Prof. Dr. med.
ATOS Clinic Heidelberg
Coxarthrosis / Hip TEP
Hip joint arthrosis or coxarthrosis is a degenerative disease of the hip joint. It is caused by an organic illness, an accident or age-related wear. Hip joint arthrosis causes stress-dependent severe hip pain. Complaints can be permanently resolved, for example with an artificial hip joint.
The hip joints are the most heavily loaded joints. After the knee joints, the hip joints are the second largest joints in the human body creating the connection between the thighs and pelvis. As with all joints, the surfaces of the hip joint bones are covered with hyaline cartilage, which ensures low-friction mobility of the hip joints. If the cartilage of the acetabulum and/or the femoral head is damaged by illness, accident or wear, then large-scale cartilage destruction occurs in the region of the greatest pressure load, which finally leads to the exposure of the bone surface at the joint. “Bone on bone” rubbing causes inflammation and stress accompanied by severe hip pain. Often crunching in the hip joint is felt or heard.
As a result compression of the bone structure (subchondral sclerosis) occurs in the affected bone due to the mechanical overstressing The femoral head loses its spherical shape and the bones below the cartilage develop holes in the further course. To absorb the mal-loading of the bone, the body deposits bone material around the edges of the acetabular cup. This leads to joint pain and a restriction of mobility.
A distinction is made between the primary and the secondary form with coxarthrosis. Primary hip arthrosis arises without apparent cause, i.e. without a previous illness. This form occurs due to age-related wear mostly after the age of 60. Secondary hip arthrosis arises as a result of another disease. It often occurs in younger patients and on one side.
The causes of hip osteoarthritis can be femoral head necrosis (circulatory disorder due to death of part of the femoral head), hip dysplasia (congenital malocclusion and ossification disorder), gout diseases (deposits of urinary crystals in the hip joints), rheumatoid arthritis, or accidents.
Patients with hip osteoarthritis typically complain of hip pain, which initially only occurs during prolonged exercise, and become more common as the disease progresses. Pain can be localised to the groin, front thigh, hip, or buttocks, radiating to the knee and even to the lower leg. “Start-up pain”, which is pain in the first steps after getting up from sitting or lying down, and later also resting and chronic pain are typical. Furthermore, painful restriction of movement of the hip joint is often noted, which is due to the osteoarthritis-related shrinkage of the hip joint capsule and bony attachments in the joint. In addition, crunching noises are typical when moving the hips.
In addition to the medical history (anamnesis) a physical examination is important at the start. During the examination, the doctor palpates the hip joints and assesses the sensitivity to pressure and pain. Subsequently, posture and gait are checked for possible abnormalities. With advanced hip osteoarthritis bone changes can already be noticed here. In most cases, an X-ray is done if the disease is suspected. The distance in the joint space is then assessed. An ultrasound examination is also often performed. Muscles, ligaments and joint fluids can be accurately represented.
Conservative therapy aims to alleviate hip pain and favourably influence the further course of the disease. This includes activity modification with regular exercise while avoiding shock and maximum stress, physiotherapy treatment to improve mobility, drug and anti-inflammatory treatment and biological treatment by injections in the joint, which protect the cartilage and favourably affect the articular environment (e.g. hyaluron, autologous blood, etc.). However, should there be an increase in symptoms, further hip treatment needs to be discussed.
If the conservative therapy brings no improvement over time, an artificial hip joint (hip TEP) has to be considered. The artificial hip joint is the most well-known implant in humans. More than 5 million citizens suffer from arthrosis of the hip, and more than 90 percent of over-65s are affected by hip osteoarthritis (coxarthrosis). The decades of experience of our clinicians, the modern surgical procedures and the first-class quality of the implants used ensure the best medical care and safety when inserting an artificial hip joint.
Choosing the “right” hip implant requires a specialist orthopaedic surgeon with years of experience and knowledge of the market. It is also dependent on the degree of osteoarthritis and the personal circumstances of the patient.
Cemented hip endoprostheses have proven to be the safest method for older patients and have been steadily developed for almost 50 years. According to global statistics, they are just as durable as cementless implants. They are mainly used in patients over 80 years. With this method, a total hip endoprosthesis is fixed by bone cement in the thigh and in the pelvis. The cemented hip endoprostheses have the advantage of offering the patient immediate unrestricted stability even with non-ideal bone conditions (e.g. osteoporosis, aged bone). The procedure is also associated with a lower tendency of bleeding.
Cementless hip endoprostheses are ideal for patients between the ages of 60 and 80 years. Mostly the Taperloc prosthesis stem is used, which is a titanium stem that has proven itself over twenty years. The socket is a titanium screw ring with a ceramic inlay. This technology has the lowest abrasion rates on the material and no bone damage from polyethylene. Studies prove intact ceramic heads and cups even after 20 years. After 10 years, almost 97 percent of these prostheses are still functioning, and after 15 years about 95 percent.
Using hip arthroscopy (keyhole surgery), a surgeon can diagnose and treat the disease with a camera and fibre optic system. During the procedure, the surgeon can remove free joint bodies and smooth out joint lips.
Rehabilitation – Time and methods
Rehabilitation begins right after the operation, because early mobilisation helps the habituation and strengthening of the surrounding muscles. Follow-on treatment is of course still dependent on the condition of the surrounding tissue and the constitution of the patient. Walking training, stair climbing etc. are incorporated as soon as possible in the rehabilitation program. The aim of the physiotherapeutic treatment is also to correct the improper stress levels arising due to the restriction in movement over the past months and years. Many patients return to their car after 6 weeks and return to work after 12 weeks.
Hip impingement describes a mechanical conflict, through which the normal motion play in the hip joint is disturbed and the femoral neck strikes the front rim of the socket. This leads to blocking of the hip during certain movements.
Femoroacetic impingement or hip impingement is an acquired malformation of the hip, which is one of the most common causes of coxarthrosis. The cause is bony attachments on the femur and/or on the acetabulum. Through these bony attachments impingement of the thigh bone and the bony margin occurs with movement especially during hip flexion. Repeated impingement repeatedly squeezes intervening structures such as articular cartilage and the cartilaginous lip (labrum).
Hip impingement describes a mechanical conflict, through which the normal motion play in the hip joint is disturbed and the femoral neck strikes the front rim of the cup. This leads to blocking of the hip during certain movements.
Possible causes are deposits on the femoral head in question which cause it to lose its round shape (CAM impingement). On the other hand, the acetabulum can also be twisted too much or unfavourably so that it extends too close to the joint. This disorder is also known as pincer impingement. A combination of both (so-called mixed impingement) is the most common cause. The changes in shape described cause the transition from the femoral head to femoral neck to strike the joint socket and the labrum running around the socket (joint lip). The more often such an impact occurs and the higher the speed and force involved (in certain sports, stooping, working while sitting, driving), the sooner the articular cartilage and/or the rim or the labrum are damaged. This causes the joint to become inflamed and causes pain. Over time, this mechanism can lead to hip arthrosis.
Similar to osteoarthritis, patients with hip impingement complain of hip pain in the groin area (at the front and at the side of the hip joint), which occurs initially especially during and after exercise. Deep sitting can also trigger the typical pain. Patients also often notice limited mobility of the hip joint. Later sufferers complain of severe pain during prolonged sitting and walking short distances. Blockage is already clearly noticeable at this stage.
In addition to the medical history (anamnesis) a physical examination is important at the start. During the examination, the doctor will perform a so-called provocation test. Two movements are performed simultaneously, which causes the typical groin pain. If the suspicion is confirmed, an X-ray is taken to see if the symmetry between the femoral head and the socket is present. Bony elevations are also clearly visible on the x-ray. For more detailed imaging of the soft tissues, a CT would be the method of choice.
Conservative therapy aims to alleviate hip pain and favourably influence the further course of the disease. Physiotherapeutic treatment to improve mobility is used in particular. Drug and anti-inflammatory treatment is also advised. Electrotherapy can also relieve the initial symptoms. Since this is a “mechanical problem” surgery is necessary in most cases.
If pain already exists while sitting and large bony attachments are present, they cannot be remedied through exercise but only removed by a hip operation. This can usually be done by an experienced hip specialist in a minimally invasive manner using keyhole surgery (hip arthroscopy). Hip arthroscopy is a relatively new surgical procedure. The most common disease in which hip arthroscopy is performed is hip impingement.
With arthroscopy, the exact extent of the damage can be determined and, if possible, corrected immediately during the exploration. As part of this procedure, a joint lip can be re-attached to the socket edge, a deformed condyle, socket or femoral neck removed and adapted or a femoral neck can be re-modelled. The aim is that after treatment pain-free movement of the joint will be possible again, and the degeneration processes, which were caused by the impingement of the hip joint, are slowed down or prevented.
Hip arthroscopy is performed on a so-called “extension table” in the supine position. Access to the joint is via 2-4 small cuts on the thigh of about 1 cm in length. A camera and the respective working tools are then introduced. Now, the structures of the hip can be viewed and treated under 2.3x magnification. The operation takes between 30 and 90 minutes.
Rehabilitation – Time and methods
The rehabilitation depends on whether bone has been removed during hip arthroscopy or if cartilage damage has been treated. If this is the case, only a partial load is initially recommended. Waling aids are then recommended for about 10 days. Walking training, stair climbing etc. are incorporated as soon as possible in the rehabilitation program. The aim of the physiotherapeutic treatment is also to correct the improper stress levels arising due to the restriction in movement over the past months and years. Hip-friendly sports such as swimming or cycling can be resumed as early as 6 weeks after surgery.
The use of an artificial hip or knee joint is now one of the standard orthopaedic operations. A periprosthetic fracture may, however, occur during an accident. In technical terms this refers to the fracture of the bone in which the prosthesis is anchored.
Implants of artificial hip or knee joints are among the most common operations in Germany. This results in an increased number of periprosthetic fractures in accidents. Increasing life expectancy and the increase in sports and leisure activities intensify this. The causes of these fractures in the vicinity of a prosthesis are primarily falls in the home environment of the patient, but also traffic or leisure accidents, uncontrolled falls as a result of secondary diseases, and additional burdening due to the loosening or changing of inserted prostheses.
Risk factors include bone density reduction (osteoporosis), dissolution of bone tissue (osteolysis) as a result of inflammation or tumours, damage to the bone (cortical perforation), and mechanical overstressing of loose prostheses.
The type of periprosthetic fracture is as diverse as the causes. With artificial hip joints, fractures of the femur occur below the shaft of the prosthesis, in the area of the prosthesis socket and multiple fractures or debris fractures occur in the region of the shaft. The periprosthetic fractures in the artificial knee joint usually occur above the implant in the femur (supracondylar femur fracture); fractures of the lower leg bone (tibia), however, are less common.
For the best possible therapy (and to avoid postoperative complications) a preoperative analysis is necessary. It is sufficient to take a normal x-ray for simple fractures. For complex fractures, however, computerised tomography (CT) should be used.
Conservative therapy is dispensed with in this type of fracture or is an exception. Conservatively, a fracture could only be treated at a magnitude of category 1 and a fracture angle less than 30 degrees. Only the pain therapy is conservative.
At ATOS pursue several goals in the event of a periprosthetic fracture. First and foremost is the acute pain therapy to relieve the pain of the patient. The second goal is the correction of the fracture and the restoration of the proper anatomical conditions. Targeted post-operative pain therapy, early mobilisation of the patient, the fastest possible healing and support for healing through special physiotherapy are further steps.
There are special implants for hip and knee surgery as well as other special materials for the treatment of a periprosthetic fracture. These include various special plates, special screws, wires and titanium tapes, with which the fractures are fixed. These procedures use a combination of these materials and prosthesis replacement techniques.
The duration of the operation is usually around 2 hours.
Rehabilitation – Time and methods
Following the surgery, periodic checkups and targeted physiotherapy are important. In most patients, full mobility is restored within 8-12 weeks.
Artificial hip joints are usually very safe and durable. Nevertheless, they can become loose for a variety of reasons. When this happens an operation to replace the prosthesis is often necessary. The replacement of the hip prosthesis is more complex than the first implantation. But you are in good hands in our clinics: Thanks to many years of experience with replacement surgery, the specialist team in or department of hip arthroplasty offers you security for this technically demanding operation.
The most common reason for a replacement operation is loosening of the artificial hip joint. This loosening can be generally differentiated into septic or aseptic loosening. Aseptic loosening is more common. After insertion of an artificial hip joint, this can lead to increased abrasion of the sliding component due to incorrect loading. These abrasion products then cause a loosening of the previously incorporated prosthesis components. Likewise, changes in the tissue, circulatory disorders or mechanical stress can loosen the anchoring of the artificial hip joint in the bone. Incorrect implantation by inexperienced surgeons should also be mentioned here.
Septic loosening is caused by bacterial infections that damage the bone and tissue surrounding the artificial hip joint, thereby loosening the prosthesis. If the wearer of an artificial hip joint has complaints such as inguinal, hip or leg pain, it must be clarified whether they are caused by the artificial hip joint or other diseases.
Loosening of the prosthetic is barely noticeable in the early stages and hardly causes any problems. But the loosening of the socket can later cause inguinal problems. The situation is different with the prosthesis stem. In this case, pain will be felt relatively quickly in the thigh. Start-up pain under stress is also typical. Such pain often radiates to the knees. If the leg lengths are different it means the hip prosthesis has sunken into the medullary region of the bone. Metal abrasion in metal-to-metal prostheses can cause neurological symptoms due to the released metal particles. Worsened kidney function may be an indicator here.
The exact extent of bone damage is determined via the preoperative X-ray checks, and a precise plan is made regarding which prosthesis is to be implanted in which size. A CT image of the hip prosthesis can better show a spatial representation of the bone around the prosthesis. Since special surgical issues cannot be predicted with certainty during a replacement operation at the hip, the necessary special implants are always available in most of our clinics.
Conservative therapy is not used with this type of diagnosis. Only the pain therapy is conservative.
With modern surgical techniques, an access route, as in a standard prosthesis implantation, may be sufficient to depict the joint and remove articular mucosa. The prosthesis stem is checked for its strength. If it shows loosening, the prosthesis stem is removed. Any existing bone cement is also completely removed. Then the acetabulum is revealed and also removed in case of loosening. Any existing cement is then completely removed.
If there are bone defects, these can be filled in with the body’s own bone or donor bone and subsequently replaced by special implants. The combination of these methods is also useful, especially if the conditions surrounding the bone are difficult.
Rehabilitation – Time and methods
Immediate mobilisation is possible after the replacement operation. The patient leaves the bed as much as possible on the day of the operation with the aid of physiotherapeutic agents. Increasing mobilisation takes place in the next few days. The leg can be fully loaded immediately. Two underarm crutches have to be used for four to six weeks for safety so you do not fall or trip. Patients can walk without an aid starting in the fifth week.
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