When you need a new hip

By Esther Williams

For the past five years, Miranda, (62), who had been active earlier had been experiencing pain around the hips. Her condition worsened during the last year, the pain in her groin so excruciating that it woke her up at night.

She was unable to squat, climb stairs or even kneel for prayers at church. Applying balm or taking painkillers gave her no relief.

Upon seeking medical attention, an x-ray was taken and it was diagnosed that she suffered from Osteoarthritis, a degenerative bone joint condition requiring hip replacement.

A painful hip can severely affect your ability to lead a full active life. Limitation of motion, stiffness, severe pain restricting normal activities and deformity of joints leading to a limp are conditions considered for surgery.

When is hip replacement required?

"Any disease condition which causes destruction of joints beyond repair will require joints to be replaced except in infections of the joints and certain other rare conditions," explains Consultant Orthopaedic Surgeon and Acting Chief Surgeon at the Accident Service of the National Hospital, Colombo, Dr. Narendra Pinto.

Conditions that can result in degeneration of the hip joint requiring surgery:

• Osteoarthritis: A degenerative condition where there is excessive wear and tear usually affecting elders. The 'wear and tear arthritis' usually affects weight-bearing joints such as hips and knees. In the west it affects the elderly more on the hips whereas in Asians, knees are commonly affected which can be attributed to an increased tendency to squat in daily activities.
• Rheumatoid arthritis: An inflammatory disease of the joints often seen in young adults usually women. It can affect any joint and cause total damage if untreated. When it occurs on the hip, it can damage the joint, requiring surgery.
• Osteonecrosis: It is an uncommon condition that occurs when part of the bone dies owing to lack of blood supply, even in young people due to medical reasons such as in high dose steroid treatment of Nephrotic syndrome and connective tissue disorders.

Alcoholism can also contribute to the condition. However, often no definite cause is found (idiopathic).
While Osteoarthritis develops over a period of 5-10 years among both men and women, Rheumatoid Arthritis and Osteonecrosis can rapidly worsen within a year or two. Certain fractures in the hip which are not amenable to internal fixation may also require hip replacement. However, when there is stiffness without pain and ability to manage daily activities surgery may not be required.

Hip replacement is considered a last resort once other forms of conservative management such as pain killers, other medications and physiotherapy have failed to provide relief for a damaged hip. Modification of lifestyle and use of walking aids can provide some relief. Each year at the National Hospital only around 150 hip operations can be accommodated with an equal number of knee replacements.

These are done by the four surgeons, amidst other urgent surgeries. Hip replacement, however, is not considered an option for children.

Other surgical options

Formerly there were other surgical options such as fusing the joint (Arthodesis) or various Osteotomic procedures that are considered obsolete today. However certain decompression and bone grafting procedures are available for Osteonecrosis in young patients before considering arthroplasty (artificial joint replacement).

"With the availability of good hip implants and the refined technique of the operative procedures, arthroplasty is considered safe and effective," reassures Dr. Pinto.

Complications

As in any other surgical procedure there can be complications. Those specifically related to the procedure are: dislocation, infection, loosening of prosthesis, Deep Vein Thrombosis and Pulmonary Embolism - the last two considered rare in Sri Lanka.

Dr. Pinto assures that complications are kept to a minimum according to accepted standards and the procedure itself is rather safe. Age itself is not a contraindication for surgery as more and more elderly patients are keen on being independent and mobile.

To prevent complications after surgery, a patient would need to strictly adhere to the surgeon's instructions, such as on posture to prevent dislocation during post operative recovery. Patients are advised to keep their physicians aware of their artificial hips so that infections in any part of the body are promptly and adequately treated with antibiotics.

Even certain minor surgical procedures such as dental fillings need to be covered with prophylactic antibiotics to prevent late infection of the new joint.

Surgery as a last option: A person with symptoms of joint degeneration needs to have a period of conservation therapy that includes medication and physiotherapy to prevent deterioration of the condition and strengthening of muscles prior to considering surgery. "Surgery is definitely the last resort," Dr. Pinto emphasizes, while cautioning that artificial joints too have a life span depending on the patient's activities. The average life span for artificial joints is 15-20 years and this can reduce in young and active patients.

Consequently, in young patients who have total hip replacement, a repeat surgery called revision or a re-revision may be on the cards during their life time.

At the same time, if the operation is unduly delayed, the disease can destroy the joint to such an extent that the procedure can be technically difficult.

In conclusion Dr. Pinto stresses that after a hip arthroplasty a patient should not expect the function of a normal hip such as the ability to squat normally. He/she will have to modify lifestyle and restrict high impact sports such as tennis and basketball.

However arthroplasty has revolutionized the management of the crippling end-stage arthritis providing relief to millions of patients who are otherwise confined to the bed or wheelchair, improving their mobility and allowing pain-free movement.