Welcome to Sussex Hip Replacement. This site is an information resource to assist people with hip pain or hip arthritis who might benefit from treatment. This site has been developed by the team at the Sussex Hip Clinic, and focuses on non-operative treatment, prevention advice and conditions where operative treatment may have a role. Proceedures such as Hip Arthroscopy, Hip Replacement, and Hip Revision (re-do) are discussed using some of the most modern, state-of-the-art procedures available, including Custom Hip Replacement from Symbios, PrP injections for early hip degeneration, and Hip arthroscopy for Cam Impingement.
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Prevention of Hip Arthritis
Some aspects are beyond our control such as genetics, hover there is a role for optimising our "hip health" for the prevention, or delay of hip arthritis. What can we do?
1. Slim DownExtra body weight is bad on two counts; firstly increased forces through the hip and secondly the fat tissue has a role in secreting "bad" or damaging chemicals that effect the health of the surface cartilage.
There is a direct link between body mass and hip arthritis, both in those coming to hip replacement and those with developing hip problems in from young adulhood. Loosing wieght is the number one prevention strategy to reducing your risk of hip or arthritis.
Extra carried pounds are amplified by factor of three, because the hip acts as a fulcrum with body weight on one side being balanced by powerful muscles on the other side. The good news is for each pound lost there are three pounds less going through the hip joint (both of them). Furthermore the fat tissue (called adipose) secretes messenger chemicals which are harmful to cells.
To loose weight the combination diet works well; eat less and exercise more. Non or low impact exercise is prefered over impact exercises such as running. The BBC have a wonderful Body Mass Calculator that works in both metric and good old fashioned units.It is also thought that forces through the hip from extra body weight and/ or sports during the hip growth years (to late teens) can affect the shape of the hip ball, probably leading to a non-spherical, or cam shaped hip ball. This presents later as cam impingement or a labral tear (hip cartilage). Strategies such as training modifation and weight control during the hip growth years may be useful. We know that non ball shaped hips can be seen as early as age 10 from CT scan studies.
2. Eat with flavour: Alliums.
There is increasing evidence between the role of nutrician (diet) and health, for example the mediterran diet which is rich in fish, fruit vegetables and olive oil is assosciated with a 15 year increase in longevity and a reduction in just about every disease state. The food group most assosciated with a powerful reduction in hip arthritis risk are the alliums. The alliums include onions, garlic, and chives. Eye watering.
There is powerful evidence for glucosamine and chondroitin in the knee, however the hip is less well studied. There are good levels of support and positive background theory for Rose Hip extract, (the word hip in this context is purely coincidence)
4. Shock absorbing footwear.
In theory the peak stresses through the joint are reduced by the dampening effect of shock absorbing footwear. Running shoes (trainers, not the ones with spikes) designed for running and the absorption of musculoskeletal stress at heel strike, therefore lessens the peak stress through the joints. In fact one company has produced arthritis shoes. Some patients find walking on hard surfaces more painful than softer surfaces such as grass so there probably is some merit in the concept of peak stress reduction.
Land based exercise has a powerful effect in reducing pain from hip arthritis (2010 OARSI study).
Treatment without surgery
The Osteoarthritis Reasearch Society International allows ranking of non-operative treatments. In order of effectiveness, top first (most important), non-medical:
- Chontroitin Sulphate effect size 0.75
- Glucosamine Sulphate effect size 0.58
- Exercise on land for hips effect size 0.38 (this is non specific, any exercise helps. An exercise bike is a logical choice, set the saddle hieght high.)
- Rosehip extract effect size 0.38
- Acupuncture effect size 0.35
- Mild weight reduction (6kg) effect size 0.20. - (so go large!, well thin) Read this 1 stone weight loss, nutrician improvement and exercise program study.
- Electromagnetic therapy effect size 0.16
- Exercise in water effect size 0.19
- Education / information effect size 0.06
Some patients report quite astonishing pain relief with dietary modification, although supportive data is lacking.
Injections into the hip joint
Thes may have a role in some patients: The options are: Corticosteroid (cortisone), viscosupplements and Platelet Rich Plasma (PrP) injections. When high quality studies only are looked at the role of viscosupplementation drops down the rankings considerably according to the OARSI. At The Sussex Hip Clinic we only use cortisone, local anaesthetic and PrP injections.
There is positive but limited, data on PrP injections for hip arthritis.
There are many data sources on corticosteroid injections to the hip. It is a procedure which we carry out frequently. Either for pain relief in the medium term (typically 3 months, but varying from no effect to 9 months of relief) or to clarify the diagnosis when injected with local anaesthetic.
Hip Injection. This is normally carried out whilst awake; checks and
consent for the procedure are undertaken. A small support behind the knee
creates more room for the fluid to be injected into the hip joint space. The
skin at the front of the thigh is cleaned with antiseptic. A thin needle
(thinner than a blood test needle) is guided down to the hip joint. This is
done with or without imaging assistance depending on experience and patient
size. 6-8mls of fluid is injected into the space where the synovial
(lubrication) fluid of the hip is. The local anaesthetic works almost
immediately, the active agent (often cortisone) can take a few days to work. Hip injections are carried out for both treatment and
diagnostic purposes. Sometimes instead of injecting fluid, fluid can be
withdrawn from the hip for analysis. One of three treatment medicines/agents are injected,
sometimes with local anaesthetic: 1. Cortisone
This is normally carried out whilst awake; checks and consent for the procedure are undertaken. A small support behind the knee creates more room for the fluid to be injected into the hip joint space. The skin at the front of the thigh is cleaned with antiseptic. A thin needle (thinner than a blood test needle) is guided down to the hip joint. This is done with or without imaging assistance depending on experience and patient size. 6-8mls of fluid is injected into the space where the synovial (lubrication) fluid of the hip is. The local anaesthetic works almost immediately, the active agent (often cortisone) can take a few days to work.
Hip injections are carried out for both treatment and diagnostic purposes. Sometimes instead of injecting fluid, fluid can be withdrawn from the hip for analysis.
One of three treatment medicines/agents are injected, sometimes with local anaesthetic:
2. A synthetic lubricant (hyaluronic acid), also called viscosupplementation.
3. Platelet rich plasma or PRP
In general the literature demonstrates a significant reduction of pain with cortisone injection into the hip joint, although it is often short-term (approximately 3months) (9). It therefore has a role in:
· pain relief from hip arthritis,
· those awaiting a hip replacement but seeking short term pain relief
· those wishing to put off hip replacement
· those seeking alternatives to hip replacement – for a time.
For hip arthritis, significant pain relief can be obtained in 65-70% of patients (3,4).
The benefits last up to 3 months in 58% of patients (4).
The injections can be repeated if the initial benefit wears off, up to 4 times a year.
Studies looking at knee arthritis show good pain relief can be obtained with injections every 3 months for up to 1 year, beyond that further injections are disappointing(7)
Hyaluronic acid (HA)
This is a synthetic lubricant, despite early enthusiasm a review of several studies shows no significant difference with its use.
In a well controlled study of 83 patients the findings were that the injection didn’t make a difference at 3 months. The injections are generally safe and well tolerated. (6).For knee arthritis, where most of the studies have been performed; there is no evidence for significant relief of pain when analysis is restricted to high quality studies(8). Looking at high molecular weight Hylan versus standard HA products in the knee, again IA Hylan was not significantly more effective in relieving pain(8).
Platelet Rich Plasma (PRP)
10mls of blood is taken, as in a blood test from the arm. The blood is centrifuged and the growth factors from the blood are then injected back into the same person a few minutes later. In this situation- the hip joint. There are very limited published studies of its use in the hip.
One study looked at 40 patients, three injections, one a week for 3 weeks.
57% showed a reduction in pain, 40% showed an excellent response with benefit maintained at 6 months.
For knee arthritis a single injection can give benefits for 6 months. Results are better with mild grades of arthritis.
Again in a knee study comparing platelet rich plasma injections versus hyaluronic acid, the PRP was superior for the milder grades of arthritis (11).
PRP How does it work?
Platelet-rich plasma counteracts effects of an inflammatory environment on genes regulating articular cartilage structure (matrix) degradation and formation in human cartilage cells (chondrocytes). Platelet-rich plasma decreases NFκB activation, a major pathway involved in the pathway of osteoarthritis (12)
An injection of local anaesthetic is used to establish whether pain is coming from the hip or not.
It involves placing local anaesthetic into the hip joint natural fluid space.
The injection of local anaesthetic into the hip numbs the structures in the hip. Simply put, if the pre-injection pain goes, it was the intra-articular structures of the
hip that were the true source of the pain rather than external structures such as the low back, ilio-tibial band, iliopsoas tendinopathy, or bursitis(1).
The local anaesthethetic starts to work within minutes and lasts for 3-4 hours.
Risks. The risks of an adverse outcome are very low(9)
- No benefit (this is not technically a risk, however one should be prepared for this eventuality)
- Nerve injury
- Avascular necrosis (the blood supply to the ball of the hip joint stops, the ball part perishes and in that situation a hip replacement would be required.
1 Arthroscopy. 2011 May;27(5):619-27.Response to diagnostic injection in patients with femoroacetabular impingement, labral tears, chondral lesions, and extra-articular pathology.
3. Skeletal Radiol. 2011 Nov;40(11):1449-54 Intra-articular hip injection: does pain relief correlate with radiographic severity of osteoarthritis?
5. Arthritis Rheum. 2009 Mar;60(3):824-30. Effect of hyaluronic acid in symptomatic hip osteoarthritis: a multicenter, randomized, placebo-controlled trial. Richette P, Ravaud P, Conrozier T, Euller-Ziegler L, Mazières B, Maugars Y, Mulleman D, Clerson P, Chevalier X.
6. Clin Exp Rheumatol. 2005 Sep-Oct;23(5):711-6. Is there evidence to support the inclusion of viscosupplementation in the treatment paradigm for patients with hip osteoarthritis? Conrozier T, Vignon E.
7. Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G.
Cochrane Database Syst Rev 2006.
8. Osteoarthritis Cartilage. 2008 Feb;16(2):137-62. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Zhang W, et al.
10. Am J Sports Med. 2013 Feb;41(2):356-64. Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: a prospective, double-blind, randomized trial. Patel S, Dhillon MS, Aggarwal S, Marwaha N, Jain A.
11. Am J Phys Med Rehabil. 2012 May;91(5):411-7.
12 Am J Sports Med. 2011 Nov;39(11):2362-70. Platelet-rich plasma releasate inhibits inflammatory processes in osteoarthritic chondrocytes.
This allows hip surgery to be carried out via keyhole surgery, known as arthroscopy- literally meaning, “to look into a joint”.
Hip arthroscopy is an excellent method of treating femoracetabular impingement (FAI), labral tears and loose bodies.
What is keyhole surgery?
An operation carried out under general anaesthetic, using 2 or 3 small scars for access (the small scars are termed “keyhole”, medically known as a “portal”).
The leg is pulled downwards with a traction-based device to seperate the ball and socket of the hip to allow the instruments to pass between them and to allow visualisation of the hip joint surfaces.
One keyhole or portal allows introduction of a small camera and light via a metallic device about the width and length of a straw.
The other portals allow instruction of long and narrow purpose designed instruments to carry out the surgery.
What is done at Hip arthroscopy?
Trimming (resculpting of the femoral head, trimming of a torn labrum),
Stitching of a torn labrum,
Removal of loose bodies,
Insertion of flexible implants, (for example actifit meniscal implant Experimental)
Reattachment of tissues.
Assessment of the hip joint.
What conditions are treated with Hip arthroscopy?
Femoro-acetabular impingement also known as Cam Impingement
Labral tears Labral detatchment
Abductor muscle tears
Iliotibial band snapping syndrome:
Hip arthroscopy for Femoroacetabular impingement: Improvement in Quality of life after surgery.
In one study up to 83% of patients observe a noticeable improvement in the first year(0)
Evidence has emerged over the past decade that femoroacetabular impingement (FAI) may lead to early osteoarthritis of the hip, and that patients with FAI may be successfully treated by addressing the underlying pathomorphology (abnormal shape).
Ganz et al have reported on the association of primary FAI with secondary osteoarthritis. Their study recommends intervention before major articular cartilage damage occurs in cases where the normal bony anatomy can be restored, thereby potentially slowing the progression of osteoarthritis. (-1)
Good-to-excellent results in up to 75% of patients at one year (1,2)
3 year patient outcome data (3) shows an
- improvement in 77%
- unchanged in 14%
- deterioriation in 9.0%.
Greater gains where found in the under 50s, although gains in the older group were still significant, in a further study patients over the age of 60 and found an overall satisfaction rate of 75%. (4)
Data suggests the ealrier arthroscopy is done for FAI the better the results.
One of the common complications is some numbness in the thigh or perineal area due to the traction applied. Usually they recover with time but sometimes it may persist. Very rarely, a more serious damage to the nerves or blood vessels can occur. Bleeding, infections etc., are very rare. Other complications like new bone formation, stiffness, femoral neck fracture etc., may rarely occur depending on the type of the procedure done.
-1 Ganz R, Leunig M, Leunig-Ganz K, Harris WH. The etiology of osteoarthritis of
the hip: an integrated mechanical concept. Clin Orthop 2008;466:264-72.
0. Byrd JW, Jones KS. Arthroscopic femoroplasty in the management of cam-type
femoroacetabular impingement. Clin Orthop 2009;467:739746.
1. Larson CM, Giveans MR. Arthroscopic management of femoroacetabular impingement:
early outcomes measures. Arthroscopy 2008;24:540–546.
2. Gedouin JE, May O, Bonin N, et al. Assessment of arthroscopic management of
femoroacetabular impingement: a prospective multicenter study. Orthop Traumatol
Surg Res 2010;96(Suppl):59–67
3. A. Malviya, G. H. Stafford, R. N. Villar Impact of arthroscopy of the hip for
femoroacetabular impingement on quality of
life at a mean follow-up of 3.2 years J Bone Joint Surg Br April 2012 vol. 94-B no. 4 466-470
4 Javed A, O'Donnell JM. Arthroscopic femoral osteochondroplasty for cam femoroacetabular
impingement in patients over 60 years of age. J Bone Joint Surg [Br] 2011;93-B:326–331.