Hip surgery

Trochanteric Bursitis is inflammation on the side of the hip at the trochanter, the bone felt under the skin. This is due to rubbing of a tendon (Tensor fascia lata) on the bone and inflammation of the bursa (soft tissue sac) between the two. This can occur at any age and is a form of overuse associated with increased activity climbing stairs or walking uphill. This can also be caused by sleeping on your side on a hard surface or a bump or fall on the side of the hip.

Treatment consists of modifying the causing activity, stretching the TFL and injection with cortisone. Therapy that includes rubbing or cross friction of the area is likely to make it worse and should be avoided.

It may take several weeks to settle and require more than one treatment or injection.

Arthritis of the hip can be due to several causes. Arthritis is the loss of cartilage of the joint and inflammation of the surrounding soft tissue structures with pain, swelling and limitation of motion. This is a condition of slow onset and will lead to progressive pain and restriction of motion depending on the treatment and underlying cause of arthritis. Avascular necrosis of the femoral head can also lead to arthritis.

Conservative management with activity modification, therapy and anti-inflammatory medication is mostly indicated until unsuccessful. Hip replacement is a good predictable operation to fix severe arthritis of the hip not responding to conservative treatment.

Hip fractures are common in older patients due to a fall. In younger patients hip fractures are due to high impact injuries. The management differs considerably based on age and injury pattern. In younger patients all efforts should be directed to saving the hip joint and restoring the joint and leg length and alignment.

Hip fractures in older people will almost always require surgery. If the hip fracture is minimally displaced then it can be fixed with screws and or a plate or rod. If the fracture is displaced then hip replacement is the best option.

Labral tears can occur at any age and are associated with groin pain in the hip. This can be due to injury, acute or chronic associated with abnormal shape of the hip joint. Management requires an acurate diagnosis which includes a full assessment and an MRI scan is often indicated.

It is important to know that degeneration of the hip joint with age and arthritis will lead to labral tears and in this instance the management is completely different to the younger age group that may require joint surgery and labral repair. If there is some arthritis in the joint then labral tear repair is of no value and may even cause rapid deterioration of the joint that could lead to hip replacement. Labral tears are often reported as a finding on MRI and may be of no relevance and should not be treated in a joint with degeneration or arthritis. This is a normal finding in these patients.

Gluteus Tendonosis is the degeneration and partial gluteus tendon tear at the trochanter at the side of the hip. This mostly occurs after the age of 50 in active people and looks and feels like trochanteric bursitis. The diagnosis is often made by elimination and injection in a specific area to determine if the bursa or tendon is most inflamed as the can occur together.

MRI scan can assist in the diagnosis but only with a full assessment of all possible causes of pain at the side of the hip as this is an area of local and referred pain where it is often difficult to make a specific diagnosis.

Hamstring Tendonosis is tendon pain and degeneration felt in the buttock and upper hamstring area. This occurs in active people after the age of 40 years and sometimes difficult to diagnose without an MRI. The condition is due to overuse and is mostly settles with time and specific eccentric hamstring stretches. It may take up to 2 years to heal which can be very frustrating to active people.

Intra Articular Hip Pathology is a collection of possible causes of hip pain and different ages due to injury or degeneration of structures in the hip joint. This can include labral tears, articular surface damage or delamination, cartilage fragments free floating and ligament damage and instability of the joint. The best way to assess the joint is by full assessment and an sometimes an MRI scan.

Articular Damage is mostly due to high impact injury associated with twisting or dislocation. This can be with or without a fracture of the hip and should be assessed on an individual basis to determine the best action and treatment to be done.

There is a common misconception that pain on the side of your hip is related to the hip joint. Hip pain that originates from the joint is typically felt in the groin and front of your leg, then down towards your knee.

If it originates from your back, it will be felt at the back of your hip (buttock), the side of your hip (trochanter) and radiates down your leg to your lower leg and or foot. This may not be due to hip pathology but rather a pinched nerve in your back.

The best way to get a diagnosis is a full examination by a specialist in hip conditions. This may include some X-rays or an MRI.

Common conditions that originate from the hip include trochanteric bursitis, gluteus tendonosis, hamstring tendonosis and intra articular pathology. Joint conditions include labral tears, articular damage and arthritis.

A short course of non-steroidal anti-inflammatories and rest allows most conditions causing hip pain to settle. After this initial treatment a specific diagnosis should be made and a treatment plan determined.

Patients often need to be examined and assessed by means of X-rays and or MRI scans to ensure that they do have arthritis of the hip and that the pain is not due to other causes.

Total hip replacement is one of the most successful and cost-effective procedures to improve the quality of life of a patient.

This procedure has been done for many years and several improvements in implants and techniques have resulted in rapid recovery and long-lasting replacements.

It is best suited for patients with significant hip pain after failed conservative treatment of hip arthritis.

Surgery is performed through a minimally invasive technique and patients stay one or two nights after surgery during which physiotherapy twice a day will ensure that the patient is able to deal with activities of daily living and stairs before discharge. We assist in arrangements for step down care if required. This ensures the most cost-effective state of the art replacement experience to patients.

Hip replacement technique and improved pain control have made it possible for patients to go home on the same day as the operation. The patients suitable to be included in this surgery are carefully selected to ensure that there will be minimal risk and maximum patient satisfaction.

Patients with minimal medical risk (good general health) and good muscle strength are most suitable. Motivation to want to get up and go is important and a positive attitude towards the surgical event will make this an easy procedure. This has become common practice in many countries across the world and several of these procedures are being done in South Africa.

The long-term recovery and outcome of surgery is not in any way influenced by the day of discharge, but patient satisfaction in the immediate post-operative period may be improved by same day discharge after surgery.

The procedure of replacing a hip is done with minimal tissue damage to ensure optimal muscle function early after surgery. The arthritic hip has no cartilage left and inflammation causes pain and restricted motion. This pain is often much better very soon after surgery due to the new “joint” in place. The materials used are Titanium metal stem and cup with removable “modular” cup liners made of very high-grade plastic (Crosslinked High-density Polyethylene) and femoral heads made of ceramic or highly polished metal (cobalt chrome).

The procedure is usually done under spinal aneasthetic with sedation or general aneasthetic, this will be decided on by the aneathetist. During the procedure long lasting local aneasthetic is injected around the hip to ensure minimal pain after the operation. This should last for 48 to 72 hours and will slowly wear off. Pain medication will be prescribed to take as required for when the local aneasthetic has lost effect.

Once awake and the aneasthetic has worn off the patient will be assisted by a physiotherapist to get up and walk. Specific exercises will be done and demonstrated. Techniques to get in and out of bed and on and off the toilet will be shown. Patients are taught how to negotiate stairs.

The decision to be discharged home will be carefully evaluated by all the medical staff involved with the procedure. Only those patients that are fully recovered, mobile and medically stable will be able to go home on the same day as surgery. All patients receive contact details for any questions that may arise.

Information on what to do at home will be communicated and a follow up will be arranged to ensure that the recovery at home is comfortable, safe and effective. This will ensure the best possible outcome after surgery. Patients recover better at home integrate back into normal life much quicker and easier.

• Know that you want to have surgery and that the procedure has been explained to you to your satisfaction and you know what you want to about surgery.
• Have blood tests and bacteriology swabs to ensure that you are fit for surgery. Some patients may have to see a physician for a full medical check. If you feel you still have doubt about your fitness for surgery, then request a Physician appointment. The aneathetist will see you before the surgery for a final check and ensure that you are fit enough for surgery before proceeding.
• Confirm the date of surgery and authorization for the procedure by your medical aid.
• Make sure that you are as fit as you can be, you have taken your regular medication as prescribed and you have no open or septic wounds on your skin as this may lead to you being cancelled on the day. We do not want to take any risks with infection.
• The night before and the morning of surgery you need to shower with Hibiscrub soap (pink liquid). Apply top to toe and leave for 2 minutes before rising. Dry with a clean towel and do not apply any cream or lotion the morning of surgery.
• Nothing to eat or drink from midnight the night before surgery, not even water.

• Bring your regular medication along in original boxes and with a list of your medication
• Toiletries and masks
• Crutches if you have, not a walking frame as we have one
• Comfortable night clothes or clothes to walk around in
• Headphones, chargers and other gadgets you use
• You will have your own lockable cupboard to store small items
• Snacks and drinks if you like something special
• Don’t bring lots of money or jewelery

• Someone to assist you
• Easy access to your bed
• Bathroom access and rails if required to make it safe to go to the loo and get in and out of the shower
• No loose rugs on the floor and open space to move around coffee table to get to your chair in the lounge

Admission day, what to do:

• Go to front desk and get admitted
• You will be escorted to the ward and made comfortable by the nursing staff
• Final few things are done to prepare you for theatre:

  • Blood test and ECG if not already done
  • Meet the aneathetist and get a premed
  • Relax before surgery

  • You will be transferred to a waiting area before going into theatre for surgery
  • You will be out of the ward for approximately two hours

What happens after surgery?

• You can access your phone and contact your family
• You will be offered food and drinks
• Nursing staff will monitor your general condition and pain management will be in place.

• Your legs will be numb and can’t move for a few hours after surgery

• The physio will see you for mobilization once your legs have recovered

• You need to try and empty your bladder as soon as you regain bladder control

3D printing can assist in various ways in hip and knee replacement surgery in both primary and revision surgery. Complicated anatomy can be scanned in a CT scanner and the scanned files converted to printable files. This will enable the surgeon to get a to-scale printed model of the joint. Planning can now be done before surgery to decide on the size of the implant and placement of screws and augments to secure the implant. This will shorten the surgical time and prevent situations where the correct implants and screws are not available in theatre.

Most of the implant companies can now offer custom printed implants to compensate for lost bone in revision operations. These implants are usually printed in titanium alloy, which is compatible with bone and can be fixed directly to bone for immediate stability, allowing the patient to walk soon after surgery.

Total hip replacement is a safe procedure. Complications are rare and reported to be approximately one percent. The risk of complications can be minimized by meticulous peri-operative assessment and identification of potential complications. Despite the best intensions and protocols, some complications can occur. I have developed protocols to be followed to limit complications.

Possible complications include but are not limited to:

Dislocation of the hip joint is where the ball slips out of the socket. This is a much less frequent complication due to improved design and larger heads used. Dislocation is mostly a problem of abnormal positioning of the leg in the first six weeks after surgery. Patients are informed by the physiotherapists on what to do to prevent dislocation. In most cases the hip can be relocated under sedation.