Labrum is a ring of strong fibrocartilaginous tissue lining around the socket of the hip joint. Labrum serves many functions where it acts as shock absorber, lubricates the joint, and distributes the pressure equally. It holds the head of the femur in place and prevents the lateral and vertical movement of the femur head with in the joint. It also deepens the acetabular cavity and offers stability against femoral head translation.

Diagnosis

Labral tear may be caused by trauma, femoroacetabular impingement (FAI), hip hypermobility, dysplasia, and degeneration. It is one of the rare conditions and is common in athletes playing sports such as ice hockey, soccer, golf and ballet. Structural abnormalities may also cause hip labral tear. Patients may have hip pain, clicking and locking of joint and restricted range of motion. Patients may also experience dull pain on movement of hip joint that may not subside on rest. Hip labral tear is often diagnosed with symptoms, history, physical examination and radiological techniques. Magnetic resonance arthroscopy may be more appropriate for diagnosing hip labral tear.

Treatment

Your doctor may start with conservative treatment prescribing nonsteroidal anti-inflammatory drugs and advising you to rest. These methods may offer symptomatic relief while surgery is required to repair the torn labrum. Your doctor may perform arthroscopic surgery using fiber-optic camera and surgical instruments through the smaller incisions. Depending on the severity of tear, the damaged or torn labrum may be removed or may be sutured.

Hip dysplasia is a condition which is seen in infants and young children as a result of developmental problems in the hip joint. The femur (thigh bone) partially or completely slips out of the hip socket causing dislocation at the hip joint. It is most common in first born baby with family history of the disorder. The exact cause for hip dysplasia is not known. Genetic factors play an important role in causing this birth defect.

The common symptoms of hip dysplasia include:

In normal hip, the head of the femur (thigh bone) fits well into the socket (acetabulum) whereas in hip dysplasia, the socket and femoral head are not congruent because of their abnormal development. Patients with hip dysplasia may have undergone one or more hip operations during their childhood which might have caused considerable skeletal changes and scarring of the soft tissues. Secondary osteoarthritis may develop later in life which may cause pain and stiffness in the hip. This is an indication for total hip replacement surgery. During this surgery, your surgeon enlarges and prepares the socket to receive the acetabular component. A bone graft may sometimes be placed to recreate the roof of defective hip socket.

Femoroacetabular impingement (FAI) is a condition where there is too much friction in the hip joint from bony irregularities causing pain and decreased range of hip motion. The femoral head and acetabulum rub against each other creating damage and pain to the hip joint. The damage can occur to the articular cartilage (the smooth white surface of the ball or socket) or the labral tissue (the lining of the edge of the socket) during normal movement of the hip. The articular cartilage or labral tissue can fray or tear after repeated friction. Over time, more cartilage and labrum is lost until eventually the femur bone and acetabulum bone impact on one other. Bone on bone friction is commonly referred to as Osteoarthritis.

FAI Impingement Types

FAI impingement generally occurs as two forms: Cam and Pincer.

CAM Impingement 
The Cam form of impingement is when the femoral head and neck are not perfectly round, most commonly due to excess bone that has formed. This lack of roundness and excess bone causes abnormal contact between the surfaces.

PINCER Impingement
The Pincer form of impingement is when the socket or acetabulum rim has overgrown and is too deep. It covers too much of the femoral head resulting in the labral cartilage being pinched. The Pincer form of impingement may also be caused when the hip socket is abnormally angled backwards causing abnormal impact between the femoral head and the rim of the acetabulum.

Most diagnoses of FAI include a combination of the Cam and Pincer forms.

Symptoms of FAI

Symptoms of femoroacetabular impingement can include the following:

Risk Factors

A risk factor is something that is likely to increase a person’s chance of developing a disease or condition. Risk factors for developing femoroacetabular impingement may include the following:

Diagnosis

Hip conditions should be evaluated by an Orthopedic hip surgeon for proper diagnosis and treatment. Such as:

Treatment Options

Conservative Treatment (Non-Surgical) Measures

Conservative treatment options refer to management of the problem without surgery. Non-surgical management of FAI will probably not change the underlying abnormal biomechanics of the hip causing the FAI but may offer pain relief and improved mobility.

Surgical Treatment

Hip arthroscopy to repair femoroacetabular impingement is indicated when conservative treatment measures fail to provide relief to the patient. Hip arthroscopy is a surgical procedure in which an arthroscope is inserted into the hip joint to assess and repair damage to the hip. Hip arthroscopy is performed in a hospital operating room under general or regional anesthesia depending on you and your surgeon’s preference.

This surgery is usually performed as day surgery or outpatient surgery, enabling the patient to go home the same day. The arthroscope used in hip arthroscopy is a small fiber-optic viewing instrument made up of a tiny lens, light source and video camera. The surgical instruments used in arthroscopic surgery are very small (only 3 or 4 mm in diameter), but appear much larger when viewed through an arthroscope.

The television camera attached to the arthroscope displays the image of the joint on a television screen, allowing the surgeon to look throughout the hip joint. The surgeon can then determine the amount or type of injury, and then repair or correct the problem as necessary.

In arthroscopic repair of FAI, your surgeon may perform the following procedures:

  1. Chondroplasty: This refers to surgery to repair torn cartilage or a torn labrum. Sutures are used to reattach the torn labrum or cartilage.

  2. Microfracture: This involves drilling holes into bare bone where cartilage is missing to promote the formation of new cartilage.

  3. Labral/Cartilage debridement:</strong> This type of debridement refers to cutting out and removing pieces of torn or frayed labrum or cartilage.

  4. FAI decompression: This involves removing any pressure areas, such as bony bumps, causing the impingement.

  5. Osteoplasty: This refers to a surgical procedure to modify or alter the shape of a bone

For FAI surgery, your surgeon will use a special instrument called a shaver to cut away or debride any frayed cartilage. If the labrum is torn, your surgeon will use sutures to preserve and reattach the labrum.

Any bony bumps present contributing to the impingement will also be shaved away and smoothed. Your surgeon may drill holes in bone that has no cartilage covering it. This technique is called microfracture and stimulates the formation of new cartilage.

Once your surgeon is satisfied with the results the instruments and arthroscope are removed from the portals. The portals (incisions) are then closed by suturing or by tape.

Arthroscopic repair of FAI, offers several advantages to the patients and they include:

Risk And Complications

As with any major surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery takes place. Complications can be medical (general) or specific to hip arthroscopy surgery.

Read more about general risk and complications with any surgery and hip surgery here.

Complications are rare after hip arthroscopy surgery, but unexpected events can follow any operation. Please talk to your surgeon for more information on femoroacetabular impingement.

Osteoarthritis, also called degenerative joint disease is the most common form of arthritis. It occurs most often in older people. This disease affects the tissue covering the ends of bones in a joint (cartilage). In a person with osteoarthritis, the cartilage becomes damaged and worn out causing pain, swelling, stiffness and restricted movement in the affected joint. Although osteoarthritis may affect various joints including hips, knees, hands, and spine, hip joint is most commonly affected. Rarely, the disease may affect the shoulders, wrists and feet.

Osteoarthritis is characterized by damaged articular cartilage, cartilage lining the hip joint. Advanced age is one of the most common reasons for osteoarthritis of hip. You may also develop osteoarthritis if you had hip injury or fracture in the past, if you have family history of osteoarthritis, suffering from hip diseases such as avascular necrosis and other congenital or developmental hip diseases.

How do you know that you have osteoarthritis of hip? The characteristic symptoms and diagnostic test helps in diagnosing the condition. You will experience severe pain confined to hip and thighs, morning stiffness and limited range of motion. Based on the symptoms your orthopedic surgeon will perform physical examination, X-rays and other scans, and also some blood tests to rule out the other conditions that may cause similar symptoms.

Management of Osteoarthritis

There are several treatments and lifestyle modifications that can help you ease your pain and symptoms.

Medications
Pain-relieving medications such as NSAIDs, COX-2 inhibitors and opioids may be prescribed. Topical medications such as ointments can be applied over the skin where there is pain. If the pain is very severe, corticosteroid injection can be given directly into the affected joint to ease the pain.

Treatments
Your physiotherapist will teach you exercises to keep joints flexible and improve muscle strength. Heat/cold therapy which involves applying heat or cold packs to the joints provides temporary pain relief. Lifestyle modifications can be done to control weight and avoid extra stress on the weight-bearing joints

Surgery
Hip replacement surgery is considered as an option when the pain is so severe that it affects your ability to carry out normal activities.

Hip replacements can be preformed through a direct anterior approach, an anterior lateral approach, a lateral approach, a posterior approach, and a superior approach. Some surgeons will use 2 incisions, both the anterior and superior approach. Each approach has advantages and disadvantages.

Types of Hip Replacement (Approach)

Superior Approach
The superior approach is a relatively new approach that has recently been developed in Boston by Dr. Stephen Murphy. This superior approach is my preferred approach because I feel it offers the most advantages and the least disadvantages. Most notably, the hip stability after a superior approach is remarkable because neither the anterior nor posterior capsule is cut during this approach. In addition, the leg is never dislocated during the entire procedure and typically the hip can not be dislocated on the operating table even with the patient pharmacologically paralyzed and the leg in the most compromising positions. The excellent stability typically allows patients to move their leg after surgery without any restrictions on their motion. The leg is held in a normal position during the entire operation, so the blood vessels and nerves are not stretched and twisted like during other approaches. The femoral canal is prepared prior to the femoral neck is cut, so the femur is structurally more sound during the preparation of the canal. This fact may decrease the risk of femoral fractures during the canal preparation. Preparing the femoral canal before cutting the femoral neck also allows the surgeon to use a special leg length measuring device to recreate the patient's leg length and offset. Although larger body size makes any joint replacement a little harder, the superior approach seems to be easier than other approaches at dealing with the difficulties of joint replacement in larger patients. The relative easy with the superior approach in larger patients is because of the special leverage retractors and the inherent femoral stability while preparing the femoral canal. The disadvantages of the superior approach is that the surgeon can not deliberately lengthen a patient more than 1-2 cm because the intact joint capsule will not stretch more than about 1 cm. Another disadvantage of the superior approach is that it is more difficult to insert screws into the acetabular component, although I routinely do insert screws. Special equipment and training is required to perform this technique. The superior approach can easily be extended into a posterior approach if the surgeon needs more access to the femur or pelvis. The superior approach is most similar to the posterior approach without cutting the posterior capsule or short external rotator muscles and without dislocating the joint.

Anterior Approach
The direct anterior (Smith-Peterson) and anterior lateral (Watson Jones) approach have the advantage of not violating the posterior muscles (Gluteus Maximus). There is often less damage to the posterior capsule as well. The intact gluteus maximus muscle is the main purposed reason for the quicker recovery touted by some doctors. I personally think that the rate of recovery between my anterior approach hip replacements and my superpath approach hip replacements are very similar. The direct anterior approach is the most direct approach to the hip joint going through a thinner amount of soft tissue (2-3") than the posterior approach (3-5"). Most (90%) of hip dislocations occur posteriorly, and therefore the anterior approach likely has lower dislocation rate than a traditional posterior approach, although the dislocation rate is not zero. Most surgeons do not restrict their patients' hip motion after an anterior approach.

The anterior approach has the disadvantage of possibly injuring the lateral femoral cutaneous nerve, which can cause lateral thigh numbness. This numbness usually does not bother patients much. Surgeons often use a special operating table (Hanna table) to force the leg in a hyper-extended and externally rotated position in order to insert the femoral component into the femoral canal. This extreme leg position is not something the patient could do while they were awake. The anterior approach often requires using curved, tapered style femoral component because there is a limit to the amount of hip extension the surgeon can force the patient's leg into. The patient's body and limited hip extension can make it difficult to get a straight femoral component down the femoral canal. This is similar to a professional golfer deliberately hitting a slice onto the green to avoid a tree that blocks his direct shot. Because of the stress on the femoral bone by all of the attached muscles and the extreme leg position, there is a slightly higher rate of intra-operative femoral fractures with the anterior approach. The anterior approach is definitely easier at inserting the socket component and more difficult at inserting the femoral component.

Lateral Approach
The lateral approach (Hardinge) has the advantage of not cutting the posterior capsule and muscles (lower dislocation rate) and not inadvertently injuring the abductor muscles. The anterior 1/3 of the abductor muscles are dissected off the femur and then repaired at the end of the operation. The muscle belly is retracted and protected during the insertion of the femoral component. The disadvantage of the lateral approach is that the repaired abductor muscles must be protected after the surgery by limiting the patient's weight bearing status. The patient may also limp if the abductor muscles do not heal or are damaged from the dissection.

Posterior Approach
The posterior approach (Kocher-Langenbock) has the advantage of not injuring the abductor muscles and the dissection can be extended in case more access to the femur or pelvis is necessary. The posterior approach is probably the most popular approach for a total hip replacement today. The disadvantage of the posterior approach is that the posterior capsule and muscles are cut during the approach. They are typically repaired at the end of the case which helps prevent dislocations, but the posterior approach does have a higher dislocation rate than the other approaches. Most surgeons limit the patient's motion after surgery with a posterior approach to prevent any compromising leg positions that might cause a hip dislocation. Because the abductor muscles are spared, most patients have historically had the lowest rate of limping with the posterior approach.

Two Incision
The two incisions technique combines the anterior approach and the superior approach. The acetabular component is inserted through a traditional anterior incision and the femoral component is inserted through a superior incision. Advocated of this approach claimed that the two incisions approach offered the hip stability of an anterior approach and the abductor protection of a posterior approach. Skeptics of the two incisions approached have published high complications rates and claimed damage to the abductor muscles from the blind preparation of the femoral canal and insertion of the femoral prosthesis without protecting the abductor muscles. Initially, there was considerable marketing and publicity surrounding this approach, but recent reports are mixed.

Good results after a total hip replacement can be achieved with any of the above approaches. Patients should allow the surgeon to perform the approach the surgeon is most comfortable with.

The goal of hip replacement surgery is to help regain natural hip function. Hip replacement surgery involves replacement of the damaged hip joint with an implant. Hip joint resembles a ball and socket joint where acetabular cup forms socket and head of femur bone rotates within the acetabular cup.  During hip replacement surgery worn out acetabular component, femur head, or both may be replaced and these implants may be made up of different materials.

The implant comprises of acetabular cup and femoral head. Acetabular cup contains a shell and a liner. The ball, replacement for femoral head, will be attached to the stem. This ball attached to stem will then be placed into the socket and this forms the artificial hip joint. The site at which the movable parts of new hip joint unite to form a movable joint is called as ‘bearing’.

Types

Bearing is made of different materials and selection of the type of material (bearing surface) is very important. Different materials used for these implants are metal, ceramic, and polyethylene. Combination of these materials may also be used. Each of these bearing surfaces has their unique advantages and disadvantages. Therefore your surgeon decides on which bearing surface would be best for you. Your surgeon considers various factors such as your age, standard of living and body weight for selecting the bearing surface. One or more than one type of bearing may be used by your surgeon depending upon the durability, level of performance, wear resistance, and your personal needs.

Cross-linked Polyethylene

Cross-linked polyethylene is usually used for lining the acetabular cup. The acetabular cup and the ball will be made up of stainless steel, cast or wrought cobalt, or metal-alloy.

Advantages Of Cross-linked Polyethylene

Disadvantages Of Cross-linked Polyethylene

Metal On Metal 

Metal on metal bearings was commonly used earlier and advent of polyethylene surfaces replaced the metal-on-metal surfaces. However with increase in demand for better designs, stronger and long lasting surfaces metal-on-metal bearings regained their importance. In metal on metal implants the acetabular cup, lining and femoral head will be made of metals

Advantages Of Metal On Metal

Disadvantage Of Metal On Metal

Ceramic

These bearings are available in two forms, a ceramic femoral head with a polyethylene liner, or a ceramic femoral head with a ceramic liner.

Advantages Of Ceramic

Disadvantages Of Ceramic

Anti-rhuematic drugs include nonsteroidal anti-inflammatory drugs (NSAIDs), disease modifying anti-rheumatic drugs (DMARDs) and biologic agents. NSAIDs are anti-inflammatory agents that are devoid of steroidal components but effective in relieving the pain & inflammation. They are available in the form of pills, liquids and topical creams and are recommended to relieve arthritic pain. They are available as both over the counter drugs and prescription drugs.

Disease modifying anti-rheumatic drugs (DMARDs) considered as first line of agents for arthritis and these drugs retard the progression of joint damage. Biological agents are the antibodies developed using genetic engineering technology and they destroy the inflammatory agents causing arthritis.

These injections of steroids are given directly into the affected joint for severe pain when use of NSAIDs does not bring much relief. Steroids are very strong anti-inflammatory drugs and if used orally cause various side effects on other body systems. Local analgesics that prevent the sensation of pain are sometimes given along with steroids in the same shot to bring relief quickly.

Chrondroitin sulphate and glucosamine are naturally occurring substances in the body that prevent degradation of cartilage and promote formation of new cartilage. Chrondroitin sulphate and glucosamine obtained from animal sources are available as over the counter products for arthritis. Apart from these various other nutritional supplements are also available such as calcium with magnesium and vitamin D as a combination, S-Adenosyl-Methionine and Methylsulfonylmethane.

Introduction

Revision Hip Replacement means that part or all of your previous hip replacement needs to be revised. This operation varies from very minor adjustments to massive operations replacing significant amounts of bone.

Total Hip Replacement (THR) procedure replaces all or part of the hip joint with an artificial device (prosthesis) with a plastic liner in between to restore joint movement.

Hip Bone

The hipbone is a large, flattened, irregularly shaped bone, constricted in the center and expanded above and below. It consists of three parts, the ilium, ischium, and pubis, which are distinct from each other in the young subject, but are fused in the adult; the union of the three parts takes place in and around a large cup-shaped articular cavity, the acetabulum, which is situated near the middle of the outer surface of the bone.

Why (Reasons) Hip revision

  1.  Pain is the primary reason for revision. Usually the cause is clear but not always. Those hips without an obvious cause for pain, in general, do not do as well after surgery.

  2. Dislocation (instability) which means the hip is popping out of place.

  3. Loosening of either the femoral or acetabular component. This usually presents as pain but may be asymptomatic. It is for this reason why you must have your joint followed up for life as there can be changes on X-ray that indicate that the hip should be revised despite having no symptoms.

  4. Infection-usually presents as pain but may present as an acute fever or a general feeling of unwell.

  5. Osteolysis (bone loss). This can occur due to particles being released into the hip joint which result in bone being destroyed.

  6. Pain from hardware e.g. cables or wires causing irritation.

Hip Revision Surgical Procedure

  1. The surgery is performed under spinal, general or epidural anesthesia. A combination of techniques are used.

  2. The surgeon makes an incision along the hip exposing the hip joint.

  3. The femur (hipbone) is separated from the acetabulum (pelvic socket).

  4. The old plastic liner and the metal socket are removed from the acetabulum.

  5. The acetabulum may be prepared with extra bone to make up for the socket space. Sometimes wire mesh may also be necessary to hold the socket shape.

  6. The new metal shell may be press fit or fitted with screws. Occasionally cement may be used depending on the surgeon’s preference.

  7. A plastic liner is fitted to the metal socket.

  8. The surgeon then concentrates on the femur. The damaged bone is cut.

  9. To remove the femoral component, the bone around the component may be cut.

  10. The parts of the bone are cleared of any old cement.

  11. The new femoral component is pressed or cemented into place.

  12. Wires may be used to hold the bone and femoral component.

  13. Then a ball made of metal or ceramic is placed on the femoral component. This ball acts as the hip joints original ball.

  14. The ball and socket are fixed in place to form the new hip joint. The muscles and tendons are then approximated.

  15. Drains are usually inserted to drain excessive blood.

Remember this is an artificial hip and must be treated with care.

AVOID THE COMBINED MOVEMENT OF BENDING YOUR HIP AND TURNING YOUR FOOT IN. This can cause DISLOCATION. Other precautions to avoid dislocation are:

Do's

Don'ts

Risks and complications

As with any major surgery, there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. 

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