Hip Joint

When to have a hip replacement?

You may need a hip replacement operation if your hip joint is badly damaged by arthritis. This sort of damage is mostly caused by osteoarthritis but it can be due to other causes such as rheumatoid arthritis. Surgery is not needed by everyone with arthritis of the hip joint. Surgery is only recommended when the pain and disability are having really serious effects on your daily activities. Treatment with medication, using a walking stick, physiotherapy etc can be tried before deciding on surgery. The patient needs to feel the need for surgery when medical management is not working.


What can be expected from a hip replacement?

Pain should no longer be a problem. The benefit is obvious immediately after the surgery – less disability with greater mobility and a better quality of life. But it is important to remember that an artificial hip is not as good as a natural hip as it does have some limitations.


What is the new joint?

The hip is a ball-and-socket joint. In arthritis, both the ball and socket are damaged or deformed giving pain on movement due to irregular mating surfaces and also stiffness. So the ball is replaced with a smaller one which is securely fixed to the rest of the femur with cement. A cup is also cemented inside the natural socket into which the newly placed small head sits.

The artificial head is usually made of metal and the socket is usually made of plastic. In younger, more active patients, one part or both parts may be inserted without cement. If cement is not used, the surfaces of the implants are roughened or specially treated to encourage bone to grow onto them. Younger patients may also be given more durable surfaces on the socket (such as ceramic or metal).


What happens after the operation?

After recovering well from anesthesia after the operation patient may be able to take light diet or liquids in the evening. From the second day, patient is helped to start walking, first with a frame and soon with elbow crutches or sticks. How quickly you get back to normal depends on many factors – including your age, your general well-being, the strength of your muscles and the condition of your other joints. But generally, it takes about 6 weeks for you to start walking well. But even at that stage, you may still have to use a crutch for a period of 3 months. One should not try to do too much too soon.



The physiotherapist will help to get the patient moving freely and advise on exercises to strengthen the muscles. The physiotherapist will also tell the “dos and don’ts” after hip replacement surgery. It is very important to follow these rules. Avoid too much bending at the hips (such as squatting, sitting in a low chair, etc.) and never to cross legs are some rules because these positions could dislocate a new hip. Some additional gadgets may be needed (a raised toilet seat, aids to help dress up, putting on socks etc.).


Hospital period & Discharge

Most people can leave the hospital within four to six days. We shall see the patient again after about 10 days for suture removal. The patient may continue physiotherapy at home. When happy with normal walking then start training for climbing stairs.


First three months

Most people are relieved that the pain from arthritis has gone. You may find that you cannot bend your leg upwards as far as you would like – it is important not to test your new joint to see how far it will go. Great care should be taken during the first eight to 12 weeks after the operation.

People can go back to work after four to six weeks, but only if you have a job which does not mean too much moving around. Patients can start driving a car after about 2 months but getting in and out of a car can be difficult – you may need to sit sideways on the seat first and then swing your legs around. A physiotherapist can help on how to do this and other tasks safely.


You must take regular exercise – exercise is good for your mind and body. After all, that is one of the reasons for having the operation. Walking, swimming (but avoid breaststroke) and riding a bicycle is fine. Avoid running, playing squash, competitive tennis, etc., as all of these produce an excessive impact on the new hip joint. If you are unsure about a specific activity, ask your surgeon or physiotherapist.


What are the long-term effects of hip replacement?

Nowadays there are many different types of artificial joints. While some do better than others, many other factors affect the outcome. Over 80% of cemented hips should last for 15 years or more. The newer uncemented hips are being shown to give even better long-term results and hence are being used in young and active middle-aged patients.


Can there be any complications?

Hip replacement is major surgery. Risks vary according to the general health and you should discuss the risks and benefits with the surgeon. After hip replacement, some people suffer from clots which form in the deep veins of the leg. There are various ways to reduce this, including special stockings and different drugs.


There is a more serious complication where some of these clots, particularly those in the thigh veins, can detach and become stuck in the lungs (pulmonary embolism). This is very serious – it may cause sudden breathlessness or collapse, and even sudden death. Fortunately, this complication is rare.


The artificial hip may dislocate. This occurs in less than one in 20 cases and usually needs putting back into place under anesthetic. In most cases, this will make the hip stable, although patients may need to spend some time doing exercises to strengthen their muscles or keeping the joint still in some form of the brace.


To reduce the risk of infection we perform surgery in specially ventilated ‘clean air’ operating theatres. We also use a short course of antibiotics at the time of the operation. Despite this, a deep infection can occur (but only in around one in 200 cases). This is a serious complication. The artificial hip usually has to be removed until the infection clears up. The hip is then re-implanted six to 12 weeks later.


The plastic in the artificial socket may wear over time. The worn particles cause inflammation and this can wear away the bone next to the new hip. To reduce this problem we are using special plastic sockets and ceramic heads, especially in younger patients.


The most common cause of ‘failure’ of hip replacements is when the artificial hip loosens. This can happen at any time but is most common after ten to 15 years. It usually causes pain and your hip may become unstable. When this happens, the old hip joint needs to be removed and a new one inserted again. This type of surgery has made significant advances in recent years. Failed hips can be revised, with over 80% of patients reporting success for between five to ten years. Some revisions may need a bone graft. The hip can be revised almost as often as necessary, although the results are slightly less good each time.

Hip Problems in Children




The most common hip problem in children is congenital or developmental dysplasia of the hip (DDH). It affects babies and young children. The condition develops in utero or during the child’s first year of life. It’s a much more common condition in girls than boys. The relationship between the femur and the hip socket is affected in one or both hips. DDH can be mild or severe depending on the child and situation. If it’s mild, the child’s hip is in the joint but may become dislocated rather easily. That’s called unstable hip dysplasia. If DDH is severe, the hip may be partially or completely dislocated, which is called subluxation.



You may not notice any symptoms because some children may not experience any pain. However, the child’s legs and buttocks may look different. This may not be noticeable until he begins walking. There may be uneven skin folds in the region. Your child may have a slight limp if one hip is affected by DDH. If the condition affects both hips, the child may have lesser mobility on one side and may sway or waddle when walking. However, it can be hard to detect an abnormality during movement if both hips are completely dislocated.



Doctors cannot explain why hip problems occur in children. This disorder is found in many cultures around the world. However, clinical studies show a familial tendency toward hip dysplasia, with more females affected than males. The incidence of congenital hip dysplasia is also higher in infants born by caesarian and breech position births.


Evidence also shows a greater chance of this hip abnormality in the firstborn compared to the second or third child. Hormonal changes within the mother during pregnancy, resulting in increased ligament laxity, is thought to possibly cross over to the placenta and cause the baby to have lax ligaments while still in the womb.



Early diagnosis of hip problems in children is essential to avoid major problems. The pediatrician’s early checkups are the most important tool in diagnosing hip dysplasia. Have your baby screened as early as possible, especially if it was breech or if you have a family history of hip problems. The doctor will use tests such as Barlow’s test or Ortolani’s maneuver test to detect if the baby’s hip is moving inappropriately.


X-ray films can be helpful in detecting abnormal findings of the hip joint and also in finding the proper positioning of the hip joint for treatments of casting. Ultrasound has been noted as a safe and effective tool for the diagnosis of hip dysplasia.


Treatment Options

Treatment of hip problems in children varies depending on the severity and age of the child. You may need to put two or three diapers on your baby at all times. If this doesn’t work, a Pavlik harness and von Rosen splint can be used up to the age of six months. This keeps the hips in place. If your child is older, the doctor may recommend a standing program to help the hip develop correctly.


In some cases, in older children between six to 18 months, surgery may be necessary to reposition the joint. However, after the age of eight years, surgical procedures are primarily done for pain reduction measures only. Total hip surgeries may be inevitable later in adulthood


The hip is one of the largest weight-bearing joints in the body. A ball (femoral head) at the top of the thighbone (femur) fits into a rounded socket or cup-like cavity (acetabulum) in your pelvis. Bands of tissues called ligaments form a capsule connecting the ball to the socket and holding the bones in place.


A layer of smooth tissue called cartilage cushions the surface of the bones, helping the ball to rotate easily in the socket. Fluid-filled sacs (bursae) cushion the area where muscles or tendons glide across bone. The capsule surrounding the joint also has a lining (synovium) that secretes a clear liquid called synovial fluid. This fluid lubricates the joint, further reducing friction and making movement easier.


Hip osteoarthritis is a form of arthritis where the cartilage which cushions the bones in the hip joint as they move against each other, becomes progressively degraded and damaged. Since the hip is a weight-bearing joint, osteoarthritis can cause significant problems. This causes problems such as pain, stiffness and impaired movement. Pain is not present in all cases, however, with some patients imply suffering joint stiffness.



Hips that have suffered severe physical trauma are much more likely to develop hip osteoarthritis. A hip injury can result in altered hip biomechanics and function. This, in turn, tends to increase stress loading and friction on the hip joint cartilage, a condition that accelerates cartilage breakdown, leading to osteoarthritis.


Hip Fractures

Hip fractures, especially severe breaks that result in bone displacement, oftentimes presage osteoarthritis. One severe fracture creates many smaller ruptures, which cannot align perfectly with the other fractured ends to heal properly. This creates a large area of bony discontinuity, which changes the way that force is transmitted through the hip joint. This altered hip biomechanical profile increases stress and load on the hip joint, which heightens the risk of hip osteoarthritis.


Hip Dysplasia

Hip dysplasia is a condition whereby the hip joint does not fit into the hip socket correctly. A dysplastic hip can be caused by a shallow hip socket, or by a socket that does not provide adequate coverage for the femoral head. The development of osteoarthritis is a major risk factor for hip dysplasia due to the fact that a dysplastic hip experiences altered biomechanics and abnormal stress loading throughout its main weight-bearing areas, which increases the level of wear and tear on the joint cartilage, leading to increases in the risk of osteoarthritis.



The list of signs and symptoms mentioned in various sources for hip osteoarthritis includes:

  • Joint pain
  • Joint stiffness
  • Joint tenderness
  • Joint inflammation
  • Crepitus (Creaky joint)
  • Joint redness
  • Weakness in adjacent muscles
  • Burning sensation in associated muscles
  • Burning sensation in associated ligaments
  • Movement difficulty
  • Enlarged joint
  • Crunching feeling in joint
  • Grating joint sensation
  • Swollen joint
  • Joint Locking
  • Joint warmth



Hip osteoarthritis is caused by deterioration of articular cartilage and wear-and-tear of the hip joint. There are several reasons this can develop:

  • Previous hip injury
  • Previous fracture, which changes the hip alignment
  • Genetics
  • Congenital and developmental hip disease
  • The subchondral bone that is too soft or too hard
  • Avascular necrosis

Primary osteoarthritis occurs as the person ages but results from repetitive use and/or high mechanical stress on the joint. It is not a direct result of the aging process.


Secondary osteoarthritis is the result of such things as injury to the joint, joint infection, obesity, ligament damage, joint overuse, hormonal problems, pregnancy and various other conditions. Family history seems to play a factor in developing the condition.



The diagnosis of hip OA starts with a complete history and physical examination by your doctor. X-rays will be required to determine the extent of the cartilage damage and suggest a possible cause for it.


Other tests may be required if there is a reason to believe that other conditions are contributing to the degenerative process. MRI may be necessary to determine whether your hip condition is from problems with AVN.


Blood tests may be required to rule out systemic arthritis or infection in the hip.


Treatment Options:

Medication: Medications are one way to treat hip osteoarthritis. For mild cases, acetaminophen is usually tried first. NSAIDs (nonsteroidal anti-inflammatory) and opioid analgesics are used for moderate to severe hip osteoarthritis.

Non-Medication: There are also a few non-drug treatments that can help:

  • Weight loss (normal weight people have a 20% risk of hip OA, overweight have 25% risk, and obese have 39% risk)
  • Water exercise programs
  • Physical therapy (range of motion and strengthening exercises)
  • Occupational therapy (assistive devices, joint protection)
  • Patient education


Surgery: This is considered a last resort treatment option. Surgery is appropriate for patients with hip osteoarthritis who have failed other more conservative treatment options. Surgical procedures include:

  • Arthroscopy – an arthroscope checks the condition of the articular cartilage
  • Osteotomy – realigns angles of the hip joint
  • Total hip replacement – new acetabular and femoral components are implanted

Hip fractures are fractures of the “neck” of the femur; the long bone of the upper part of the leg. The femoral neck is the area between the main part of the bone and the head of the femur (the “ball” that fits into the “socket” of the hip).


Patients with hip fractures may present in a variety of ways, ranging from an 80-year-old woman reporting hip pain after a trivial fall to a 30-year-old man in hemorrhagic shock after a high-speed motor vehicle accident. Osteoporosis in the elderly contributes to most of these fractures. Females have been reported to be twice as likely to fracture their hips as men.


Types of Hip Fractures:

Many subtypes of fractures of the hip joint are colloquially known as ‘hip fractures’. Although a true hip fracture involves the joint, the following four proximal femur fractures are commonly referred to as hip fractures. The differences between them are important because each is treated differently.

  • Femoral head fracture denotes a fracture involving the femoral head. This is usually the result of high energy trauma and a dislocation of the hip joint often accompanies this fracture.
  • Femoral neck fracture (sometimes Neck of Femur (NOF), subcapital, or intracapsular fracture) denotes a fracture adjacent to the femoral head in the neck between the head and the greater trochanter. These fractures have a propensity to damage the blood supply to the femoral head, potentially causing avascular necrosis.
  • Trochanteric fracture denotes a break in which the fracture line is beyond the neck on to the trochanter. It is the most common type of ‘hip fracture’ and prognosis for bony healing is generally good if the patient is otherwise healthy.
  • Subtrochanteric fracture actually involves the shaft of the femur immediately below the lesser trochanter and may extend down the shaft of the femur.


Symptoms a hip fracture:

  • Immobility immediately after a fall
  • Severe pain in your hip or groin
  • Inability to put weight on your leg on the side of your injured hip
  • Stiffness, bruising and swelling in and around your hip area
  • Shorter leg on the side of your injured hip
  • Turning outward of your leg on the side of your injured hip



In older adults, a hip fracture is most often a result of a simple fall, due to weak bones. In young people, it is due to a major injury like a car accident.

Other things that increase your risk of breaking your hip include:

  • Being female.
  • Your family history-being thin or tall or having family members who had fractures later in life.
  • Poor eating habits. Not getting enough calcium and vitamin D can weaken bones.
  • Not being active. Weight-bearing exercise, such as walking, can help keep bones strong.
  • Medical conditions that cause dizziness or problems with balance, or conditions such as arthritis that can interfere with steady and safe movement.
  • Taking certain medicines that may lead to bone loss.



AP and lateral view X-rays of the affected hip usually make diagnosis obvious.

In situations where a hip fracture is suspected but is not obvious on x-ray, a CT scan with 3D reconstruction may be helpful. MRI has gained importance in the diagnosis of occult fractures of the femoral neck. Within 24 hours changes can be seen on MRI. A bone scan is less useful because it may take up to 1 week to demonstrate changes especially in the elderly.


As the patients most often require an operation, the full pre-operative general investigation is required. This would normally include blood tests, ECG and chest x-ray.


Treatment Options

Treatment for hip fracture often involves a combination of three approaches, including:


Surgery: Surgery is almost always the best hip fracture treatment. Doctors typically use nonsurgical alternatives, such as traction, only if you have a serious illness that makes surgery too risky.


Femoral neck fractures: Doctors repair this type of fracture by one of three methods:

  • Metal screws: If, after the break, the bone is still properly aligned, your doctor may insert metal screws into the bone to hold it together while the fracture heals. This is called internal fixation. Often metal screws are placed in combination with bone nails (gamma nails) for additional stability.
  • Replacement of part of the femur: If the ends of the broken bone aren’t properly aligned or they’ve been damaged, your doctor may remove the head and neck of the femur and replace them with a metal prosthesis. This is known as a hemiarthroplasty.
  • Total hip replacement: This procedure involves replacing your upper femur and the socket in your pelvic bone with prostheses. Total hip replacement may be a good option if arthritis or a prior injury has damaged your joint, affecting its function prior to the fracture.


Trochanteric fractures: To repair this type of fracture, usually a metal screw (hip compression screw) is inserted across the fracture. The screw is attached to a plate that runs down alongside the femur. This plate is attached with other screws to help keep the bone stable. As the bone heals, the screw allows the bone pieces to compress, so the edges grow together.


Depending on the type of fracture, sometimes we use a metal rod – nail, into the bone with some screws into the neck and head of the femur. The nail helps prevent sliding and provides additional stability, and it may enable you to bear weight earlier.


A physiotherapist can help you to walk again after surgery, if you are fit, from the very next day after the operation.


Although older age increases the likelihood that you’ll need a hip replacement, the most significant factors in determining whether you need this procedure are:

  • The type of fracture you have
  • The severity of your signs and symptoms
  • Your personal risk of surgery-related problems
  • Your mobility and ability to function independently before the fracture


Medication after surgery: While surgery is the primary treatment for a hip fracture, a group of bone density-enhancing medications called bisphosphonates, calcium and vitamin D supplements may help reduce the risk of a second hip fracture.

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