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We provide information to help patients and caregivers to understand of hip anatomy, associated symptoms, and joint arthroplasty.

  • Hip is the body’s second largest weight-bearing joint. It is made up of two bones pelvis and femur (thighbone). The rounded head of the femur forms the ball, which fits into the acetabulum.
  • Bones of the hip joint
    • The femur is the longest bone in the body which forms the thigh. The part which articulates with the pelvis to form the hip joint is known as the head of the femur. This is a round, dome shaped protrusion. Close to the top of the femur are two other protrusions, known as the greater and lesser trochanters. The main function of the trochanters is for muscle attachment.
    • The pelvis is actually two large bones which connect at the front by the pubic symphysis (a cartilage disc) and at the back by the Sacrum. The Sacrum is part of the spine and consists of 4 fused vertebrae which do not move independently of one another. The joints formed by either side of the Sacrum and the two pelvic bones are the Sacroiliac joints (SIJ).
    • The surfaces of both the head of the femur and the acetabulum are covered with a thin layer of hyaline cartilage which acts to allow smooth movement of the joint.
  • Capsule
    • The hip joint capsule is a thick ligamentous structure with circular and longitudinal fibers that surround the entire joint. Inside the capsule is a specialized membrane known as the synovial membrane which provides nourishment to all the surrounding structures. 
  • Ligaments of the hip joint
    • Iliofemoral ligament: This is a strong ligament which connects the pelvis to the femur at the front of the joint. It resembles a Y in shape and stabilizes the hip by limiting hyperextension.
    • Pubofemoral ligament: The pubofemoral ligament attaches the part of the pelvis known as the pubis (most forward part, either side of the pubic symphysis) to the femur.
    • Ischiofemoral ligament: This is a ligament which reinforces the posterior aspect of the capsule, attaching to the ischium and between the two trochanters of the femur.
  • Muscle Groups
    • Gluteals: The gluteals are the muscles in your buttocks. The gluteals (gluteus maximus, gluteus minimus, and gluteus medius) are the three muscles attached to the back of the pelvis and insert into the greater trochanter of the femur.
    • Quadriceps: The four quadricep muscles ( vastus lateralis , medialis , intermedius and rectus femoris) are located at the front of the femur. All four attach to the top of the tibia. The rectus femoris originates at the front of the ilium.The three other quads attach around the greater trochanter of the femur and just below it.
    • Iliopsoas: This is the primary hip flexor muscle. The three parts of the iliopsoas attach the lower part of the spine and pelvis, then cross the joint and insert into the lesser trochanter of the femur.
    • Hamstrings: The three muscles at the back of the thigh are called the hamstrings. All three attach to the lowest part of the pelvis.
    • Groin muscles: The groin or adductor muscles attach to the pubis and run down the inside of the thigh.

Hip Pain Associated Causes, Symptoms & Treatment

Osteoarthritis(OA)

Osteoarthritis is the most common symptoms of hip joint. It is often described as the result of wear and tear of the joint cartilage, which explains why it is also known as degenerative arthritis.
The hip joint is surrounded with cartilage to protext the joint and allow smooth movement.
It also absorbs the pressure and shock form outdoor activities such as running and walking.
The bones to rub together when the cartilage wears down in the follwing risk factors; increasing age, obesity, joint injury or bone deformities. This causes pain, stiffness, swelling and reduced movement and function.

Osteoarthritis is a degenerative type of arthritis that occurs most often in people 50 years of age and older, though it may occur in younger people, too.
In osteoarthritis, the cartilage in the hip joint gradually wears away over time. As the cartilage wears away, it becomes frayed and rough, and the protective joint space between the bones decreases. This can result in bone rubbing on bone. To make up for the lost cartilage, the damaged bones may start to grow outward and form bone spurs (osteophytes).
Osteoarthritis develops slowly and the pain it causes worsens over time.

Cause

Osteoarthritis has no single specific cause, but there are certain factors that may make you more likely to develop the disease, including:

  • Increasing age
  • Family history of osteoarthritis
  • Previous injury to the hip joint
  • Obesity
  • Improper formation of the hip joint at birth, a condition known as developmental dysplasia of the hip

Symptoms

The most common symptom of hip osteoarthritis is pain around the hip joint. Usually, the pain develops slowly and worsens over time, although sudden onset is also possible. Pain and stiffness may be worse in the morning, or after sitting or resting for a while. Over time, painful symptoms may occur more frequently, including during rest or at night. Additional symptoms may include:

  • Deep, aching joint pain, sometimes sharp, with activith; the pain can persist at rest
  • Transient joint stiffness after a period of rest
  • Swelling and stiffness in one or more joints
  • Limited movement; loss of joint flexbility

Treatment

The goal of treatment is to reduce joint pain and inflammation, and to enhance joint function.
Treatments may include medications, dietary supplements, alternative therapies (e.g., acupuncture, relaxation therapy),medical aids (e.g., shock-absorbing shoes, splints or braces), losing weight, exercise and physical therapy andcorticosteroid injections. Surgery is the most radical option if one joint is badly damaged or is causing severe symptoms.

Nonsurgical Treatment

As with other arthritic conditions, early treatment of osteoarthritis of the hip is nonsurgical. Your doctor may recommend a range of treatment options.

  • Lifestyle modifications. Some changes in your daily life can protect your hip joint and slow the progress of osteoarthritis.
    • Minimizing activities that aggravate the condition, such as climbing stairs.
    • Switching from high-impact activities (like jogging or tennis) to lower impact activities (like swimming or cycling) will put less stress on your hip.
    • Losing weight can reduce stress on the hip joint, resulting in less pain and increased function.
  • Physical therapy. Specific exercises can help increase range of motion and flexibility, as well as strengthen the muscles in your hip and leg. Your doctor or physical therapist can help develop an individualized exercise program that meets your needs and lifestyle.
  • Assistive devices. Using walking supports like a cane, crutches, or a walker can improve mobility and independence.
  • Medications. If your pain affects your daily routine, or is not relieved by other nonsurgical methods, your doctor may add medication to your treatment plan.
  • Acetaminophen is an over-the-counter pain reliever that can be effective in reducing mild arthritis pain. Like all medications, however, over-the-counter pain relievers can cause side effects and interact with other medications you are taking. Be sure to discuss potential side effects with your doctor.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) may relieve pain and reduce inflammation. Over-the-counter NSAIDs include naproxen and ibuprofen. Other NSAIDs are available by prescription.
  • Corticosteroids (also known as cortisone) are powerful anti-inflammatory agents that can be taken by mouth or injected into the painful joint.

Surgical Treatment

Your doctor may recommend surgery if your pain from arthritis causes disability and is not relieved with nonsurgical treatment.

  • Osteotomy. Either the head of the thighbone or the socket is cut and realigned to take pressure off of the hip joint. This procedure is used only rarely to treat osteoarthritis of the hip.
  • Hip resurfacing. In this hip replacement procedure, the damaged bone and cartilage in the acetabulum (hip socket) is removed and replaced with a metal shell. The head of the femur, however, is not removed, but instead capped with a smooth metal covering.
  • Total hip replacement. Your doctor will remove both the damaged acetabulum and femoral head, and then position new metal, plastic or ceramic joint surfaces to restore the function of your hip.

Prevention

The followings can prevent the development of OA later on in life

  • Maintaining a healthy weight
  • Regular work out such as walking, stretching, swimming and yoga
  • Avoiding repetitive motions and risky activities that may cause joint pain especially after the age of 40

Rheumatoid Arthritis (RA)

Rheumatoid Arthritis (RA) is a chronic, systemic inflammatory disorder. RA causes when the function of does not work properly. The immune system normally makes antibodies (small proteins) to attack bacteria, viruses and other germs. Antibodies are formed against the synovium (the tissue that surrounds each joint) in people with RA. This causes inflammation in and around the affected joints.

Cause

Rheumatoid arthritis is not an inherited disease. Researchers believe that some people have genes that make them susceptible to the disease. People with these genes will not automatically develop rheumatoid arthritis. There is usually a "trigger," such as an infection or environmental factor, which activates the genes. When the body is exposed to this trigger, the immune system responds inappropriately. Instead of protecting the joint, the immune system begins to produce substances that attack the joint. This is what may lead to the development of rheumatoid arthritis.

Ligaments and joint capsules become less effective supporting structures. Erosion of the articular cartilage, together with ligamentous changes, result in deformity and contractures. As the disease progresses, pain and deformity increase.

Symptoms

  • Swelling, pain, and stiffness in the joint, even when it is not being used
  • A feeling of warmth around the joint
  • Deformities and contractures of the joint
  • Symptoms throughout the body, such as fever, loss of appetite and decreased energy
  • Weakness due to a low red blood cell count (anemia)
  • Nodules, or lumps, particularly around the elbow
  • Foot pain, bunions, and hammer toes with long-standing disease

Treatment

Treatment for rheumatoid arthritis varies:

  • Medication
    • Medications used to control rheumatoid arthritis fall into two categories: those that relieve symptoms and those that have the potential to modify the course of the disease. Often, they are used together. Aspirin and ibuprofen can help reduce the pain and inflammation of rheumatoid arthritis. Disease-modifying drugs include methotrexate and sulfasalazine and gold injections.
      Researchers are also working on biologic agents that can interrupt the progress of the disease. These agents target specific chemicals in the body to prevent them from acting on the joints.
  • Exercise and Therapy
    • Exercise is an important part of a treatment program. The physician and physical therapist may work with patients to develop an exercise program that helps strengthen the joints without stressing them. In some cases, a splint or corrective footwear may be required.
  • Surgery
    • Joint replacement surgery is also an option and is often effective in restoring function.

Prevention

There is no cure for rheumatoid arthritis, but a variety of treatments for RA can slow down the condition and keep joint damage to a minimum.

Avascular Necrosis (AVN)

Avascular Necrosis (AVN) is the death of bone tissue due to a lack of blood supply.
Bones are living tissues, and bones receive nutrients through blood vessels. If a blood vessel is damaged, bone can die and collapse. There are many causes of AVN and anything that interrupts the blood supply to the hip can cause AVN. The most common causes of AVN include femoral neck fracture, dislocation, smoking and excessive alcohol use. Fracture of the femoral neck and dislocation can damage the blood vessels.
Smoking causes blood vessels to constrict or narrow. Excessive alcohol use can damage the blood vessels and lead to AVN.

Cause

AVN of the hip develops when the blood supply to the femoral head is disrupted. Without adequate nourishment, the bone in the head of the femur dies and gradually collapses. As a result, the articular cartilage covering the hip bones also collapses, leading to disabling arthritis.

RiskFactors

Although it is not always known what causes the lack of blood supply, there are a number of risk factors that can make it more likely for someone to develop the disease:

  • Injury — Hip dislocations, hip fractures, and other injuries can damage the blood vessels and impair circulation to the femoral head
  • Alcoholism
  • Corticosteroid medicines — Many diseases, such as asthma, rheumatoid arthritis, and systemic lupus erythematosus, are treated with steroid medications. Although it is not known exactly why these medications can lead to osteonecrosis, research shows that there is a connection between the disease and long-term steroid use.
  • Other medical conditions — Osteonecrosis is associated with other diseases, including Caisson disease (diver's disease or "the bends"), sickle cell disease, myeloproliferative disorders, Gaucher's disease, systemic lupus erythematosus, Crohn's disease, arterial embolism, thombosis, and vasculitis

Incidence

  • Although osteonecrosis affects people of all ages, it most commonly occurs between the ages of 40 and 65. Men develop osteonecrosis more often than women.

Symptoms

  • Groin pain, buttock pain, thigh pain and limping.
  • AVN develops in stages. Hip pain is typically the first symptom. This may lead to a dull ache or throbbing pain in the groin or buttock area. As the disease progresses, it will become more difficult to stand and put weight on the affected hip, and moving the hip joint will be painful.
    How long it takes for the disease to progress through these stages varies from several months to over a year. It is important to diagnose this disease early, because some studies show that early treatment is associated with better outcomes.

Treatment

Although nonsurgical treatment options like medications or using crutches can relieve pain and slow the progression of the disease, the most successful treatment options are surgical. Patients with osteonecrosis that is caught in the very early stages (prior to femoral head collapse) are good candidates for hip preserving procedures.

Treatments for Avascular Necrosis are

  • Bone grafts; Removing healthy bone from one part of the body and using it to replace the damaged one
  • Total joint replacement; Removing the damaged joint and replacing it with a synthetic joint
  • Osteotomy; Cutting the bone and changing its alignment to relieve stress on the bone or joint
  • Core decompression
    • This procedure involves drilling one larger hole or several smaller holes into the femoral head to relieve pressure in the bone and create channels for new blood vessels to nourish the affected areas of the hip.
    • When osteonecrosis of the hip is diagnosed early, core decompression is often successful in preventing collapse of the femoral head and the development of arthritis.
    • Core decompression is often combined with bone grafting to help regenerate healthy bone and support cartilage at the hip joint. A bone graft is healthy bone tissue that is transplanted to an area of the body where it is needed.
    • Many bone graft options are available today. The standard technique is to take extra bone from one part of your body (harvest) and move (graft) it to another part of your body. This type of graft is called an autograft.
    • Many surgeons use bone that is harvested from a donor or cadaver. This type of graft is typically acquired through a bone bank. Like other organs, bone can be donated upon death.
    • There are also several synthetic bone grafts available today.

Prevention

It is required to improve general health to reduce risk of avascular necrosis;

  • Limit alcohol
  • Keep cholesterol levels low
  • Monitor steroid use

Fracture

A hip fracture is a break in the thigh bone (femur). Older people are more prone to hip fractures because bones tend to weaken with age. This bone weakening is called osteoporosis. It is causing bones to decrease in bone mass and density.

Types of Hip Fractures

  • Femoral Neck Fracture
    • The femoral neck fracture occurs in the femur about one or two inches below the femoral head. It may disrupt the blood supply and require hip replacement.
  • Intertrochanteric Hip Fracture
    • The intertrochanteric hip fracture occurs between the greater trochanter and lesser trochanter. It does not damage the blood supply.

Cause

This commonly occurs from a fall or from a direct blow to the side of the hip. Some medical conditions such as osteoporosis, cancer, or stress injuries can weaken the bone and make the hip more susceptible to breaking. In severe cases, it is possible for the hip to break with the patient merely standing on the leg and twisting.

Symptoms

Joint pain, limited joint function and abnormal appearance of the broken leg (e.g., looks shorter, turns outward).

Treatment

Considerations

  • Once the diagnosis of the hip fracture has been made, the patient's overall health and medical condition will be evaluated. In very rare cases, the patient may be so ill that surgery would not be recommended. In these cases, the patient's overall comfort and level of pain must be weighed against the risks of anesthesia and surgery.
  • Most surgeons agree that patients do better if they are operated on fairly quickly. It is, however, important to insure patients' safety and maximize their overall medical health before surgery. This may mean taking time to do cardiac and other diagnostic studies.

Nonsurgical Treatment

  • Patients who might be considered for nonsurgical treatment include those who are too ill to undergo any form of anesthesia and people who were unable to walk before their injury and may have been confined to a bed or a wheelchair.
  • Certain types of fractures may be considered stable enough to be managed with nonsurgical treatment. Because there is some risk that these "stable" fractures may instead prove unstable and displace (change position), the doctor will need to follow with periodic X-rays of the area. If patients are confined to bed rest as part of the management for these fractures, they will need to be closely monitored for complications that can occur from prolonged immobilization. These include infections, bed sores, pneumonia, the formation of blood clots, and nutritional wasting.

Surgical Treatment

  • Before Surgery
    • Anesthesia for surgery could be either general anesthesia with a breathing tube or spinal anesthesia. In very rare circumstances, where only a few screws are planned for fixation, local anesthesia with heavy sedation can be considered. All patients will receive antibiotics during surgery and for the 24-hours afterward.
    • Appropriate blood tests, chest X-rays, electrocardiograms, and urine samples will be obtained before surgery. Many elderly patients may have undiagnosed urinary tract infections that could lead to an infection of the hip after surgery.
    • The surgeon's decision as to how to best fix a fracture will be based on the area of the hip that is broken and the surgeon's familiarity with the different systems that are available to manage these injuries.
  • Intracapsular Fracture
    • If the head of the femur ("ball") alone is broken, management will be aimed at fixing the cartilage on the ball that has been injured or displaced. Frequently with these injuries, the socket, or acetabulum, may also be broken. The surgeon will need to take this into consideration as well.
    • These injuries may be approached either from either the front or back of the hip. In some cases, both approaches are required in order to clearly see and fix the injured bone.
    • For true intracapsular hip fractures, the surgeon may decide either to fix the fracture with individual screws (percutaneous pinning) or a single larger screw that slides within the barrel of a plate. This compression hip screw will allow the fracture to become more stable by having the broken area impact on itself. Occasionally, a secondary screw may be added for stability.
  • Intertrochanteric Fracture
    • Most intertrochanteric fractures are managed with either a compression hip screw or an intramedullary nail, which also allows for impaction at the fracture site.
    • The compression hip screw is fixed to the outer side of the bone with bone screws and has a large secondary screw (lag screw) that is placed through the plate into the neck and head of the hip (see compression hip screw figure above). The design of the device allows for impaction and compression at the fracture site. This may increase the stability of the area and promote healing.
    • The intramedullary nail is placed directly into the marrow canal of the bone through an opening made at the top of the greater trochanter. A lag screw is then placed through the nail and up into the neck and head of the hip. As with the compression hip screw, sliding of the lag screw and impaction of the fracture take place.

Prevention

Preventing osteoporosis is the most important ways to prevent hip fractures. Having plenty of calcium and vitamin D. Also doing weight-bearing exercise that puts pressure on bones and muscles can lead to prevent the fracture.

Hip Arthroplasty

Hip arthroplasty is the surgical replacement of all, or part, of the hip joint with an artificial device. It can allow considerable improvement in pain and disability for the patient.

One review found that patients with hip osteoarthritis reported positive outcomes from hip arthroscopy. Patients with hip osteoarthritis had inferior results compared with those who did not. More severe chondropathy and patient age were associated with a higher risk and more rapid progression to total hip arthroplasty.

The procedure can be either a total hip arthroplasty or a hemiarthroplasty.

  • Total Hip Arthroplasty
    • The articular surfaces of the femur and the acetabulum are replaced. This can be:
      • Conventional total hip arthroplasty: femoral head and neck replacement.
      • Resurfacing total hip arthroplasty: surface of the femoral head replacement.
    • Indications 
      • Pain and disability due to degenerative or inflammatory arthritis in the hip joint, where non-operative management has failed and quality of life is being significantly interfered with.
      • Fracture of the proximal femur.
      • A resurfacing total hip arthroplasty may be considered in a young person with osteoarthritis and good bone stock (the advantage is that the femoral neck is preserved which may be advantageous if a later conventional arthroplasty is needed).
    • Surgery description: In a total hip arthroplasty, the damaged bone and cartilage is removed and replaced with prosthetic components.
      • The damaged femoral head is removed and replaced with a metal stem that is placed into the hollow center of the femur. The femoral stem may be either cemented or "press fit" into the bone.
      • A metal or ceramic ball is placed on the upper part of the stem. This ball replaces the damaged femoral head that was removed.
      • The damaged cartilage surface of the socket (acetabulum) is removed and replaced with a metal socket. Screws or cement are sometimes used to hold the socket in place.
      • A plastic, ceramic, or metal spacer is inserted between the new ball and the socket to allow for a smooth gliding surface.
  • Hip Bipolar Hemiarthroplasty for Femoral Neck Fracture
    • Fractures of the hip often occur within the femoral neck, a thin section of the thigh bone that helps to connect the “ball” end of the bone to the main shaft.  When a fracture occurs in this area of the bone, it can cut off blood supply and lead to severe joint damage that cannot be treated with conservative methods.
    • Treatment for femoral neck fractures can be successfully achieved through a bipolar hemiarthroplasty.
    • Indications: Usually indicated for patients with a femoral neck fracture who meet the following conditions:
      • Neurological disease.
      • Displaced fracture that is several days old.
      • Inadequate closed reduction.
      • Severe osteoporosis.
      • Pathological hip fracture.
      • Poor general health or frailty.
      • Pre-existing hip disease (e.g., rheumatoid arthritis, avascular necrosis).
    • Surgery Description
      • Hemiarthroplasty is a surgical procedure that replaces one-half of the hip joint with a prosthetic while leaving the other half intact.  There are several different options available for the type of device to be used; we prefer to use a bipolar type, which has a femoral head that swivels during movement.  This helps to reduce the amount of wear and tear on the new joint for longer-lasting results.
      • During the hemiarthroplasty procedure, the damaged femoral head and neck are removed and replaced with the bipolar prosthetic.  The prosthetic may be held in place with or without cement.  Patients will need to undergo physical therapy after surgery to help restore movement and function to the joint.  Therapy begins as soon as the patient feels comfortable after surgery, which is often the very next day.  Most patients experience effective, long-term results from this procedure.
  • The information on this page is intended only for patients and caregivers.
  • Trademarks appearing on the website are owned, licensed and distributed by Corentec Co., Ltd.
  • Reference : American Academy of Orthopaedic Surgeons (AAOS)