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Hip Preservation Surgery

The hip is a ball and socket joint comprising of the femur (thigh bone) and the pelvic bone. The head of the femur (ball) articulates with a cavity (socket) called the acetabulum in the pelvic bone. To facilitate smooth and frictionless movement of the hip joint, the articulating surfaces of the femur head and acetabulum are covered by spongy articular cartilage. Injury, wear-and-tear and certain diseases can result in the wearing away of the cartilage tissue, causing painful rubbing of bones. Hip replacement surgeries have long been the choice of treatment, where the damaged parts of the joint are removed and replaced with a prosthesis. However, in young active patients, the prostheses are highly prone to wear-and-tear, and the need for repeat surgery. Hip preservation is a surgery that overcomes the limitations of joint replacement.

Some of the conditions indicated for hip preservation surgery include:

  • Femoroacetabular impingement (FAI): friction in the hip joint from abnormal bony irregularities
  • Hip dislocation: head of the femur moves out of the socket
  • Hip dysplasia: congenital hip condition characterized by a shallow acetabulum
  • Labral tear: tear or separation of the labrum, a cartilaginous ring that surrounds the socket and seals the hip joint
  • Avascular necrosis: disrupted blood flow to the hip joint, causing death of bone tissue

Hip preservation surgery includes various techniques:

  • Periacetabular osteotomy: Periacetabular osteotomy is a surgical procedure to treat hip dysplasia. This involves cutting the acetabulum from the pelvic bone and repositioning it with screws to allow for a better fit of the femoral head. The procedure reduces pain, restores function and prevents further deterioration of the hip joint, thereby increasing the life of the hip joint and postponing total hip replacement.
  • Surgical hip dislocation: Surgical hip dislocation is a surgical technique that involves the dislocation of the hip joint during surgery to facilitate easy access to the inside tissues of the hip joint. It helps your surgeon to clearly view and treat abnormalities present deep into the hip joint.
  • Femoral osteotomy: An osteotomy is a surgical procedure that involves cutting and reshaping of a bone. The femur is cut at the end close to the hip joint and realigned so that it forms a normal angle. This improves the distribution of force placed on the joint and prevents wear-and-tear of the cartilage.
  • Hip arthroscopy: Arthroscopy, also referred to as keyhole or minimally invasive surgery, is a procedure in which an arthroscope is inserted into a joint to check for any damage and repair it simultaneously. Hip arthroscopy is a surgical procedure performed through very small incisions to diagnose and treat various hip conditions.

The various hip preservation surgeries for severe hip pain and dysfunction in young and active patients have been found to be beneficial, and avoid or delay the need for hip replacement surgery.

Core Decompression for Avascular Necrosis of the Hip

The hip joint is a ball and socket joint, where the head of the thigh bone (femur) articulates with the cavity (acetabulum) of the pelvic bone.

Sickle cell disease, a group of disorders that affect the hemoglobin or oxygen carrying component of blood, causes avascular necrosis or the death of bone tissue in the hip due to lack of blood supply.

Avascular necrosis commonly affects the head of the femur. Necrosis leads to tiny cracks on the bone which finally causes the head of the femur to collapse. The condition causes pain due to increased pressure in the blood vessels of the bone marrow at the region of the necrosis.

Early stages of avascular necrosis can be treated by core decompression surgery, which reduces pressure, promotes blood flow and encourages healing of the bone.

Indications

Core decompression is indicated in the early stages of avascular necrosis, when the surface of the head is still smooth and round. It is done to prevent total hip replacement surgery, which is indicated for severe cases of avascular necrosis and involves the replacement of the hip joint with an artificial device or prosthesis.

Surgical Procedure

Core decompression is done under spinal or general anesthesia. The patient is placed on their back in supine position. Live X-ray imaging or fluoroscopy is used to guide your surgeon during the procedure.

A small incision is made on your hip and a guide wire is passed from the incision through the neck of the femoral bone to the necrotic area in the femoral head. A hole is then drilled along the wire. The necrotic bone is then removed. This reduces the pressure immediately and creates space for the new blood vessels to grow and nourish the existing bone.

The cavity that is left behind in the bone is sometimes filled with bone graft taken either from another part of your body or a cadaver. Sometimes synthetic bone graft material is used. The incision is then closed with sutures. Another variation of the same surgery involves drilling very small diameter holes from a single point. The surgical wound in this case is very small and may require only a single suture.

Post-Operative Care

After the operation, crutches are to be used for 6 to 12 weeks to prevent weight bearing at the hip joint until the femur bone heals completely. You will be able to resume your regular activities 3 months after the surgery.

Advantages

The advantages of core decompression include the following:

  • Prevents complications of collapse of the femoral head
  • Preserves bone of the femur
  • Delays the need for total hip replacement where the diseased femur head is replaced with an artificial prosthesis.

Risks and Complications

As with all surgeries, core decompression may be associated with certain complications such as:

  • Fracture along the core track
  • Perforations in the femoral head
  • Deep vein thrombosis

Hip Endoscopy

The hip joint is one of the body's largest weight-bearing joints and is the point where the thigh bone (femur) and the pelvis (acetabulum) unite. It is a ball and socket joint in which the head of the femur is the ball and the pelvic acetabulum forms the socket.

The trochanteric bursa is the large sac present above the greater trochanter of the femur.

The iliotibial band is the ligament that crosses the hip joint, runs down the lateral thigh and attaches to the knee; the band helps stabilize and move the joint.

Hip endoscopy is a minimally invasive procedure indicated in the treatment of various disorders of the hip such as external snapping hip syndrome, internal snapping hip syndrome, gluteus medius tears, and greater trochanteric bursitis.

The aim of the procedure is to relieve chronic debilitating hip pain. Portal incisions are one of the most challenging aspects of hip endoscopy. The incision locations depend on the surgeon’s preference and the pathology being treated.

External snapping hip occurs when the IT band snaps over the prominence of the greater trochanter during flexion and extension. During hip endoscopy, a diamond shaped defect is created on the IT band lateral to the greater trochanter and the IT band is released. The diamond shaped defect allows free mobility of the greater trochanter and prevents snapping of the IT band. The surgery is performed outside the hip joint, in the peritrochanteric space.

Internal snapping hip occurs when the iliopsoas tendon snaps over the femoral head, and mostly occurs with hip extension from a flexed position of greater than 90 degrees. Endoscopic treatment involves release of the iliopsoas tendon at the level of the hip joint or at the insertion of the iliopsoas tendon on the lesser trochanter.

Endoscopic procedures use minimally invasive techniques; a smaller incision is placed than the traditional large open incision. Some of the benefits of endoscopic procedures include:

  • Minimal trauma to the surrounding tissues
  • Shorter recovery time with minimal post-surgical complications
  • Greater range of motion with less post-operative pain

Hip Hemiarthroplasty

The hip joint is one of the body's largest weight-bearing joints and is the point where the thigh bone (femur) and the pelvis (acetabulum) unite. It is a ball and socket joint in which the head of the femur is the ball and the pelvic acetabulum forms the socket. The joint surface is covered by a smooth articular cartilage that cushions and enables smooth movements of the joint.

Hip hemiarthroplasty is a surgical technique employed to treat hip fractures. In this procedure, only one half (ball section) of the hip joint is substituted by a metal prosthesis.

Surgical procedure

The procedure is performed under general anesthesia. An incision is made along the outer aspect of the affected hip. The surgeon gains access to the hip joint and the head of the femur is removed using surgical instruments and prepared to accept the prosthesis. The stem of the metal prosthesis is placed inside the femoral bone. The surgeon now connects the metal ball that forms the femoral head. The stem prosthesis can be press-fit in patients with a strong, healthy bone or cemented in cases of weak, osteoporotic bone. The method of implantation depends on the patient’s age and condition of the bone. At the end of the procedure, the incisions are closed with sutures and a dressing is applied.

After surgery

The post-procedural instructions to be followed hip hemiarthroplasty include:

  • You will be prescribed medications to reduce pain and inflammation.
  • Crossing your legs should be avoided.
  • Avoid lifting of heavy objects.
  • Avoid bending and twisting your hip. Instead use grabbers to pick the things.
  • Avoid standing for long hours.
  • Use an elevated toilet seat.
  • Avoid sitting on low chairs.
  • Your surgeon may recommend physical therapy to strengthen the joint and the muscles and to help restore mobility to the hip joint.

Complications of hip hemiarthroplasty include infection, dislocation, deep vein thrombosis, loosening of the prosthesis, and failure to relieve pain. Discuss with your surgeon if you have concerns regarding hip hemiarthroplasty surgery.