Arthrosis of the hip

Synonymous

Arthrosis of the hip joint, hip joint arthrosis, koxarthrosis, coxarthrosis, hip arthrosis, Arthrosis deformans, osteoarthrosis, osteoarthritis deformans, Arthrosis deformans coxae, coxarthrosis.

Definition

The concept "hip joint arthrosis" (= koxarthrosis or also coxarthrosis) contains all degenerative illnesses (e.g. connatal disorder of the functional unit of femoral head – socket of the hip, or circulation or metabolic disorders, ...) in the area of the hip joint, which are caused by illness, accident (e.g. fractured neck of femur) or those which are wear- out related. All causal illnesses have in common the increasing destruction of the joint cartilage, which in the end also damages further joint structures like joint capsule, bones and the belonging musculature.

Age

In cases, in which the cause of the hip joint arthrosis is unknown (=primary coxarthrose), as a rule the disease developes only in the higher age (malum coxae senile), therefore mostly after 50.- 60. year of life. The arthrosis frequently contains both sides of the hip joint.

Hip joint arthroses which are based on hip joint illnesses not healed completely or anatomical variants in the femoral head or socket of hip (=secondary coxarthrose) as a rule appear earlier and usually only refer to one side of the hip joint. One medically describes the one-sided joint concern as a monoarthritic.

Sex distribution

Since women more frequently suffer from a dysplasia of the hip and the cartilage due to its composition is less resistant to straining than the male cartilage, women more likely tend to suffer from hip joint arthrosis than men.

Frequency

Since in the end the wearing- out must be considered to be a trigger for the hip joint arthrosis as a cause, it does not seem surprising that the risk of falling ill with a hip joint arthrosis increases with an increasing age. Studies illustrate that as of an age of 70 years about 70 to 80% signs of wearing- out show at the hip and / or other joints.

An essential risk factor for the emergence or to the acceleration of an existing hip arthrosis is overweight (adiposity).

Cause

There are different reasons for the emergence of a koxarthrosis.

In addition to that the causes are not known in the most cases. To be able to better differentiate the arthrosis with regard to its cause, one distinguishes between the primary and the secondary arthrosis. If an arthrosis develops without an obvious trigger, and this is the case in most cases, one talks about a primary arthrosis.

One describes however a secondary hip joint arthrosis as an arthrosis, which develops due to previous damages, wrong and bad straining, individual inflammation processes or the socket of hip (dysplasia of the hip) or femoral neck (impingement) being laid out faultily.

The radiograph above on the right shows you a healthy hip. One recognizes the distance between the femoral head and the socket of the hip very well. This distance implies that both the socket of the hip and the femoral head are obtained with a good cartilage layer. This is not the case at an arthrosis any more. The cartilage layer shows partly considerable damages in such a case.

Listed bolow you find the most frequent causes which can be held responsible for an emergence of a hip joint arthrosis. In most cases even further information is available for you. You can get to it by a link.

• Connatal partly or complete contortion of the hip (dislocation of the hip) at connatal dysplasia of the hip: In about 10% of all newborn children the femoral head is not correctly located in the socket. As a rule, the diagnosis is made by an ultrasound scan. Depending on individually different extent of the dysplasia of the hip a treatment by spreading association or an operation is necessary to prevent delayed effects. It is of special importance that this syndrome is recognized as early as possible since a later maturation of the socket top (reduction or abolition of the dysplasia of the hip) gets possible only within the first two years of life. At missing diagnosis or non-treatment a durable dysplasia of the hip develops with its delayed effects.

• connatal disorder in shape (dysplasia of hip): You call it a dysplasia of hip within patients whose hip socket is too flat or whose neck of femur angle is too steep (also see the anatomy of the hip joint). This has the consequence that the top of the socket does not cover the femoral head completely which means in the consequence that the load only is carried by a too small portion of the joint. This leads to the early wear-out. It therefore seems plausible, that such so-called pre- arthritical change (= malpositions causing arthrosis) will be corrected early operatively at extreme results. This can happen by so-called displacement osteotomy, for example. By the comparison of the radiograph of a dysplasia of hip with the radiograph of a healthy hip (see above) serious differences get visible. It seems logical that this cannot be without consequences. In the sex-specific comparison it stands out that women more frequently suffer from a dysplasia of hip proportionally. The relation between women / men is about 9:1.

• Metabolic disturbances: Diabetes mellitus and gout: Changes of the blood vessels, which again lead to circulation disturbances in the area of the femoral head, are caused by diabetes mellitus. For example a femoral head deformation or in the worst case the going dead of the femoral head are the consequence from this inferior supply with blood. Patients who suffer from gout show an increased urine acid content in the blood. If the uric acid content is about 8 mg / dl or above, the probability of a deposit of so-called uric acid crystals (= urate crystals) more highly is very probable in the joint. These crystals destroy the actually slippery surface of the joint. Crystals will deposite, if the uric acid content is too high in the blood. An attack of gout can occur.

• bacterial coxitis: By this infections of the hip joint which are caused bacterially are meant. The appearance of a bacterial coxitis is theoretically possible within all people, the probability to fall ill with a bacterial coxitis is increased considerably particularly within children and within patients with an artificial hip joint, though. Within children it can arise from a spreading of an infection by using the blood way, for example. So for example a tonsillitis can cause a bacterial coxitits by spreading by using the blood way. Please also read the topic of osteomyelitis in addition to this.

• Epiphyseolysis capitis femoris (within children and teenagers, within boys approximately between 12th and 16th year of life, with girls as a rule between the 10th and 14th year of life): Within the child the femoral head is separated by the so-called growth plate (= cartilage plate). This means that the femoral head and the femoral neck are not throughout bandaged of bone yet. If a loosening appears in the growth joint between the femoral head and the femoral neck, a separation and sliding can arise from it. This means that the femoral neck moves up and forward at straining (= ventrally cranially), the femoral head is held tight in the socket of the hip, though. An acute loosening of the epiphysis always represents one of the few emergencies in orthopedics. This means: The epiphysis must become reduced as quickly as possible. This means that the slipped femoral head must be taken to its original position again very fast. An operative procedure with reposition and fixation of the femoral head can become necessary. The diagnosis has to be classified as good at early diagnosis and operative therapy with a corresponding correction. A lasting damage cannot always be particularly excluded at a late diagnosis. This means, that particularly if furthermore another femoral head necrosis appears, an early secondary coxarthrosis threatens. You find more information about this topic at the epiphyseolysis capitis femoris.

• Chondromatosis of joints This is a transformation of muscous membrane fabric into cartilage cells, which form cartilage balls, which disrupt the mechanics of the joint as free joint bodies.

• Necrosis of the femoral head: A necrosis of the femoral head is a local circulation disorder of the femoral head. By the circulation disorder a deformation of the femoral head can occur. By the following incongruity of femoral head and the socket of the hip a development of a hip arthrosis can occur at short notice.

• Perthes` disease Circulation disorders of the femoral head with an increasing deformation of the femoral head. The Perthes` disease is comparable to the necrosis of the femoral head. Since, however, it appears during the growth phase, incongruities can be compensated by the growth still existing.

• Osteoradionecrosis: One means by it the dying of the femoral head due to circulation disorders ( necrosis of the femoral head ) because of a radiation treatment of an area close to the hip joint in the tumor therapy.

• Protrusion of the acetabulum: One means the socket of the hip´s outgrowth into the pelvis. You find this illness more frequently at illnesses the rheumatic form circle (rheumatoid arthritis / rheumatism).

• Rheumatoid arthritis (rheumatism, chronic polyarthritis): The illness starts at the inner skin of the joints (= synovia). Substances, which attack the own joint and even destroy it in the end, are being released by the chronic inflammation process. You can find more detailed information in the category of rheumatism / rheumatoid arthritis.

• Injuries of the hip joint or dislocation of the hip: Fractures in the area of the socket of the hip (fracture of the acetabulum) or the femoral neck (femoral neck fracture) and contortions after accidents in the hip area.

Risk factors

Overweight: • Overweight seems to make worse the pre-arthitical changes mentioned (look it up under: cause) above. The appearance of a coxarthrosis is therefore increased by overweight. As a rule, provided that there is already an arthrosis in the hip joint, the overweight works pain emphasizingly. Overweight seems to make it worse, but cannot be seen as an isolated cause, though and therefore is not producing arthrosis by itself. • Wrong straining, for example in result of a badly laid out socket of the hip (dysplasia of the hip), unfavorable femoral neck angle (Coxa valga antetorta) etc. arises. • endocrine factors (hormonal caused factors), e.g. a cortisone producing tumor • genetic influences, family accumulation of coxarthrosis by heredited dysplasia of the hip and cartilage quality

Clinic / symptoms

As a rule, an arthrosis confines itself to one or more joints in which at first no symptoms are being discovered in most cases. Even if one can already diagnose a coxarthrosis, that is the wear-out within the hip joint, on the radiograph, pains or pain-related movement restrictions etc. are not existing inevitably.

The increasing destruction of the hip joint illness-specifically is in the foreground at first. First rips in the joint cartilage appear, which enlarge themselves increasingly and trigger a inflammation of the synovia (synovitis) in consequence by small dying cartilage abrasion particles. That is, what causes partly very severe pains within the patient. An arthrosis alone is not painful! Because of the increasing pressure, which is put on the joint, it is trying to reduce the pressure by increasing the surface. Through this bone growth can occur. The consequences of the changes by destruction and deformation in the area of the hips´ socket as well as capsule shrinking and bone growth in a painful reduction of function.

The radiograph shows a used up joint cartilage, which one recognizes by the absence of a joint cavity. The changes particularly get visible, if you compare it to a radiograph of a healthy hip (far above).

Results of the coxarthrosis / hip arthrosis are:

• Pains From the descriptions you can conclude that the coxarthrosis as such represents a chronic illness which develops in the course of several years. Nevertheless there are phases of acute pains, one then talks about a so-called activated coxarthrosis. A feeling of stiffness as well as a quite diffuse joint and musculature pain (= myalgia) usually is part of the first notes. Besides that a so-called overload straining pain always more frequently appears as well as a pain within the joint which primarily appears early in the morning (after sleeping) and after a longer period of sitting, the so-called attempt pain after movement rest. This attempt pain disappears as a rule as soon as the joint has been moved for a while. It can appear after running for a long time, standing or work in connection with a muscle tiredness feeling again, though. One then talks about the so-called fatigue pain. It also can occasionally come to so-called one clamping pains in the inguinal region. They are caused by broken off particles of osteophytes (arthrosis-related bone growth), for example. Clamping pains are suddenly shooting in and as a rule connected to severe pain. Later on there is the pain on straining with straining-dependent free intervals, which then ends in the final stage in a more or less distinctive pain when resting.

Localisation of pain Inguinal region, hip outside (trochanter region), musculature of buttocks, thigh front up to the knee. Since a pain radiation is possible into the knee an interpreting the pains faultily by the patient is possible. At unobtrusive knee results in the context of an examination the treating doctor should always think of possible illnesses of the hip, too.

• Movement restriction Depending on pain extention different movement restrictions appear. As a rule, the turning (inside turn) is concerned of the restriction at first, the ability to spread which can be limited considerably under circumstances then gets more and more difficult, too. The leg shortening which arises if the patient is not able to stretch the hip completely any more is also listed below. One then talks about a so-called flexion contracture, which can lead to a functional leg shortening. It is worth mentioning that the movement restriction is initially due to the painful muscle tenseness while it is caused by the capsule shortening later.

• disturbances in walking- As a rule, the patient avoids painful movements. As a result of the hip joint arthrosis stands out, that patients bend more and more over the ill hip joint when running (shows as a swaying walk)

• Reduction of the musculature in the area of the buttocks and the thighs. shortenings of the leg up to 3 cm are possible.

Diagnosis

What should be examined to diagnose a hip joint arthrosis?

Clinical diagnostics:

• Judgement of movement range and movement pain
• Judgement of walking
• Differences in length of the legs
• Muscle atrophy
• Judgement of points sensitive to pain on palpation
• Judgement of neighboring joints
• Judgement of circulation, motoricity and sensibility

Apparative diagnostics:

Necessary apparative examinations:

• Radiograph: Pelvis overview photo

Into the individual case useful apparative examination:

• Radiograph: axial photo
• Radiograph: Photos of function and special projections
• Sonography (ultrasound)
• Computed tomography (CT)
• Magnet resonance imaging (MRI)
• Scintiscanning
• Clinical, chemical laboratory for the differential diagnostics
• Punction with analysis of the synovia (fine tissued examination of the joint muscous membrane cells)

Forecast

Natural course The course of a coxarthrosis is subject to many variables which do not permit to make an exact forecast in the individual case:

• The individual course
• The various causes of coxarthrosis which furthermore cannot be always defined obviously.

Therefore no scientifically exact forecast can be given with regard to illness and pain course, the possible necessity of therapies more conservatively or more operatively.

Tightly stands, that the arthrosis degree increases with the duration of the illness, though.

Forecast according to certain therapeutical methods

Displacement osteotomy / corrective osteotomy A pressure reduction is primarily caused. However, it is important to mention that with increasing arthrosis stage and age the success chances of these operation methods diminish. You learn more about it below in the text.

Hip endoprothesis The success probably after the implantation of an artificial hip joint is very high to reach a complete complaint freedom. The change rate, meaning the exchange of components of the hip joint, is approximately about 0.5% per year, the annual change rate rises after 10-15 years. You find more information about it an artificial hip joint in the context of the description.

Therapy

As general aims of the different therapy possibilities are valid: The reduction of the pains and connected to that the improvement on the "quality of life". The preservation or the improvement on the movability primarily is part of it (solve of tense conditions, bringing back the muscle functions to normal), the walking performance and the delaying of the progress of the coxarthrosis.

Mostly it is important to turn off the so-called "interference factors". For example axis malpositions, one-sided strainings, overweight or also metabolic disturbances are included. This is not always easy under circumstances.

Conservative therapy:

Advice In the context of the advice patients are informed about the illness as well as the natural course and the influenceability by possible therapy forms. Due to the many individual invoices, such a piece of advice is more individually always nature. Particularly the individual habits find their consideration here.

In the context of conservative therapy the patient is being demanded particularly. He she must amend usual behaviors under circumstances. So it has to be taken care, for example, that a responsible relationship is created between the actual straining and the possible capacity. Avoiding walking and standing all day long as well as the reduction of the load put on the joint is connected to that. Mentioned last implies particularly: No lifting of heavy objects and no sportive overexertion etc.

Medicinal therapy: This therapy form does not give therapy to the cause. The medicinal treatment rather serves the reduction of the pains and the stopping the inflammation. There are different possibilities for it: You can give therapy systemically and locally with various substance groups. This shall be explained followingly more precisely.

• Antiphlogistics (NSAR): medicine, such as Diclofenac, Ibuprofen and also these, counts new so-called Cox 2 inhibitor e.g. Celebrex as one of this medicine group.
• As a rule, steroides only get locally injected and therefore close to the hip joint. For example the cortisone belongs to the steroides.
• Anti-inflammatory drugs:

Anti rheumatic, cortisone free medicine but also cortisone itself belong to this group. Side effects frequently appear proportionally. For this reason a therapy should always be carried out only on a medical instruction!

• In the initial stages of an arthrosis are classified as promisingly cartilage protection preparations (e.g. hyaluron acid or chondroitinsulfate). A treatment therefore seems primarily sensible in the initial stages. The continents argue about the markedness of the effectiveness. While European doctors are rather restrained, American doctors see greater therapy approaches.
• Nature remedy, especially there has to be named the devils claw. The devils claw can be used for the support of the existing therapy at slight pain alone and at more severe pains. The devils claw shall reduce the symptoms of the hip arthrosis.

• Syringe treatment: cortisone and a local anesthetic into the joint, ordinary concerned

Physical therapy: The possibilities of physical therapy are very various. Some conceivable therapies are listed below:

• Physiotherapy (physical therapy)
• Massages (also: underwater massages)
• Damp warmth (mudpacks, ...)
• Mobilization, muscle strengthening, muscle stretching and coordination training.
• Thermal therapy (warmth-/ cold therapy)
• Hydro- and balneotherapy (water-/ air therapy)
• Electrotherapy (current therapy)
• Pulling treatment at the leg (with a weight of approx. 1 kg) for relaxation of the hip musculature.

Orthopedics technical therapy:

• Cane or forearm walking support on the healthy side. The patient must learn a special walking technology in dealing with this measure: The walking cane and the ill leg first are being put forward together, the healthy leg then follows.
• So-called buffered heals
• Wedge-shaped pillows, seat rises, arthrodesis chair, relief orthesis

Operative therapy:

Nowadays operations are carried out to avoid a threatening deformation but also for the pain fighting or for the restoration, on the one hand.

General indication criteria:

• Cause of the arthrosis, stage of the illness, previous course
• Pains, ailment
• Are there other joint diseases
• Individual factors (age, general condition and accompanying illnesses)
• Compliance and motivation, work situation, social status, activity level of the patient
• The choice of the operation method depends on considerable measure of the indication criteria. Different operation methods are therefore available.

Frequent operation methods:

Joint preserving operations

• Correction osteotomy on thigh bone and pelvises

If a coxarthrose is diagnosed, it is always checked whether the complete replacement of the hip joint (endoprothesis of the hip) can be prevented by a joint- maintaining surgery. Perhaps one primarily takes into account pre- arthrotical changes, so to speak specific changes which would almost inevitably lead to the development of an arthrosis in the appropriate joint areas.

Falling among this:

a too steep or too flat femoral neck angle which is corrected in the context of an intertrochantrical displacement osteotomy of the thigh, for example, a too flat socket which can be deepened by the so-called pelvic osteotomy, Malpositions after fractures Nowadays the stiffening (= arthrodesis) of the hip is only carried out in special cases. By the stiffening a pain liberty is primarily achieved. Installing a necessary inevitable hip endoprothesis might become very difficult, though, if the hip was already stiffened before.

As one can state using the descriptions, the different displacement osteotomy can only be used very individually. There must always be certain prerequisites.

One can therefore hold tight, that operations of the correction of malpositions of one or both joint bodies are used. The mechanical straining is supposed to be improved and progressing of the arthrosis shall primarily be delayed in the area of the hip joint. The success chances of displacement osteotomy are higher if the operation maintaining the joint takes place in the early arthrosis stage. The success chances therefore diminish at an increasing arthrosis stage.

Planning and preparation:

• Implants, instruments
• blood economizing tecniques
• Intraoperative radiograph possibility
• Plan outline

Possible consequences and complications:

When general risks and complications are valid:

• Development of hematomas, • Cicatrization disturbances, • Wound infections, • Deep vein thrombosis, • Embolism, • Vessel and/or nerve injury • Special/specific consequences: • Leg length difference • mostly temporary gluteal insufficiency (= a durable weakening of the buttocks musculature) • Widening of the hip silhouette

Complications • Delayed fracture healing, • fracture healing failing to appear, • Implant failure, • Correction loss, • Persistence of pains (pain remains unchanged)

Joint substitute (artificial hip joint) In the context of an endoprothesis surgery, at first a complete removal of all destroyed joint parts is carried out. These removed joint partes are then replaced by artificial parts. This has the consequence that the patients as a rule get painless.

Artificial hip prothesis as such have been quite "durable" for a long time by now although change operations take place particularly within very young and active patients. Therefore, it is necessary, to delay the joint substitute just as long as possible.

It also has to be considered that the loosening risk rises with an increasing implantation duration.

One can therefore hold tight: Younger patients should only risk such an operation, if alternatively only a stiffening or a hip head resection (removal of the femoral head) is possible. Further information You find general further information under the arthrosis topic as well as at the knee arthrosis (gon arthrosis)!!!