Hip Joint Health
Do you know that the hip joint is one of the body’s largest joints? It is a ball-and-socket joint; the socket is formed by the acetabulum, which is part of the large pelvis bone, and the ball is the femoral head, which is the upper end of the femur or most commonly known as thighbone.
The bone surfaces of the ball and socket are covered with articular cartilage, which is a slippery substance that protects and cushions the bones besides enabling them to move more smoothly. The surface of the joint however, is covered by synonium, a thin lining that produces a small amount of fluid that lubricates the cartilage and aids in normal movement.
What you need to know:
A hip fracture is a break in the upper quarter of the femur (thighbone), to which the severity of the break is varied by the force or impact that causes it. The severity of the fracture, as well as the bones and soft tissues that are affected will largely determine what type of surgery or treatment is more effective in restoring optimum hip joint health.
Hip fractures most commonly occur from a fall or from a direct blow to the side of the hip. Certain medical conditions such as osteoporosis, cancer, previous or existing stress injuries can weaken the bone, making the hip more susceptible to breaking and fractures. In severe
cases, it is possible for the hip to fracture even from the patient merely standing on the leg or doing slight twists.
- Experience pain over the outer upper thigh area or around the groin.
- Significant discomfort with any simple attempt to flex or rotate the hip.
- If the bone has been weakened by disease – stress injury or cancer – the patient may also notice aching in the groin or thigh area for a prolonged period of time before the actual fracture occurs.
- If the bone is completely broken, the affected leg may appear to be shorter than the non-injured leg. The patient’s foot and knee will appear to be turned outwards (external rotation) in an attempt to hold the injured leg in a still position.
The diagnosis of a hip fracture is generally made by an X-Ray imaging of the hip and femur area, since it usually occurs at the upper end of the femur (thighbone).
IN SOME CASES WHERE AN INCOMPLETE FRACTURE MAY NOT BE VISIBLE ON A REGULAR X-RAY, A MAGNETIC RESONANCE IMAGING (MRI) SCAN MAY BE RECOMMENDED. THE MRI SCAN WILL USUALLY SHOW A HIDDEN FRACTURE.
IF A PATIENT IS UNABLE TO UNDERGO AN MRI SCAN DUE TO ASSOCIATED MEDICAL CONDITIONS, A COMPUTED TOMOGRAPHY (CT) SCAN MAY BE REQUIRED INSTEAD. HOWEVER, A CT SCAN IS NOT AS ROBUST AS AN MRI SCAN IN SHOWING HIDDEN HIP FRACTURES.
Types of Fractures
There are three different types of hip fractures; the type of fracture depends on which area of the upper femur is involved.
- Intracapsular Fracture
Intracapsular fractures occur at the neck and head area of the femur, and are generally within the capsule, hence its namesake.
INTRACAPSULAR FRACTURE OCCURS AT THE ‘NECK’ LEVEL OF THE BONE, AND MAY RESULT IN LOSS OF BLOOD SUPPLY TO THE BONE.
- Intertrochanteric Fracture (Extracapsular Fracture)
This type of fracture occurs between the neck of the femur and a lower bony prominence called the ‘lesser trochanter’, which is an attachment point for one of the major muscles of the hip
INTERTROCHANTERIC FRACTURES OCCUR FURTHER DOWN THE BONE AND TENDS TO HAVE BETTER BLOOD SUPPLY TO THE FRACTURED PIECE
Subtrochanteric fractures occur below and within 2.5 inches below the lesser trochanter. In more complicated cases, the amount of breakage of the bone may involve more than one of these zones, or broken into several pieces.
SUBTROCHANTERIC FRACTURES OCCUR EVEN FURTHER DOWN THE BONE, AND THE BONE MAY BE BROKEN INTO SEVERAL PIECES.
Once the diagnosis of the hip fracture has been confirmed, the patient’s overall health and medical condition will be evaluated. Most surgeons recommend that patients’s prognosis and recovery is better if they are operated on as soon as possible. However, it is very important to ensure that the patient’s safety and overall medical health allows for any surgery to be done, thus this may mean taking the appropriate time to perform cardiac and other diagnostic studies.
- Non-surgical treatment
Patients who are too ill or unfit for anesthesia and those who are unable to walk before their injury or have been confined to a bed or wheelchair will be considered for non-surgical treatment.Certain types of fractures may also be considered stable enough to be managed without surgery, however doctors will need to follow up with periodic X-ray scans of the affected areas to control these ‘stable’ fractures, for risk of displacement over time. If patients are confined to bed-rest as part of the fracture managements, they will be closely monitored for risk of complications that might occur from prolonged immobilisation such as infections, bed sores, pneumonia, blood clots and nutritional wasting.
STABLE IMPACTED FRATURE. CERTAIN FRACTURES THAT HAVE NOT DISPLACED OR MOVED MAY NOT REQUIRE SURGERY, BUT ARE OFTEN FIXED SO MINIMISE THE RISK OF MOVING LATER ON.
- Surgical treatment
The surgeon will recommend the best surgical option to fix a fracture based on the area of the hip that is broken as well as the surgeon’s familiarity with the different systems that are available to do so.Before any surgery is undertaken, anesthesia will be employed, it could be either general anesthesia with a breathing tube or spinal anesthesia. In very rare cases where only a few screws are planned for fixation, local anesthesia with heavy sedation can be considered. All patients will receive antibiotics during surgery and for 24-hours post-surgery.Appropriate blood tests, chest X-rays, electrocardiograms and urine samples will be obtained before surgery. In some instances, elderly patients may have undiagnosed urinary tract infections that could lead to an infection post-surgery.
Patients will be discharged from the hospital back home or to a rehabilitation facility to assist them regain the ability to walk and recover.
- Pain Management: Pain that is associated with post-surgery is a natural part of the healing process, but doctors and nurses will work together to reduce your pain and discomfort, which will help to speed up recovery. Medications are often prescribed for short-term pain relief post-surgery or injury as well.
- Rehabilitation: Patients may be encouraged to get out of bed on the day following surgery with the assistance of a physical therapist who will work with the patient to help him or her to regain the strength and ability to walk. Usually the rehab process may take up to three months.
- Medical care: Occasionally post-surgery, a blood transfusion may be required after surgery, but longer term antibiotics are generally not needed. Most patients will be given medication in the form of pulls or injections to thin their blood to reduce the risk of developing blood clots, this may take up to 6 weeks. Elastic compression stockings or inflatable compression boots may also be used.
- Follow-up care: During appointments that take place after surgery, the surgeon or doctor will want to check the wound, remove sutures, check-up on the healing process using X-rays or prescribe additional physical therapy if necessary. Most patients will regain much, if not all, of the mobility and independence they had before injury post-surgery.
Arthritis is the inflammation of the body’s joints such as the knees or hips, causing a breaking down of cartilage tissue that it causes pain, swelling and deformity. Osteoarthritis – also known as degenerative joint disease or age-related arthritis – it is the most common type of arthritis and is more likely to develop slowly over many years and as people get older. Cartilage is a firm, rubbery material made up of water and proteins that covers the ends of bones in normal joints, serving as a ‘shock absorber’ and to reduce friction in the joints. Damaged cartilage may undergo repair, but the body does not grow new cartilage after injury.
There is no single specific cause for osteoarthritis, however there are certain factors that makes an individual more susceptible to the disease:
- Increasing age
- Family history of osteoarthritis
- Previous hip joint injury
- Developmental dysplasia of the hip – an improper formation of hip joint at birth
Yet, one might still develop osteoarthritis even if he/she does not have any of the above risk factors.
A patient with hip osteoarthritis will experience pain around the hip joint that usually develops slowly and worsens over time, although sudden onset is also possible. The pain and stiffness is usually worse in the morning or after sitting or resting for a while. Over time, the pain symptoms may occur more frequently, during rest time or at night.
Additional symptoms include:
- Pain in the groin or thigh area that spreads to the buttocks or knees
- Pain that flares up with vigorous activity • Hip joint stiffness that makes it difficult to even walk or bend
- Joint ‘locking’ or ‘sticking’ and a grinding noise (crepitus) during movement. This is caused my loose fragments of cartilage and other tissues interfering with normal hip motion
- Decreased hip motion range that affects the ability to walk, and may cause a limp
- Joint pain that increases with rainy weather
Before conducting physical examinations and other diagnostic tests, the Doctor will talk with the patient about his/her symptoms and medical history.
During the physical examination, the Doctor will ask look the following signs:
- Tenderness around the hip area
- The range of assisted and active motion
- Any grinding sensation inside the joint with movement (crepitus)
- Whether there is any pain when pressure is placed on the hip
- Any other signs of injury to the muscles, tendons and ligaments surrounding the hip.
Besides, the Doctor will also assess the way you walk and if there is any problems or issues with it.
Further imaging tests like X-rays provide detailed pictures of the impacted area. The X-ray image of an arthritic hip may show a narrowing of the joint space, changes in the bone, and the formation of bone spurs (osteophytes).
Occasionally a magnetic resonance imaging scan (MRI), a computed topography scan (CT) or a detailed bone scan may be needed to better determine the condition of bone and soft tissues of the hip.
There is no cure for osteoarthritis, fortunately there are a number of treatments that can help relieve pain and improve a patient’s mobility.
- Non-surgical treatment
Early treatment of hip osteoarthritis is non-surgical treatment, as with other arthritic conditions. There are a range of non-surgical treatment options available such as lifestyle modifications, regular individualised physical therapy programmes, the use of assistive devices and medications, depending upon the extent of disorder.
- Surgical treatment
Surgery will be recommended by the doctor if the pain from arthritis causes disability and is not relieved by non-surgical treatment. Possible surgical treatments include total hip replacement, hip resurfacing and osteotomy, although it is rarely a treatment option.
As with any surgery, complications are possible, however, the Doctor will take the necessary steps to minimise the risks, most commonly infections, excessive bleeding, blood clots, hip dislocation, limb length inequality and damage to blood vessels or arteries.
Recovery time for any hip osteoathritis surgery and rehabilitation depends on the type of surgery performed. Doctor may recommend physical therapy post-surgery to help patients regain strength in their hips and to restore range of motion. Canes, crutches or walkers may be required for some time after surgery as well.
Osteonecrosis of the Hip / Avascular Necrosis (AVN) of the Hip
Osteonecrosis of the hip (also called avascular necrosis or septic necrosis) is a painful condition that occurs when the blood supply to the thighbone (head of the femur) is disrupted. Bone cells require a steady supply of blood to stay healthy, and osteonecrosis can ultimately lead to the destruction of the hip joint and severe arthritis. Osteonecrosis can occur in any bone, yet it most often affects the hip; more than 20,000 people seek treatment for osteonecrosis of the hip each year, and in many cases, both hips are affected by this condition
When the blood supply to the femoral head is disrupted, the bone in the femur head is unable to receive adequate nourishment, causing it to gradually collapse and die. As a result, the articular cartilage covering the hip bones collapses as well, leading to disabling arthritis. Although osteonecrosis can affect anyone, it is more common in people between the ages of 40 and 65. Men are also more at risk compared to women.
- The actual cause for lack of blood supply to the femoral head is not always known, but doctors have identified various risk factors that makes someone likely to develop osteonecrosis:
- Previous hip injuries such as hip dislocations, fractures can damage the blood vessels and impair circulation to the femoral head.
- Excessive alcohol use over time can cause fatty deposits to form in the blood vessels which in turn elevate cortisone levels that results in decreased blood supply to the bone.
- Corticosteroid medicines that treat many diseases including asthma, rheumatoid arthritis and systemic lupus erythematosus may increase the risk of osteonecrosis of the hip. Although it is still not known exactly how or why these medications can lead to osteonecrosis, research do show that there is a connection between long-term corticosteroid use and the onset of this condition.
- Osteonecrosis is associated with other medical conditions such as Caisson disease (diver’s disease or ‘the bends’), sickle cell disease, myeloproliferative disorders, Gaucher’s disease, systemic lupus erythematosus, Crohn’s disease, arterial embolism, thrombosis and vasculitis.
Osteonecrosis of the hip develops in stages. Hip pain is typically the first symptom, this may then lead to a dull ache or throbbing pain in the groin or buttock area. As the disease progresses, it will become more difficult to stand and to put weight on the affected hip, even the moving of hip joint is painful. This disease progression may take several months to over a year, thus it is important to take note of any pain in the hip and to obtain early diagnosis, as early treatment is associated with better outcomes.
THE FOUR STAGES OF OSTEONECROSIS: THE DISEASE CAN PROGRESS FROM A NORMAL, HEALTHY HIP (STAGE I) TO THE COLLAPSE OF THE FEMORAL HEAD AND SEVERE OSTEOARTHRITIS (STAGE IV)
After discussing the patient’s symptoms and medical history, the Doctor will examine the hip to determine which specific motions causes the pain. Patients with osteonecrosis often have severe pain in the hip joint but relatively good range of motion. This is because in the earlier stages of the disease, only the femoral head is involved, but as the surface of the femoral head collapses in the later stage, the entire joint becomes arthritic. Loss of motion and stiffness then develops.
X-rays provide detailed insights as to whether the bone in the femoral head has collapsed and to what degree.
(LEFT) AN X-RAY OF A HEALTHY HIP JOINT. (RIGHT) THE COLLAPSE OF THE FEMORAL HEAD IN THE LATER STAGES OF OSTEONECROSIS (RIGHT)
Osteonecrosis is typically seen as a wedge-shaped area with a dense whitish sclerotic border in the superior lateral portion of the femoral head. On lateral view, the a lucent line called ‘crescent sign’ can often be seen just right below the surface of the femoral head.
THIS X-RAY SHOWS OSTEONECROSIS OF THE HIP. (RIGHT) VIEWED UP CLOSE, THE X-RAY REVEALS THE CRESCENT SIGN THAT IS TYPICALLY SEEN BEFORE THE COLLAPSE OF THE FEMORAL HEAD.
Magnetic resonance imaging scans (MRI) can detect early changes in the bone that may not show up on an X-ray scan. These scans are used to evaluate the degree of bone affected by the disease. An MRI scan may also show early osteonecrosis that has yet to cause symptoms (eg. osteonecrosis that may already be developing in the opposite hip joint).
THIS MRI SCAN SHOWS OSTEONECROSIS IN THE PATIENT’S RIGHT HIP (WHITE ARROW). THE DARK LINE (RED ARROWS) DENOTES THE BORDER BETWEEN DEAD BONE AND LIVING BONE. THE PATIENT’S LEFT HIP IS NORMAL AND UNAFFECTED.
Non-surgical treatment options such as anti-inflammatory medications, activity changes, and using assistive devices like crutches, can relieve pain and slow down the progression of the disease. However, osteonecrosis of the hip are most successfully treated with surgical treatments such as core decompression, osteochondral grafting, vascularised fibula graft, and total hip replacement. Patients with osteonecrosis in its early stages (before the femoral head collapses) are potential candidates for hip preserving procedures.
The surgical treatment options depend on the stages of osteonecrosis diagnosed.
Post surgery and rehabilitation, it usually takes a few months for the bone to heal and during this time, patients will need to use a walker or crutches to avoid putting extra stress on the damaged bone. Patients with successful core decompression procedures typically recover to walk unassisted in approximately 3 months with complete pain relief. A majority of patients with total hip replacement surgery performed will successfully be relieved of pain with hip function restored.
Adult Dysplasia of the Hip / Neglected Developmental Dysplasia of the Hip (DDH)
The hip is a ‘ball-and-socket’ joint; with the ball at the upper end of the thighbone (femur) fitting firmly into the socket, which is part of the large pelvis bone. In babies and children with developmental dysplasia (dislocation) of the hip (DDH), the hip joint has not formed normally – the ball is loose in the socket causing it to dislocate more easily.
Although DDH is most often present at birth, it may also develop during a child’s first year of life. Recent research shows that babies whose legs are swaddled too tightly with the hips and knees straight have a notably higher risk of developing DDH after birth, thus it is crucial that parents learn to properly and safely swaddle their infants, as when done improperly, swaddling may lead to problems in later life such as DDH.
Adolescent and adult dysplasia come in three forms:
- dysplasia that was previously treated
- dysplasia that was not treated
- Long-term untreated dysplasia that progressed to early arthritis
DDH tend to run hereditarily, and can present in either hip and in any individual. It usually affects the left hip and is predominant in girls, firstborn children and babies cradled in low levels of amniotic fluid are also at . Babies born in the breech position (especially with feet up by the shoulders) are also at risk of being affected by DDH, thus the American Academy of Paediatrics now recommends ultrasound DDH screening of all female breech babies.
The patient would normally be coping with varying severity of limb shortening their whole life, and often present with an onset of hip or groin pain later in life. Patient would have been limping as well due to the limb length discrepancy.
After discussing the patient’s symptoms and medical history, the Doctor will examine the hip to determine which specific motions causes the pain. Patients with DDH often have sever pain in the hip joint and lost in a range of motion, especially internal rotation. There may also be varying severity of limb shortening as the most severe form may have a dislocated femoral head that has migrated superiorly and form a pseudojoint at a higher hip center
X-rays may show the varying severity of dislocation, the position of the femoral head in relation to the acetabulum, the severity of the acetabulum dysplasia and the existence of pseudojoint and the degenerative changes associated with prolonged neglect. CT scans may also be necessary to assess the bone deformity prior to any surgical intervention, if needed.
Non-surgical treatment options such as supportive measures are usually the first line of treatment for adult dysplasia of the hip. The Doctor may recommend surgical measures such as periacetabular osteotomy with / without a femoral osteotomy, salvage pelvic osteotomy, or even total hip anthroplasty depending on the severity of the dislocation and condition.