ARTHRITIS OF THE HIP Roy I Davidovitch, MD Assistant Professor of Orthopaedic Surgery NYU School of...

ARTHRITIS OF THE HIPRoy I Davidovitch, MD

Assistant Professor of Orthopaedic SurgeryNYU School of Medicine

NYU Hospital for Joint Diseases

Director, The New York Hip Center

Agenda 1. How your hip works &

why it hurts

2. Is hip arthritis preventable?

3. What are the options for the arthritic hip?

4. Your questions

How your hip works

Anatomy of the hip

• Ball-and-socket joint

• Ball (femoral head) at the end of the leg bone (femur)

• Hip socket (or acetabulum) holds the ball

What Is Arthritis?

Healthy hip The end of each bone in the joint is covered with cartilage, acting as a cushion so the joint functions without pain

Diseased hip (osteoarthritis) Wear and tear deteriorates natural cushion, leading to bone-on-bone contact, soreness and swelling

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NORMAL HIP ARTHRITIC HIP

Arthritis—Background• Arthritis is the second most common chronic

condition in the US (sinusitis is first)– Most common among elderly

• 20-30% of people over age 70 suffer from osteoarthritis (OA) of the hip

• Arthritis affects over 32 million people in the US

• Total costs associated with arthritis are over $82B/year, including hospital and drug costs, nursing home costs, and lost productivity and work

Types of Arthritis

• Osteoarthritis (MOST COMMON)• Post-Traumatic • Inflammatory (rheumatoid arthritis)• Secondary to childhood hip disease• Many more…..

Is Arthritis of the Hip Preventable?

• 5 years ago the answer was NO!

• Today, the answer is… SOMETIMES!

Femoral Acetabular Impingement

(FAI)

• Mismatch between the roundness of the head (ball) and the roundness of the acetabulum (socket)

• Associated with congenital abnormality, childhood hip injury.

QuickTime™ and aTIFF (Uncompressed) decompressor

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QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Hip Labrum Tear is Caused by FAI

• Labrum: outer thickening of the cartilage of the socket that cushions the soft cartilage of the surface of the socket.

Labrum Tears May Progress to Arthritis of the Hip at an Early Age

How do I know if I have FAI?• Groin pain with sitting or

deep flexion of the hip (squatting)

• Clicking/popping at hip (with golf swing)

• Pain is progressive

• Pain is not constant

Treatment

• Hip Arthroscopy• Mini-open

decompression• Hip Surgical Dislocation• Hip socket reorientation• Physical therapy usually

not helpful

These treatments are effective at relieving pain.

May slow down or prevent the progression of cartilage damage and

development of arthritis

Symptoms of Arthritis

• Do you sometimes limp?

• Does your hip feel stiff?

• Are you losing motion in the hip?• Is it difficult to perform daily tasks—

like walking, housework or tying shoes?• Does pain limit your activities & lifestyle? • Does one leg feel “shorter”? • Do you experience pain in the groin or front of thigh?

Treatment Options: Non-operative• Activity Modification• Weight Loss• Cane/walker• Physical Therapy

• Medications:– NSAIDs (aleve, motrin, advil)– COX-2 Inhibitors (celebrex)– Nutritional supplements

• Injections:– Corticosteroid– Viscosupplementation

There is only one “CURE” for arthritis.

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Total Hip Replacement (THR)

• Implants replace damaged surfaces

• Helps relieve pain and restore mobility

• 260,000 each year in the U.S.

Goals of Joint Replacement Surgery

• Relieve pain!!!

• Restore function, mobility to the prearthritis levels

What is Hip Replacement

Technique: Total Hip Replacement

Technique: Total Hip Replacement

Technique: Total Hip Replacement

Technique: Total Hip Replacement

Background• Total joint replacement is one

of the most commonly performed and successful operations in orthopaedics as defined by clinical outcomes and implant survivorship*

• Current technology has improved the bearing surfaces

• Makes total hip replacement a viable option in young patients.

• Components are more durable.

Implant Considerations

Bearing surfaces are the contact points of ball and socket

When should you have a hip replacement?

• Arthritis has caused an unacceptable level of pain and decreased ability to participate in activities that the PATIENT considers essential.

• Age is less of an issue with current technology

Risks of Hip Replacement

• Dislocation• Leg length discrepancy• Infection (surgical treatment)• Blood clots (DVT)• Fracture• Loosening of components• Future surgery to revise components

Dislocation Precautions

Dislocation precautions, leg length discrepancies and recovery can be

dependent on the surgical approach used to enter the hip

Surgical Approach• Posterior (the back of the hip)

– Highest dislocation rate – Easiest for surgeon

• Lateral (the side of the hip)– Lower Dislocation rate– Most damage to the muscle

• Anterior (the front of the hip)– Lowest dislocation rate– Hardest for the surgeon

Minimally Invasive Surgery(MIS)

• “traditional” incision was 12”

• MIS incisions are 4”

• Supposed to have lower dislocation rate and decreased pain

MIS???• Currently no proven

benefit to smaller incision other than cosmetic appearance

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MIS= Minimal Incision Surgery

• The goal of MIS should be minimal disturbance of natural and healthy structures during replacement of the damaged structures

• This should allow an anatomic reconstruction of the joint and thereby maintain the stability of the hip

Anterior Total Hip ReplacementWhat is it?

• Incision is made on the front (anterior) of the leg rather than the side (lateral) or back (posterior)

• A natural interval BETWEEN muscles exists in the front of the hip

• Surgery is performed through this natural interval

• Muscles and tendons are not cut during the procedure.

Traditional MIS Surgery

• Patients typically lie on side or front

• Incision on side or back of leg

• Surgeon detaches muscles, disrupts tissue

• Surgeon relies on post-operative X-ray to check component placement & leg length

Anterior Approach

• Patients lie on back

• Incision on front of leg

• No detachment of muscles, minimal disruption of tissue

• Surgeon can check component placement & leg length during procedure

Benefits of the Anterior Approach

• Dislocation rate <1%• NO HIP PRECAUTIONS• Leg length more reliably assessed• Recovery time significantly accelerated (no

cane within 2-3 weeks)• Less pain

Who is NOT a candidate for Anterior Approach Total Hip

Replacement?• Severe deformity of the femur (diagnosed

with an xray)• Morbid obesity (BMI> 40)• History of previous hip replacement

surgery on the same side

95% of patient ARE candidates for an anterior approach. This

can be determined rapidly by an experienced surgeon examining

the patient and the xrays.

Thank You!

NYHipCenter@NYUMC.org