Hip joint surgery is done when conservative therapy is ineffective or in case of emergency. Modern medicine has a wide range of techniques for joint treatment, and high quality rehabilitation methods can help you to return to a life of full value after an intervention.
Hip Joint Surgery: Indications and Contraindications
Surgical treatment of the hip joint is required when bone tissue is severely damaged by progressive diseases of the musculoskeletal system. In this case, joint replacement is necessary. Before the intervention, additional examination is carried out to study the manifestations of pathology and reduce risk factors. For various types of hip joint surgery, contraindications can be different because they depend not only on general recommendations, but also on systemic factors, such as age, concomitant diseases, blood disorders and the nature of the intervention (primary or secondary).
But in most cases, surgery is not performed if a patient has one or more of the following diseases:
- Severe chronic cardiovascular diseases
- Cardiac or respiratory failure that can cause problems with anesthesia and other complications
- Open form of tuberculosis
- Purulent inflammation of the hip joint
- Progressive chronic infection in the body
- Neurological or mental disorders
- Metastatic cancer
Arthrotomy and Hip Joint Resection
Hip arthrotomy is any surgery involving hip joint opening and providing intraarticular access. It is used for:
- removing purulent exudates, free bodies and foreign bodies in the joints;
- correcting old or congenital joint dislocations;
- resection hip joint tumors or infectious foci;
- arthroplasty in case of ankylosis.
As already said, resection of the hip joints mostly is an atypical operation, often of a more extended type as that for closed coxitis. It should be performed with the utmost accuracy, adhering to the general rules reassigned in protocols.
Conservative treatment of patients with severe hip injuries is not very promising: it leads to complete immobilization for a long time, difficult rehabilitation, whilst there is no any guarantee of success. It is especially related to the older people with weakened calcium metabolism and osteoporosis. So, non-surgical options are used for them only when surgery is contraindicated.
Young people also hardly can like the complete immobilization. Therefore, always when possible, osteosynthesis of the femoral neck is considered in the first place.
Indications for osteosynthesis are following:
- Basal fractures of the femoral neck in patients with active lifestyle
- Transcervical damage in bone integrity (fractures) in people under 60
- Punctured fractures
- Subcapital neck of femur fractures (NOF)
- There are contraindications to joint replacement
There is a variety of concepts of metal osteosynthesis for the neck of the femur fractures. Many different factors influence the process of selection a particular method of reposition and osteosynthesis. Closed reduction of bone fragments with use of screw fixation is one of the well-proven techniques.
Closed reduction has a number of great advantages:
- It is a minimally invasive technique. As a rule, no more than three (sometimes two) screws are required.
- It does not take much time, which is important for combined injuries.
- It is just perfect for fixing fragments in case of intraarticular fractures.
- It provides a high level of reduction and immobilization of bone pieces.
- Titanium alloy does not cause rejection and complications in patients after surgery.
- The screws are easily removed after the consolidation of hip fracture.
The fixation, which is achieved by different ways, can be:
- Relatively stable: slight micro movements between bone fragments are possible, but they do not cause pain and, furthermore, contribute to coalescence of fragments by forming a periosteal callus.
- Absolutely stable: there are no any movements between bone fragments in the damaged area.
The core feature of the method is a special mode of screw fixation. Screws are screwed into the bone at the twisted thigh bones area, pass inside the femur neck in parallel to its surface and end in the central part of the femur head.
The start and end points were chosen not by chance, since the density of bone tissue is maximal in these areas, which ensures a high stability of the fixation of the bone fragments – what is needed for a better bone healing.
On practice, the best effect of osteosynthesis with screws is achieved for locomotor fractures, provided that displacements of the bone pieces are relatively small.
Ultrasonic osteosynthesis also deserves to be mentioned: with this method, connecting fractured fragments, filling the hip joint cavity and creating bone conglomerates in order to restore bone integrity are done by means of ultrasonic welding.
Hip joint surgery involving an excision or fracture of the bone with medical instruments to eliminate deformation is called hip osteotomy.
Osteotomy is performed on the hip joint when there are violations of the functions of the musculoskeletal system or deformations of the bones. For the hip joint, this surgery is performed in the case when the femoral head and the hip socket are not aligned properly.
Frequent causes of such pathology are cerebral palsy (CP), joint dysplasia, osteoarthritis, and Legg-Calve-Perthes disease.
During this operation, a surgeon corrects the shape of the femur neck and, then, rotates the acetabulum for a better alignment. Healthy cartilage is replaced and, due to this, the femur head has a good covering that does not allow it to move.
The surgery is performed under general anesthesia; its duration is about 2 hours. After the surgeon corrected the bone deformation, a plaster cast is applied to be worn for about 7-8 weeks. After it is removed, the patient, at first, moves with crutches in order not to overload the joint, but after some time he or she can return to normal activities.
Hip arthroscopy is a surgical procedure that is performed with a special device called an arthroscope. It is equipped with ultra-precise optics and light and used for diagnosing and treatment of diseases of the hip joint. The main advantage of arthroscopy is low trauma, since they are carried out through a small incision and minimally damage soft tissues.
Arthoscopy of the hip joint is indicated when the diagnosis requires extensive examinations and numerous studies. A regular pain in the groin or in the pelvic area can be an indication for arthroscopy. During this procedure, it is possible to remove free bodies and to eliminate damage cartilage from the hip joint.
During arthroscopy, the surgeon examines the space between the hollow of the thigh, the femur head and other areas of the hip. All manipulations are performed under general or local anesthesia. The operation is carried out with a stretched leg, which allows doctors to ease access to the damaged area.
The following diagnoses may be a reason for surgery:
- joint rupture;
- free bodies, namely cartilage fragments, in the joint;
- snapping of the hip joint;
- arthritis on early stage;
- cartilage damage of different origin.
The undisputed advantage of arthroscopy of the hip joint is quick recovery. It is much easier and with lesser pain than with open hip surgery. Starting from the very first day after surgery, patients have to do special exercises to restore joint mobility. The patients who have limp are advised to use crutches or walkers for one and a half to two months after the surgery. Later, patients can try to start light physical activities, such as cycling or swimming. Usually, the recovery takes from three to four months; however, in more complex cases, a longer recovery may be required.
Arthrodesis is a surgical technique intended to return or improve support ability of the joints by fixing them in an immobile state. There are some cases when, without this procedure, you can get limited ability to move, or even complete disability. This treatment has some specific features. Please note, that arthrodesis is not indicated to all patients, even though their symptoms are similar.
Hip arthrodesis is one of the possible surgical interventions to treat deforming osteoarthritis. This type of surgery is aimed to stabilize the joint by immobilization. Trauma surgeons use this a method when it is necessary to reduce or eliminate the symptoms of pain syndrome, but, for some reason, arthroplasty and joint replacement are contraindicated.
There are four methods of arthrodesis mostly used:
- compression (open or closed).
This procedure may be required at the following joint diseases and conditions:
- Dangling joint: complete or partial misalignment of the joint, causing limited or complete atrophy of intraarticular mobility (flaccid paralysis syndrome, ligament integrity damage, consequences of gunshot wound, genu recurvatum, etc.).
- Deforming arthritis: pathological deformity or tuberculosis of bones and osseous joints, acute purulent or traumatic arthritis.
- Complicated osteoarthrosis: degenerative dystrophic diseases of the joints, characterized by damage to the cartilaginous tissue of the articular surfaces.
- Consequences of poliomyelitis (cerebral palsy).
- Improperly fused/ fusing fractures.
- Impossibility of plastic surgery on problematic joints using a partial / total endoprosthesis or plates;
- Other causes that lead to reducing of active movements in the joint and increasing of passive movements.
During the surgery, all functionally altered tissues are removed and cartilage of the femur head and acetabulum is excised, as well as the spongy layer of the bone. The articular surfaces are joined in such a way to provide later their reliable fusion. In case when the femur head and the main part of the femur are not viable, they have to be resected. After the surgery, a plaster cast is applied that are removed after not less than three months.
After the plaster cast is removed, an X-Ray scan is done for a check-up. With satisfactory fusion, another plaster bandage is applied for 3-4 months more. Six months after the surgery, the patient can walk.
Surgery to replace the hip joint with a prosthesis is often called endoprosthetics. It gives patients an opportunity to return to a full life without pain and limitations. It is recommended in case of a neck and/or head of the femur fracture, tumors of the proximal part of the femur, progressive bone diseases (deforming arthrosis, necrosis of the femoral head, Still's disease, etc.), and other pathologies that are not treatable with medication and may lead to disability. Modern prostheses have high wear resistance that can be estimated in dozens of years. In case of severe injuries of the femur and hip joint, and tumors, only leg amputation can help.
Risks of Hip Endoprosthetics
There is a long list of serious complications with possible harm to health. Pneumonia and thrombophlebitis may occur quite often after surgery. There is also a risk of revision in case of failed hip replacement surgery. Bleeding in the site of operation is another possible complication.
There is a small but not non-existing probability that surgery may lead to inflammation, due to infection in the wound, which will significantly complicate recovery.
But complications are rare in this kind of surgery, medical experts say. Also, during surgery, the vessels or nerves in the adjacent area may be affected.
Sometimes a surgical intervention causes a fracture of the femur.
It is important to know: even if the surgery was successful, the risk of complications in the hip joint exists even many years later. But many patients still agree to it in the hope that arthroplasty of the hip will give them relief from pain and the newly obtained mobility of the limbs. To date, there is no better way to restore the hip joint in case of irreversible alterations in the bone tissues.
The goals of rehabilitation are:
- to eliminate contracture, or limitation of movements;
- to reduce edema of soft tissues;
- to regain muscular strength and functionality of the joint;
- to prevent complications.
The postoperative period and its duration are of particular importance for successful treatment. The time needed for restoration of the normal functioning of the limbs varies in the medical literature.
The postoperative recovery usually lasts one day and, then, it is followed by a rehabilitation period. After surgery, a patient may stay is in a clinic about one week. There are two points of view on how to help to the patient in the first 24 hours. Mainly, everything depends on the patient's condition and hip joint surgery success. Often, patients do their first attempts to move with the help of medical staff already the same day surgery. On the average, people return to their normal physical activity in 3-6 months after surgery.
There is a special program of exercises for the hip joint and for general strengthening of the body that is mandatory for every patient. If the patient's condition does not improve, the length of his or her stay in the hospital after the operation, respectively, increases. After surgery, continuous measures are undertaken to increase daily activities of the patient. In general, the recovery lasts up to six months and during this time the functionality of the limbs and hip joint is completely restored, provided that the patient follows all the recommendations of the doctor.
Walking, swimming and cycling are not restricted in the rehabilitation period, as they contribute to a faster recovery of the hip joints. But you have to forget about energetic and contact sports because they may cause harm to the hip joint in the rehabilitation and even post-rehabilitation periods.