Hip Surgery - Causes, Treatment, and Complications

Introduction:

It is a surgery of the hip joint and is performed to address various complications, pain being the most common. The surgery typically involves replacing the damaged part of the joint with an implant (artificial joint).

What Causes Pain in the Hip?

Hip pain is one of the most common complaints affecting patients of all ages. It can be due to a degenerative disease like arthritis, a sports injury, trauma, hip fracture, obesity, a birth defect, or even depression, for that matter. Location of the pain guides with the diagnosis, for example

A. Anterior Hip and Groin Pain- Observed in:

• Arthritis- Commonly seen as swelling and tenderness of the joints.

• Labral Tears- It is the injury to the tissue that holds the ball and socket joint together.

• Femoroacetabular Impingement- This happens when the hip joint is shaped abnormally, causing the bones to rub against each other.

• Iliopsoas Bursitis- It is the inflammation of the fluid-filled sac located below the iliopsoas muscle.

• Stress Fractures- These are tiny cracks in the hip bones due to overuse.

• Transient Synovitis- Often seen in children and lasts for a short time due to inflammation and swelling of the tissues around the hip joint.

• Osteonecrosis- Occurs when protective cartilage cushioning the hip bones gets worn down.

B. Posterior Hip Pain- Is seen in:

• Piriformis Syndrome- A condition where the piriformis muscle in the buttock region spasms and causes pain.

• Sacroiliac Joint Dysfunction- It is the improper movement of the joint between the sacrum and the pelvis.

• Lumbar Radiculopathy- It is a referred pain in the hip due to spinal nerve inflammation.

• Ischiofemoral Impingement- The impingement of soft tissues between the hip bones causes it.

• Vascular Claudication- This happens when the blood vessels supplying the hip become narrow, often due to fat deposits

C. Lateral Hip Pain- Commonly seen in:

• Greater Trochanteric Pain Syndrome- It is where the fluid-filled sacs near the hip get inflamed.

Radiographs and magnetic resonance imaging (MRI) are the most commonly preferred diagnostic tests.

How Is Hip Pain Treated?

Depending on the condition, the treatment is surgical, non-surgical, and sometimes both.

1) Non-surgical Options :

• Medication- Non-steroidal anti-inflammatory drugs (NSAIDs) are the drugs of choice if the pain is moderate and caused due to inflammation; they are also prescribed post-surgery.

• Physical Therapy- Often used in conjunction with surgery to strengthen the muscle and increase flexibility.

• Injections- It is an outpatient procedure that helps to relieve pain and to diagnose. Intra-auricular injection, psoas injection, and trochanteric bursa injection are the different types prescribed; all of them use corticosteroids.

Prolotherapy, stem-cell therapy, and platelet-rich plasma injections have recently gained popularity; however, they are often not suggested due to their limited availability.

2) Surgical Procedures: Depending on the anatomy, pathogenesis, and the surgeon's skill, they may suggest open surgery (surgical hip dislocation), hip arthroplasty (also known as a hip replacement), or hip arthroscopy.

A. Open Surgery (Surgical Hip Dislocation) - It is the preferred surgical technique for patients with-

• Femoroacetabular Impingement.

• High-Riding Trochanter from Old Perthes- It is a developmental disorder where the femur regenerates irregularly, causing pain and stiffness in the joint.

• Slipped Capital Femoral Epiphysis- Is seen in adolescents when the growth plate gets damaged, causing the femoral head to slip with respect to the rest of the femur.

• Anticipated Labral Reconstruction- Labral reconstruction is a surgical procedure that uses a graft to reconstruct the damaged labrum.

• Coxa Profunda or Global Overcoverage- It is where the acetabulum covers the femur.

• Posterolateral Cam Lesions- Occurs when the ball-shaped end of the femur is not perfectly round.

It is contraindicated for patients-

• Over 40 years and above.

• Extensive cartilage damage.

• Anterior hip subluxation.

• Anterior and posterior cartilage damage.

• Smokers.

Technique- The Ganz technique for surgical hip dislocation is considered the safest approach without the risk of avascular necrosis. It starts with trochanteric osteotomy through the posterior approach followed by anterior dislocation of the hip, avoiding injury to the femoral circumflex artery.

This technique allows almost 360° visualization of the femoral head and complete access to the acetabulum. This technique is sufficient for many pathological conditions, given that the surgeon has good experience in subluxation of the femoral head while preserving the round ligament.

B. Hip Arthroplasty (Hip Replacement Surgery)- It is an open surgery where the damaged parts are removed and replaced with a prosthesis. It is indicated for patients with-

• Osteoarthritis.

• Rheumatoid arthritis.

• Osteonecrosis.

• Hip fracture.

• Tumor in the hip.

• Congenital hip disorders.

Based on the amount of hip joint removed, this procedure is further subdivided into-

• Total hip replacement (or total hip arthroplasty).

• Partial hip replacement (hemiarthroplasty).

• Hip resurfacing.

Technique- The surgeon decides the approach based on the hip access, type of implant used, patient age, activity level, shape, and health of the bone. The most commonly used are the posterior approach (PA), direct lateral approach (DLA), and direct anterior approach (DAA).

In a traditional hip replacement, a single large incision, about 8 to 12 centimeters long, is made to access the hip. It starts with femoral neck osteotomy followed by periacetabular osteotomy or acetabular reaming, depending on the amount of damage and deformity. The implants are then placed in place of the removed bone and cartilage.

Three separate implants are involved in a hip replacement surgery: the stem, the ball, and the socket. The stem is made of titanium or cobalt chrome and is inserted into the femur. The ball is also made of metal and placed on the stem. Finally, the socket is a combination of a plastic liner with titanium backing.

A minimally invasive has become a popular choice recently, where the surgeon accesses the hip joint through one or two small incisions along with the muscle. Still, it is not appropriate for all patients.

C. Hip Arthroscopy- It is a minimally invasive approach to treat many problems. It is indicated in patients with:

• Chondral Defects- This happens when the cartilage lining the bones gets damaged.

• Ligamentum Teres Injury- A condition where the ligament connecting the ball and socket joint gets ruptured.

• Synovial Disease- It is caused due to defects in the synovial fluid lining the bones.

• Septic Arthritis- It is an infection in the joints of the hip.

• Capsular or Gluteal Tears- Mostly seen in athletes because of repetitive trauma.

• Trochanteric Bursal Debridement- A procedure that decompresses the iliotibial band rubbing against the bursa.

• Piriformis Debridement- It is a procedure done to decompress the sciatic nerve by decompressing the piriformis muscle.

• Femoral Acetabular Impingement.

• Labral Tears- These are injuries of the labrum; a labrum is a thick tissue present in the ball and socket joint of the shoulder.

• Ischiofemoral Impingement- It is a type of pain caused due to impingement of the soft tissues present between the joints of the femur.

• Proximal Hamstring Tears- Hamstrings are muscles present in the back of the thigh, and any injury to these muscles is known as hamstring tears.

Technique- In hip arthroscopy, a small incision is made to the hip to insert an arthroscope (flexible tube with a camera). The arthroscope displays the injuries, damage, and other abnormalities on the monitor; two additional cuts are made to insert special surgical tools for treatment. Different procedures that can be performed using a hip arthroscopy are:

• Synovectomy.

• Labral debridement.

• Labral refixation.

• Partial psoas release.

• Acetabuloplasty.

• Osteochondroplasty.

• Arthrotomy.

• Iliotibial band release.

• Trochanteric bursectomy.

• Gluteus medius repair.

• Chondroplasty.

How Long Does Hip Surgery Take?

Depending on the procedure, surgical hip dislocation takes around two to three hours, total hip replacement takes around two hours, whereas hip arthroscopy takes one and half hours, give or take.

Who Will Be Put Under for Hip Surgery?

Hip arthroscopy is done under local anesthesia, whereas hip replacement surgery and other open surgeries are done under general anesthesia. An epidural is commonly used, but for procedures that take more than three hours, a spinal block is preferred.

Should the Patient Be Hospitalized After the Surgery?

A few arthroscopic procedures can be done on an outpatient basis. For most of them, patients will have to stay in the hospital for one to two nights.

What Are the Complications of Hip Surgery?

Complications following hip surgery are usually low; some of them include-

• Infection.

• Blood clots.

• Dislocation.

• Change in leg length.

• Nerve damage.

• Implant wear.

To prevent post-op complications, specific precautions depending on the type of hip surgery, will be provided to the patient by the surgeon or a physical therapist. Typically, a brace is worn to prevent extreme flexion; the patient is actively encouraged to move using crutches or a continuous passive motion (CPM) machine.

How Long Do the Implants in Hip Replacement Surgery Last?

Hip replacement implants last around 10-15 years, depending on the type of implant and the patient's age. If the prosthesis wears off in due time, the patient will need hip revision surgery.

Can Both Hips Be Replaced at the Same Time?

Patients younger than 75 years with no history of heart disease can have both hips replaced at once.

Conclusion:

The ultimate aim of any hip surgery is to reduce the pain and discomfort of the patient. It is a multidisciplinary approach involving an orthopedic surgeon, physician, nurse practitioner, and physical therapist. Hip surgeries are well tolerated and have a consistent success rate in orthopedics.