Treatment Options for Hip Disease

Hip arthritis is never life threatening, the main aim of treatment is therefore symptomatic for pain and to try to keep mobility and range of movement of the joint. Treatment follows a progression from simple measures to major surgical intervention.

Exercise – Low impact exercise such as walking, swimming and cycling keeps muscle strength and tone. Hip joint stretches to keep the hip supple are beneficial. A consultation with a physiotherapist for education and a home exercise program can be useful.

Walking stick – Using a walking stick in the opposite hand reduces load in the hip and usually increases your walking distance. A strong stick of correct length with a non slip rubber end is best.

Paracetamol – A simple but safe analgesic when used correctly. Often needs to be used 3 or 4 times a day (1000mg / 2 tablets on each occasion). This can be safely used by most people at prolonged periods at these doses.

Natural remedies – Often not proven but some people gain relief from various naturopathic potions, magnets, acupuncture and the like. This affect may be placebo but some plant substances have proven anti-inflammatory effects. You should check the use of these with your local Doctor as some may react with other medicines or be dangerous.

Glucosamine and Chondroitin Sulphate – The most common arthritis remedies at the present time. There is some early evidence that over time they may help to maintain articular cartilage and slow progression of Osteoarthritis. Nothing can ‘put cartilage back’ after Osteoarthritis is established. Some people also report a reduction in arthritis symptoms when taking these substances. Their main side effect is diarrhoea. They should not be taken if you are pregnant or allergic to shellfish.

Fish oils – Have been associated with some improvement in cartilage quality and may be beneficial.

Anti-inflammatories (NSAID’s) – Several types of Non steroidal anti-inflammatories are available. They can be very effective in reducing pain and swelling associated with osteoarthritis. All these medications have potential side effects and are not always tolerated. The most common effects are: exacerbating asthma, stomach upset (ulcers etc), increased blood pressure and ankle swelling.

Weight loss – There is no doubt that if you are above ideal weight, weight loss can have a significant impact in reducing pain from osteoarthritis. Weight loss can also reduce the risk of anaesthetic complications and wound healing. Many people after loosing weight no longer need surgery for their Osteoarthritis. You may be given an ideal weight to attain prior to consideration for surgery. Consulting a dietician may be beneficial.

Injections – A hip injection is often used by your specialist to differentiate between back pain and hip joint pain. An injection is given to ‘numb’ the hip and you then keep a record of the pain experienced. Sometimes steroids are used to provide longer relief of pain. The procedure is done under X-ray guidance with a small risk of infection.

Surgical Treatments

Arthroscopy – Hip arthroscopy is gaining both popularity and acceptance amongst hip surgeons. It is an ideal way to treat patients who have pincer or CAM lesions around the hip which are interfering with their activities. Such patients do not have disease which is sufficient to require joint replacement but can get symptomatic relief, though not a cure via hip arthroscopy.

Hip replacement – Hip replacement is considered when non-operative options have been used but have not proven beneficial. It is considered when a patient’s pain is affecting their function and quality of life to such a great degree that they cannot carry out routine activities of daily living, cannot sleep, cannot continue with their employment or enjoy activities with their families.

Clearly the indications for surgery can therefore vary in different age groups. In younger patients, traditionally using cemented hip replacements with a ultra-high molecular weight polyethylene liner, hip replacement was not considered until patients were virtually wheel chair bound. Using newer technologies with ceramic on ceramic, metal on metal, ceramic on metal or ultra-high molecular weight cross linked polyethylene liners and bearings, hip replacements are becoming increasing used in younger patients and these can include patients down to their late teens. In these younger patients function is very important, to enable them to continue with work or enjoy time with their families and children. Increasingly with a much healthier older population, conventional cemented hips with a metal ball and plastic liner are not suitable for these patients who are living well into their mid to late eighties and due to increased health, are much more active than their counterparts in the 1960s and 1970s.

A total hip replacement involves replacing the worn out ball and socket joint with an artificial one. It is the most successful operation of the 20th Century with 98 of every 100 people feeling it was worthwhile. It will usually provide lasting pain relief and improve function and activity levels. I aim to advice/implant the hip which is most appropriate to the patient in front of me. Therefore this may be a traditional cemented hip replacement in an elderly patient with low demand, it can be a hybrid hip replacement in elderly patients with high demand, uncemented hip replacements with hard on hard articulations in patients with high demand or hip resurfacing in appropriate patients.

I use hip implants from Lima and Corin together with Stryker implants for revision or redo surgery.
I believe that the implants I use provide sufficient versatility and flexibility for me to treat the patient in front of me appropriately, and have published results with regard to survival, function and complications and have met appropriate industry and NICE safety standards and have an ODEP (Orthopaedic Data Evaluation Panel) rating of 10A meaning that products comply with the 10 year benchmarks set by NICE.

What type of hip replacement am I suitable for?

The type of hip replacement chosen depends on a patient’s age, sex, quality of their bone, bony anatomy, underlying disease and functional demands.

Cemented Hip Replacements

These are the traditional hip replacements which have been used since the late 1950s. They are well established and have good results. They were initially designed for a patient population with low functional demand and were designed to provide pain relief only. They have limitations in that due to the biomechanics of the ball and socket, flexion of the hip beyond 90 degrees is not possible without an increased risk of dislocation and wear of the polyethylene liner.

Published results show that they can fail at between 10 and 12 years and the mode of failure is generally aseptic loosening. This is a condition where the metal ball wears away at the plastic liner and then the body mounts an inflammatory type reaction which causes loosening at the interface between the bone and the cement or grout which holds the hip replacement in place.

Cemented hip replacements are suitable for elderly patients with low functional demand. They are not advisable in the younger/active patient population as they can be associated with increased risk of redo or revision surgery and are not designed to meet the functional demands of such patients.

Hybrid Hip Replacement

This is a hip replacement which aims to get the best of both worlds in the older patient population. It uses cemented stem in the femur or thighbone and an uncemented cup. It can be used with a variety of head sizes and articulations. It relies on appropriate bone quality and therefore may not be appropriate for patients on high dose steroids or who are heavy smokers.

It is best used in the more elderly population who have high demand with regard to activities, and it provides them with a safer compromise and improved function over traditional cemented hip replacements.

Uncemented Hip Replacements

These form the bulk of my practice. They are used in patients from their late teens to their late eighties. These are very popular hip replacements in Europe, America and the Far East. These are technically more challenging to get right, though more rewarding if you have got them right.

The advantage lies in the fact that cement is not required and that these types of hip replacements have coatings which encourage natural bony in-growth into the implants.

These implants can be used in conjunction with a variety of articulations/bearing surfaces such as ceramic on ceramic, metal on metal, ceramic on metal or metal on ultra-high molecular weight cross linked polyethylene liners.

They can be used with a variety of head sizes from 28mm to 36mm and one can also do hip resurfacing on a stem with head sizes which are the same as the native ball in the ball and socket joint of the hip.
The usual head size I use is 36 mm and this can be used with metal, ceramic or highly crosslinked bearings and is associated with very few functional limitations i.e. doubles tennis is OK, but singles tennis is not.

With my uncemented hip replacements I use a Lima SL stem and a Delta TT Cup. This is a trabecularTM metal cup which allows excellent bony in growth and is very stable. I also use the Corin Metafix stem and Trinity Cup.

Hip Resurfacing

Hip resurfacing remains an excellent choice of hip replacement provided that the surgeon is experienced and patients are correctly chosen.

There has been much said in the Press about ALVAL and failures of hip resurfacings, and a group in Oxford and Tees have reported as much as a 10% failure rate.

The fact remains however that in men with over 52mm cup hip resurfacing are successful in 98.1% of cases.

In women the success rate falls to 89.1% however if one uses hip resurfacing only if one can get a 52mm cup and above in, then the success rate increases to approximately that of men.

The fact remains that women have an increased risk of ALVAL, hip resurfacing should only be done if one can get a 52mm cup and above in and that careful implant placement is important to reduce the risk of edge loading.

In women of child bearing age who have yet to start or complete their families, there is a theoretical risk of fetal abnormalities, though research from Birmingham suggests that the metal ions do not cross the placenta and so there is no real risk.

In addition hip resurfacings are suitable for women physiologically under 50 or men physiologically under 55. They are not appropriate for people with inflammatory arthritis or in people who are heavy smokers.

In my own series of hip resurfacings over the last several years, with an average of 100 hip resurfacings a year, my failure rate is 2.47%.