Hip

Femoroacetabular Impingement or FAI is now recognized as a reason for disabling hip pain in adolescents and adults and a possible etiology of early hip arthritis. It is estimated that 10% of our population has some degree of FAI. There are two types of FAI, namely the Cam type and the Pincer type. Cam type FAI describes impingement originating from the femoral side of the joint. Typically in this situation the femoral head neck junction is more oval shaped than round. With continued rotation and use of the hip joint with activity, this mismatch or conflict between the oval shaped head and the round cup eventually can tear the acetabular labrum and can damage the acetabular cartilage. The acetabular labrum is a fibrocartilagenous extension of the acetabular rim, and is believed to be important for both hip stability and as a seal for the hip joint. Pincer type of FAI originates on the acetabular side. In this type, the cup can be retroverted which causes anterior over coverage or the cup can simply be too deep for the head. This creates impingement between the two sides of the joint by over covering or constraining the femoral head. This conflict also can result in tearing of the acetabular labrum and cartilage.

The treatment for FAI can be either an open procedure with surgical dislocation of the hip or an arthroscopic procedure. With either technique, the goal is to remove bone from both the acetabular and femoral sides of the joint to remove the impingement conflict and improve the biomechanics of the joint. In addition, the acetabular labrum is repaired and cartilage injuries are addressed. Not surprisingly, hip arthroscopy performed by those with appropriate training can result in improved outcomes and a quicker recovery compared to the open approach

Pain coming from the Hip joint can be felt in several locations. Classically hip pain is in the groin or in the bikini line, but it can also be present in the side, buttock or down the front of the thigh to the level of the knee. Typically, when pain radiates down the back of the thigh past the knee it is coming from the lower back.

The Hip joint is a ball and socket joint between the femoral head or ball and the acetabulum or cup. It is very important that the ball and cup are appropriately shaped for one another. If the two are not perfectly matched, impingement between the ball and cup can occur with hip motion. This is called FAI or Femoroacetabular Impingement. Impingement in active individuals can ultimately lead to tearing of the labrum and cartilage of the hip. This can be quite painful and patients ultimately have difficulty with long sitting, driving, walking, running and twisting activities. Also, sometimes the hip can feel like it is catching and or popping.

The labrum is a lip of cartilage that extends off of the cup. Tearing of this produces pain within the joint. It is important to note that the cartilage and the labrum run together, so often with a labral tear there is some element of cartilage injury or the beginning of arthritis in the joint. If pain is significant and a patient’s activity is adversely affected, arthroscopic surgery is recommended to repair the labrum and cartilage and to reshape the ball and cup so that they fit better together.

Hip pain can have many causes, one of which is arthritis, a condition in which the joint's protective cartilage surfaces break down and deteriorate. The layer of cartilage that coats the surfaces of the ball and socket of our hip joints is very important. Cartilage is extremely slick and slippery, providing a low friction bearing for easy and efficient joint motion. It is also one of the few tissues in the human body that has no nerves in it, so it is completely numb. Beneath this thin layer of cartilage is bone. Bone is not slick and slippery, but rather rough and abrasive, and, unlike cartilage, is full of sensitive nerve fibers (think of the last time you had work done on your teeth). In arthritis, the numb, slick protective layer of cartilage is damaged by either "wear and tear" (osteoarthritis) or a misguided immune system (rheumatoid arthritis). The destruction of surface cartilage results in areas on the ball and socket of exposed bone, making the joint stiff and painful. The thickness of the layer of cartilage in the hip joint is usually easy to measure with a simple X-ray, making arthritis one of the easiest conditions to diagnose in an office evaluation. If the cartilage is completely gone, and the joint is "bone on bone" a hip replacement operation is offer a very effective solution. Because of it's ability to relieve the pain of arthritis and it's low complication rate, hip replacement surgery has extremely high patient satisfaction scores.

Avascular necrosis, also know as osteonecrosis, is a rare but serious disease that can destroy the hip joint and necessitate hip replacement surgery. The hip is a ball and socket joint, and AVN is a disease affecting the blood supply to the ball. It is easy to forget that bone is living tissue, and like all other living tissues, it requires a steady stream of blood to supply it with the oxygen and nutrients it needs to survive. The disease of avascular necrosis clogs or blocks the small and delicate arteries that deliver blood to the ball of the hip joint, causing the bone in the center of the ball to die and decay. AVN can result from trauma and injury to the blood vessels that nourish the ball, or it can result from the use of certain medications, like prednisone. As the pocket of decay grows inside the ball, the thinning layer of normal bone above it can fracture and collapse, changing the shape of the ball so that it is no longer round. Once the ball (known as the femoral head) has collapsed, the proper fit between the ball and socket is lost and the joint, now stiff and painful, wears out quickly. In its early stages, the goal of treatment is to arrest the disease before the femoral head has collapsed. It is not clear what the single best method of treatment is for this early form of AVN. Options vary from simple solutions such as electrical stimulation and protected weight bearing with crutches to surgical procedures like core decompression or even bone grafting with a vascularized section of the fibula from the patient’s leg. In the late stages of the disease (after femoral head collapse) hip replacement may be necessary to eliminate pain and restore function.

This is very common reason for pain on the side of the hip. It often occurs in women in their 40’s to 60’s and is characterized by a deep, achy pain over the bony prominence on the outside of the hip. The pain is often worsened with lying on the affected side at night and also with activity. This is caused by inflammation of the bursal tissue on the side of the hip. This bursa provides a cushion on the bony portion of the hip and provides lubrication to allow the IT band to move without friction over the side of the hip. When it is inflamed it can create a significant amount of discomfort itself and also prevents the IT band from moving smoothly back and forth. This inflammation can also create problems for the gluteus medius tendon, which inserts on the bone in this region as well.

The treatment for this typically involves judicious use of steroid injections into the bursa, anti-inflammatories and Physical Therapy to stretch the IT Band and strengthen the Gluteus Medius muscle. It is a problem that likes to recur and is best treated by preventive stretching and therapy once the acute flare is treated.

Hip fractures are a common problem for our elderly population. They typically result from a fall. In younger patients, much more energy is required to break the hip, so these types of fractures are much less common in this patient population. The hip is a ball and socket joint. The term hip fracture refers to a break in the top part of the femur, which becomes the ball portion of the joint. The hip can break on the neck right next to the ball or further down where the neck joins the shaft of the femur. These fractures are termed femoral neck fractures and Inter-trochanteric hip fractures respectively.

Essentially, all inter-trochanteric hip fractures are treated surgically. Non-surgical treatment is reserved only for those far too sick to tolerate anaesthesia/surgery, but even then great consideration is given for surgery for palliative reasons. Our goal with surgery is to stabilize the fracture so that the patient can get moving and out of bed as soon as possible. This diminishes the complications of prolonged immobility such as bed sores, pneumonia, blood clots, and muscle de-conditioning.

There are two different type of fracture implants used to stabilize inter-trochanteric hip fracture: nails that go down the shaft of the femur and plates which attach to the side. The goal of the implant is to hold the fracture ends together in a manner that provides enough rigidity and stability to allow the patient to ambulate. The fracture takes usually eight weeks to heal depending on the severity of the fracture. Physical therapy and rehabilitation is a very important element in the recovery.

These fractures can be very difficult for patients and their families. Often after hip fractures, patients can lose one level of ambulation. In other words, if they walked independently before, they may require a cane after they heal. If they used a cane, they may need a walker. These fractures are a tremendous physical stress for a patient and an emotional stress for the family. Often patients loose some level of independence and may require some level of assisted living after.