Introduction
Anatomy:
The hip joint is the joint between the upper end of femur (thigh bone) and the pelvis. It is shaped like a ball (femoral head) in a socket (acetabulum). The ends of these bones (articulating surfaces) are lined by a smooth and tough but elastic layer of hyaline cartilage. The joint is enclosed by a covering called the capsule. This is lined on its inner surface by a layer of synovium which secretes synovial fluid into the joint. This fluid lubricates the joint and provides nourishment to the hyaline cartilage. The hip derives its stability from the shape of the bones, and strong capsulo-ligamentous soft tissues. Large muscles span the joint and provide the strength to the lower limb.
Arthritis:
Damage to the cartilage can be caused by degenerative process (osteoarthritis), inflammatory process (rheumatiod arthritis, ankylosing spondylarthropathy, connective tissue diseases, etc.) or incongruity of joint surfaces (post-traumatic arthritis, avascular necrosis, developmental dysplasia, etc.). This causes pain on moving the joint. The movements become restricted and the capsule and ligaments become tight. This leads to deformities in all three planes. Hip deformities can cause severe secondary deformities in the spine and lead to leg-length discrepancy. The muscles controlling the hip become wasted. In some cases there is collapse of the femoral head and defects in the acetabulum (socket). The end-result is a painful, stiff joint with shortening (sometimes lengthening) and a severe limp. The knee is also affected secondarily. When both hips are involved the patient cannot spread his/her legs. This causes problems with perineal hygiene and difficulties with childbirth.
Treatment of arthritis of hip:
Treatment of hip arthritis in early stages involves activity modification, weight reduction, use of a stick, physiotherapy and analgesics. These modalities give partial relief in early stages. However, the wear & tear process of arthritis continues and pain worsens and patient develops stiffness and deformities. At this stage a hip replacement is advised. The decision is taken after assessing the extent of patient’s pain and disability, the physical findings on examination, the severity of arthritis on x-rays and the response to non-operative treatment.
Alternatives to hip replacement
Indications for Hip replacement
Hip replacement is recommended when there is:
- Severe pain which imposes limitation on activities of daily living like walking, getting into and out of a chair, getting up and down stairs, getting into and out of a car, going for shopping, attending family and religious functions, inability to sit on the floor or a low stool, etc.
- Pain and limited movements interfering with job
- Pain at rest or night pains causing disturbed sleep
- Severe pain with minor jerk, twist or mis-step
- Difficulty in walking on uneven surfaces or on the road; inability to walk for more the 10-15 minutes or a few hundred feet; difficulty in travelling
- Difficulty in reaching the floor, difficulty in wearing shoes, inability to reach the toes
- Difficulty with perineal hygiene (both hips need replacement)
- Inability to sit on the floor or cross-legged
- Severe limp with or without pain
- Leg length discrepancy
- Secondary deformities in the spine or knee with or without pain
- Inability to tolerate medications
- Persistent pain in-spite of using stick, medications, physiotherapy, etc.
Benefits of hip replacement:
- Provides complete and lasting relief of pain
- Improves quality of life
- Abolishes the need for painkillers
- Restores movement to the hip
- Enables activities of daily living without help
- Restores independence
- Enables outdoor activities like travelling, shopping, attending social functions, etc.
- Enables gainful employment
- Improves walking ability which has a positive impact on control of diabetes, hypertension, ischemic heart disease and obesity
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