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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
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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
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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
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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
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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
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Types of Arthritis
• Osteoarthritis (MOST COMMON)• Post-Traumatic • Inflammatory (rheumatoid arthritis)• Secondary to childhood hip disease• Many more…..
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Is Arthritis of the Hip Preventable?
• 5 years ago the answer was NO!
• Today, the answer is… SOMETIMES!
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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.
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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.
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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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.
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Labrum Tears May Progress to Arthritis of the Hip at an Early Age
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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
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Treatment
• Hip Arthroscopy• Mini-open
decompression• Hip Surgical Dislocation• Hip socket reorientation• Physical therapy usually
not helpful
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These treatments are effective at relieving pain.
May slow down or prevent the progression of cartilage damage and
development of arthritis
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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?
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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
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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.
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Goals of Joint Replacement Surgery
• Relieve pain!!!
• Restore function, mobility to the prearthritis levels
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What is Hip Replacement
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Technique: Total Hip Replacement
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Technique: Total Hip Replacement
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Technique: Total Hip Replacement
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Technique: Total Hip Replacement
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Background• Total joint replacement is one
of the most commonly performed and successful operations in orthopaedics as defined by clinical outcomes and implant survivorship*
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• Current technology has improved the bearing surfaces
• Makes total hip replacement a viable option in young patients.
• Components are more durable.
Implant Considerations
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Bearing surfaces are the contact points of ball and socket
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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
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Risks of Hip Replacement
• Dislocation• Leg length discrepancy• Infection (surgical treatment)• Blood clots (DVT)• Fracture• Loosening of components• Future surgery to revise components
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Dislocation Precautions
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Dislocation precautions, leg length discrepancies and recovery can be
dependent on the surgical approach used to enter the hip
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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
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Minimally Invasive Surgery(MIS)
• “traditional” incision was 12”
• MIS incisions are 4”
• Supposed to have lower dislocation rate and decreased pain
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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
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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.
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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
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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
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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
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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
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95% of patient ARE candidates for an anterior approach. This
can be determined rapidly by an experienced surgeon examining
the patient and the xrays.