Phil Downer, MD : Seattle Hip Surgery, Seattle Hip Replacement, Seattle Hip Impingment

Hip Bursitis

A bursa is a small, jelly-like sac that holds a small amount of fluid. These structures are located throughout the body and act as cushions between the bones and overlying soft tissues. When a bursa becomes inflamed, the condition is known as bursitis. In order to diagnose hip bursitis, the orthopedic specialist will perform a complete physical examination. He may also perform additional tests to rule out other conditions or injuries. These include bone scanning, magnetic resonance imaging (MRI), and X-rays.

What are the symptoms of hip bursitis?

Hip bursitis causes pain in the groin area. The pain usually extends to the outside of the thigh region, and is described as sharp and intense in the early stages. The pain becomes more of an ‘aching’ later on and spreads out along the thigh and hip. Many complain that the pain is worse at night, when getting up from a sitting position, or when lying on the affected hip.

What are the risk factors for hip bursitis?

Although hip bursitis is more common among women, it can affect almost anyone. Also, middle-aged persons and the elderly are more commonly affected. Some risk factors associated with hip bursitis include:

Hip Injury – An injury to a certain area of the hip can occur when you fall on the hip, lie on that side for an extended period of time, bump the hip on the edge of a table, or fall on the hip.

Repetitive Stress – This is known as “overuse” injury, and it occurs when stair climbing, bicycling, running, or standing for long periods of time.

Spine Disease – People with spine problems are at risk for hip bursitis. This includes arthritis, scoliosis, and other disorders.

Leg-Length Inequality – When one leg is shorter than the other by an inch or more, it could affect the way you walk and lead to bursitis of the hip.

Previous Surgery – The bursa can become inflamed from surgery of the hip or prosthetic implants.

Rheumatoid Arthritis – This condition leads to more inflamed bursa.

Bone Spurs or Calcium Deposits – These may develop inside of the tendons that attach to the upper portion of the femur.

How is hip bursitis treated?

The orthopedic specialist will first try to treat your hip condition with conservative measures. Many people with bursitis of the hip can achieve pain relief with simple lifestyle modifications. This involves avoidance of activities that worsen symptoms, the use of nonsteroidal anti-inflammatory drugs (NSAIDS), and the use of crutches or a cane on occasion. Also, the doctor may recommend that you see a physical therapist for a short period of time to help the condition.

In extremely rare cases of hip bursitis, surgery may be recommended. This surgery removes the bursa either with an incision or with arthroscopy. Again, this bursa removal is very rarely recommended.

Snapping Hip Syndrome

Snapping hip syndrome is a disorder that is depicted by a snapping sensation and by an audible ‘popping’ sound when the hip is extended and flexed. This condition can be sometimes diagnosed with an X-ray of the hip, but occasionally, the orthopedic specialist must obtain an MRI to look for the problem.

What is the cause of snapping hip syndrome?

There are many causes of this condition, but it is most commonly due to tendons catching on bony prominences and making a snapping sound when the hip is moved. There are three basic causes for snapping hip syndrome. These include:

Iliotibial Band Snap – The iliotibial band is a wide, thick tendon that is on the outside of the hip joint. When the iliotibial band snaps over the bony prominence over the outside of the hip joint (known as the greater trochanter), this creates the snapping hip syndrome.

Iliopsoas Tendon Snap – The Iliopsoas tendon is the main hip flexor muscle and the structure that passes just in front of the hip joint. When this tendon catches on a bony prominence of the pelvis, a snap occurs with hip flexion.

Hip Labral Tear – This is the least common cause of snapping hip syndrome. It occurs with a tear of the cartilage within the hip joint. When the hip is moved, the loose flap of cartilage catches within the joint creating an audible ‘pop’.

How is snapping hip syndrome treated?

Many cases of snapping hip syndrome can be treated with a short course of anti-inflammatory medications. Sometimes the orthopedic specialist finds it necessary to inject the hip with a cortisone medication. In certain cases, the doctor will recommend physical therapy to stretch out the muscles and tendons and help correct the problem.

While surgery is not always necessary, those patients with severe symptoms that persist over extended periods of time may be candidates. The surgery is done to relax the tendons and remove cartilage that is damaged or torn. Snapping hip syndrome surgery is safe and beneficial for many who suffer with this condition.

A hip fracture is a break in the upper portion of the thigh bone, called the femur bone. The extent of the break will depend on the force that is involved. The type of surgery used to treat a hip fracture is typically based on the bones and the soft tissues that are affected and on the level of the fracture.

Most hip fractures occur from a fall or from a direct blow to the side of the hip. Medical conditions such as cancer, stress injuries, or osteoporosis can all weaken the bones and make the hip more susceptible to breaks. It is possible for the hip to break from the patient standing on the leg and twisting sideways.

Types of Fractures and Treatment   

In general, there are three different types of hip fractures. The type of fracture depends on what area of the upper femur is involved. These include intracapsular fractures, intertrochanteric fractures, and subtrochanteric fractures.

Intracapsular Fractures – These breaks happen at the level of the neck and the head of the femur bone and are generally within the capsule. The capsule is a soft-tissue envelope that contains the lubricating fluid that helps the hip joint move easily.

When the ball or head of the femur bone is broken, repair will be aimed at fixing the cartilage. Sometimes with these types of fractures the socket itself is injured and will need repaired. For intracapsular hip fractures, our orthopedic surgeons will either fix the fracture with individual screws or a single larger screw that slides within the barrel of a plate.

This compression hip screw allows the break to become more stable. Sometimes the blood supply to the ball of the femur is damaged during injury and this leads to a condition called avascular necrosis. With this type of injury, the surgeon must realign the fracture and hold it in place with screws and plates.

Intertrochanteric Fractures – This type of break occurs between the neck of the thigh bone and the lower boney prominence known as the lesser trochanter. This is the area of attachment for major muscles that allow the hip movement.

These fractures are managed with either a compression hip screw or a special kind of nail, which will allow for impaction at the fracture site. This screw or nail is fixed to the outer side of the bone with other pieces of metal that allow for increased stability and promote healing at the site.

Subtrochanteric Fractures – These types of breaks occur below the lesser trochanter in a region that is approximately 2 to 3 inches below. Most of these fractures are managed with a long intramedullary nail and a large lag screw.  In order to keep the bones from rotating the nail or from shortening on the nail, additional metal pieces may be placed at the lower end of the nail in the area of the knee, what is known as interlocking screws.

For certain cases, the orthopedic specialist may choose to use a plate rather than a nail and this plate will have screws that go into the bone on the sides of the femur.

Before and After Surgery

You will need to have a spinal, or general anesthesia before you have hip surgery. This involves a breathing tube or spinal anesthesia. Most of our orthopedic specialists prefer you to be have a spinal anesthetic during the procedure for your comfort. Also, before surgery, you will have a full work-up of X-rays, urine and blood tests, and electrocardiograms to assure you are in generally good health. The surgeon’s decision as to how to best fix your fracture will be based on the area of the hip that is broken and the doctor’s familiarity with the different systems available to manage these types of injuries.

You will stay in the hospital for a couple of days after your hip surgery and will be discharged home or to a rehabilitation facility. Rehabilitation will involve physical therapy where a therapist will work with you to help you regain strength and increase your ability to walk. You will follow-up with your orthopedic surgeon who will check your wound, remove sutures, and follow the healing process of your hip using X-rays.

Hip impingement is a bothersome condition where the hip bones do not go together smoothly and they rub against one another. There are three types of this condition: Pincer, Cam, and Combined. Hip impingement occurs when the developing structures don’t form properly during childhood.

The symptoms include pain, stiffness, and limited range of motion. Treatment for this condition involves arthroscopic surgery for repair of the damaged joint or, in severe cases, hip replacement surgery.

What is Hip Impingement?

Hip Impingement, known as femoroacetabular impingement (FAI) to doctors, is a condition where the bones of the hip are not normally shaped. The hip bones do not fit together correctly so they rub against each other, causing damage to the joint.

The hip is a type of ‘ball-and-socket’ joint. The acetabulum-which is part of the pelvic bone-helps form the socket. The ball is the head of the femur bone, which is the upper portion of the thigh bone. There is a slippery tissue known as the articular cartilage that covers the surface of this ball-and-socket to create a low-friction, smooth surface that allows these bones to glide easily across each other.

With hip impingement, bone spurs form around the head of the femur and along the acetabulum, causing the hip bones to hit against each other rather than glide smoothly along. This can result in tears and breakdown to the cartilage and joint structures, creating the condition of osteoarthritis.

What are the Types of Hip Impingement?

There are basically three different types of femoroacetabular impingement or hip impingment. The first type is called Pincer. The pincer type occurs because extra bone sticks out over the normal rim of the acetabulum and the joint area structures become crushed under this prominent rim.

The second type is known as Cam. With this type of impingement, the femoral head is not round and cannot smoothly rotate inside the joint as it should. A bump forms along the edge of the femur head and this grinds the cartilage that is inside the joint area.

The third type of femoroacetabular impingement is called Combined. Combined impingement simply means that both Pincer and Cam types of damage are present.

What is the Cause of Hip Impingement?

Some people can live long, active lives with this condition and never have limitations or complications. Others, however, develop symptoms that may include stiffness, pain, and limping. This occurs when there is significant damage to the cartilage and the disease progresses or worsens. Hip impingement occurs because the hip bones do not form adequately during the childhood growing period. The joint damage is the result of a deformity of a cam bone spur or a pincer bone spur, or both, that causes the joint damage and the femoroacetabular impingement.

What are the Symptoms of Hip Impingement?

Many people have hip impingement for years and do not even know this because it is not usually painful in the early stages. The orthopedic specialist will refer to it as ‘Hip Impingement Syndrome’ when symptoms develop. These include stiffness in the groin or front part of the thigh and loss of range of motion of the hip joint.

During the early stages, you may only have pain when you move the hip near its motion limits but as this condition progresses, you start to feel pain with more subtle activities. These include sitting for long periods of time or walking up hills.

What is the Treatment for Hip Impingement?

There are many things your orthopedic specialist will recommend, like rest, modification of activities, exercise, and use of anti-inflammatory and pain medications. If these treatments do not work for you, the surgeon may recommend hip impingement surgery, a common procedure.

The type of surgery really depends on the extent of your impingement and how much of your cartilage is damaged. Often, the doctor can perform surgery by means of arthroscope. This is known as arthroscopic surgery and this technique involves the use of a lighted scope that goes into the joint through tiny incisions. The doctor can visualize the inside of your hip on a TV monitor and repair damage and improve your range of motion. If you have severe damage, hip replacement surgery may be necessary to improve function and limit pain and stiffness.

Arthritis means “inflammation of the joint”. The most common kind of hip arthritis is osteoarthritis. This is often referred to as “wear-and-tear” arthritis of the hip or degenerative joint disease. Basically, osteoarthritis is characterized by a progressive wearing away of the joint cartilage. This results in inflammation within the joint itself. The cartilage is a protective structure of the hip and when it wears away, the bare bone is exposed within the joint. Other types of hip arthritis include rheumatoid arthritis (a systemic immune system disease), ankylosing spondylitis (an inflammatory disease of the spine and sacroiliac joint), and systemic lupus erythematosus (an autoimmune disease where the body harms its own healthy cells and tissues).

Who has Hip Arthritis?

Hip arthritis usually affects people over the age of fifty. It is seen more commonly in those who are overweight. Weight loss can reduce the symptoms that are related to hip arthritis.

Hip osteoarthritis can be cased by such mechanical issues as hip dysplasia (shallow hip socket), or hip impingement. Other factors that can lead to hip arthritis include traumatic injuries to the hip and fractures to the bone of this joint.

What are the symptoms of Hip Arthritis?

Hip arthritis symptoms worsen as the condition worsens. Patients will often report good months and bad months, as symptoms change with the weather conditions. The most common symptoms include:

Dull, aching pain in the groin, outer thigh, and/or buttocks
Limited range of motion of the hip joint
Stiffness of the hip
Pain with activities
Walking with a limp

How is Hip Arthritis diagnosed?

A person with Hip Arthritis will need a thorough physical examination, basic laboratory tests, and X-Rays. This will serve as a baseline for the orthopedic surgeon to reevaluate later examinations and determine the progression of the disease. During the examination, the doctor will have you move your hip in a variety of different positions. X-Rays will show thinning or erosion of the bones and loss of joint space. Sometimes the doctor can detect excess fluid of the joint on an X-Ray.

What is the treatment for Hip Arthritis?

It is important to note that treatment will depend on the severity of the condition, age of the patient, and activity level of the patient. Not all treatments work for every single patient and not all are appropriate for everyone, either. You should discuss your treatment options with an orthopedic specialist. Some of the current therapies include:

Activity Modification – It may be necessary for you to limit certain activities and learn new exercise methods to help you.

Weight Loss – Being a healthy weight is one of the most important treatment modalities. The less weight the joint has to carry, the less pain you will experience.

Walking Aids – The use of a cane or single crutch in the opposite hand from the affected hip will allow a decrease demand placed on the arthritic hip.

Anti-Inflammatory Medications – Your orthopedic specialist may prescribe a Non-Steroidal Anti-Inflammatory Drug (NSAID) for you to help treat the inflammation as well as the pain. Acetaminophen (in moderation) can be an effective medication for the treatment of arthritis.

Physical Therapy – By strengthening the muscles around the affected hip joint, there will be a decrease burden on the arthritic hip. It is important for you to prevent atrophy of the surrounding muscles and structures to maintain functional use of this hip.

Joint Supplements – Glucosamine is a safe and effective joint supplement used in the treatment of hip arthritis.

Hip Replacement Surgery – When non-surgical measures fail, your orthopedic specialist may recommend hip replacement surgery.

When the hip joint has reached a point where symptoms are not controlled, a hip replacement procedure is an option. The surgeon will remove the damaged joint surface and replace it with an artificial implant. These implants will wear out as time goes by, so therefore, these surgeries are not done frequently in younger patients. Please note that hip replacement is typically reserved for those people who have tried many other treatments and therapies and still have significant pain during normal daily activities.

When a hip replacement procedure is performed, the bone and cartilage on the ball-and-socket hip joint is removed. This is done by using precise instruments to create surfaces that fit perfectly into the area and work well. This creates an artificial hip joint that functions as a new hip.

What are the risks of a Hip Replacement?

Over ninety percent of patients who have hip replacement surgery have positive results. While hip replacement is a common procedure, there still are risks involved. These include:

• Blood loss
• Blood clots
• Infection
• Leg length difference
• Hip implant loosening
• Hip dislocation

What can I expect after hip replacement surgery?

Success of this operation will depend on many factors. Hip replacement is typically a successful procedure, but a number of factors affect the outcome. Surrounding painful joints can affect hip surgery outcome. Other medical problems such as diabetes, heart and lung disease, as well as general fitness level also affect outcome after hip replacement surgery.