range of movement that slowly impacts on your ability to perform daily activities such as getting out of a chair, climbing stairs and squatting. Specific symptoms that may indicate you have hip arthritis include:
- Hip joint reduced range of movement, particularly noted when people sit in a deep chair or with any activity that rotates the hip joint, such as crossing the legs.
- Hip joint stiffness, which is often worse of a morning or after prolonged activity. Stiffness that gets better with movement is common with inflammatory arthritis.
- Weak hip muscles, most commonly noted when rising from a deep chair/car seat, squatting and stair climbing.
- Hip joint swelling can lead to joint stiffness that comes and goes.
- Hip joint deformity leads to reduced range of motion, and can also lead to a loss of leg length and subsequently altered gait (often looks like someone walking with only one shoe on).
- Pain is the dominant feature that forces people to seek assistance, and is most commonly reported as pain in the groin. However, the pain can be in the buttock, thigh and even radiate down to the knee. The pain is often dull, but can be severe with flareups, and is usually worse following activity and relieved with rest.
How can I confirm if I have hip osteoarthritis?
If you are experiencing any of the above symptoms, seek review with your local doctor and request an xray of the hips. An xray will show whether or not there are any signs of arthritis, with the features your doctor looks for being:
- joint space narrowing
- formation of osteophytes around the joint
- irregular joint surfaces
- dense subchondral bone
- formation of bony cysts
If you are found to have signs of hip arthritis and you have failed simple non-operative treatment measures, your local doctor will refer you to an orthopaedic surgeon for review. Dr Host has a special interest in disease affecting the hip joint and would be happy to review you.
What non-surgical treatments are available?
As with all types of arthritis, surgery is only contemplated when non-operative measures have been tried and failed. The first step is control of any of the risk factors that are within your power to change. These include:
- cessation of smoking
- weight loss
- treatment of any inflammatory arthritis
Focused treatments for hip arthritis include:
- pain killers
- dietary supplements
What pain killers should I be using?
For control of the symptoms of arthritis, the following measures can be used:
- simple analgesis medications such as paracetamol and over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs – neurofen, voltaren) can be used to help reduce your pain.
- stronger prescribed NSAIDs (mobic, celebrex) can be useful in some patients, but should only be taken following discussion with your local doctor as there are many potential side-effects and cross reactions with other medications.
- narcotic based analgesics such as panadeine forte, endone, ms contain and morphine should only ever be used as short term solutions to acute flare-ups of pain. These should not be taken for more than a few days consecutively. If you are requiring these drugs to perform your daily tasks, you should seek surgical review for a more permanent, drug free solution.
What supplements or alternative therapies can I use for my arthritis?
Many supplements have been marketed to help with arthritis, but sadly few have solid evidence of success in all patients. What does this mean? It means that you can try any or all of the alternative therapies available, and keep using those that have results for you, but avoid those that are not showing any signs of improvement. Therapies that have helped some patients include:
- orthotics in those who also have foot alignment problems
- fish oil
- danocrub/tiger balm
- topical ice packs
- dietary supplementation with calcium, phosphate and vitamin D
Dr Host recommends with all of these therapies that you use the therapy on a trial basis – give it a go for a month or two, and then stop. If when you cease the therapy you feel worse, then it clearly is helping you and you should continue it. If you cease the therapy and feel no different, save your time and money and look for another option. Only ever begin new treatments having discussed them first with your local doctor.
What surgery can be done for my arthritic hip?
There is only one surgical option for an arthritic hip, and that is hip replacement surgery. Older therapies involving fusion or excision of the joint have fallen out of favour and are now only used in extreme circumstances where a joint replacement is not possible. Ongoing medical implant advances have led to the production of joint replacement techniques that yield a 95% good or excellent result, and over 92% survival at 20 years. Newer bearing surfaces will likely see that survival continue for longer. The most common procedure is a total hip replacement, which involves removal of the femoral head and acetabular cartilage, and insertion of a new stem, head, and cup. There are many types and many different materials used, with the most common being a metal head on a plastic cup. The implants can be cemented in place or can be inserted with coatings to encourage bony ingrowth to the implants, with often both techniques used in a hybrid model. In some patients, a modified version of a hip replacement called a hip resurfacing is used. Should your hip be suitable for this method, Dr Host will discuss it with you in detail.
Will my hip be metal-on-metal?
No – Dr Host does not use implants that have a metal-on-metal bearing surface for a total hip replacement. These have understandably received bad press with some designs showing increased and early failures. Dr Host has never used such implants, instead preferring metal on plastic, ceramic on plastic or ceramic on ceramic bearings, as dictated by each individual’s functional requirements.
How long does the surgery take?
A total hip replacement takes between 1-2 hours to complete, though frequently the whole trip through theatres will take 3-4 hours. You will be moved to a ward following your surgery, and once you have awoken from your anaesthetic, you will begin your rehabilitation.
When will I be able to walk after surgery?
The ideal situation is that you are helped to walk the same day as your surgery – the sooner we have you up and about, the quicker we can get you going and home. Your rehabilitation will start as soon as you are medically able to tolerate it.
How long will I be in hospital for?
The average length of stay is 3 days, with some home sooner, and others requiring longer periods in rehabilitation before being able to function independently at home. You will not be discharged from hospital until you have been cleared by a physiotherapist – they will only let you go when you can safely perform the daily activities you would need to do at home. The fitter and more active you are before surgery, the easier you tend to find your recovery after surgery. For those who find the going a bit slow, that is ok too. You will usually be transferred to a specific rehabilitation unit for more intense treatment prior to your discharge home. For patients wanting to avoid a hospital stay, same day of surgery discharge in an option. Not all patients are suitable for this, but if you would like to be considered for this, please discuss the option with Dr Host and his team.
When will I be able to do full activity following surgery?
A hip replacement tends to be tolerated much better than a knee replacement, and most people find that by 4-10 weeks they are able to function with minimal problems. Again, this depends on your function prior to surgery – if you were severely limited before surgery, it will take longer to rebuild muscle and motion of the joint. Most people find that the pain side of the arthritis fades rapidly, with the function showing ongoing improvement over the first 12-24 months. There are particular activities which will need to be avoided, some in the short term, and some indefinitely. These will be discussed with you prior to any surgery, but most find they do not stop them from doing activities they would like to do.
Hip replacement via the anterior minimally invasive surgical (AMIS) technique can lead to patients achieving rehabilitation milestones and returning to regular activities earlier. If you are suitable for the AMIS technique, Dr Host will discuss the recovery with you.
When can I drive after my procedure?
You can drive when you are able to safely control your vehicle. It is a question of competence rather than a specific period of time. For most, this is between 2 – 6 weeks, but can be quicker or longer, depending on your progress with your rehab. Most cars have quite deep seats, and the motion you put your hip through in getting in and out is the exact motion that can lead to dislocation of the prosthetic joint. Your physio will show you an altered way of entering and exiting a vehicle that will protect the hip.
When you feel you can safely enter and exit the vehicle, and safely and quickly control the pedals, you can resume driving.
What should I look out for following surgery?
If you experience an increase in pain or swelling, and if the wound becomes red and hot to touch, you should seek urgent review with Dr Host or your local GP. You may be developing an infection, and the earlier treatment is started, the better your result.
If you develop any lower leg/calf swelling or pain, or any shortness of breath, chest pain or rapid breathing and pulse, seek urgent review at your closest hospital.