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Physical Therapy or Hip Replacement? A Surgeon’s Thought Process on Your Hip Pain.
What would a renowned surgeon think about when you’ve hip injury? Read everything from hip pain diagnosis to treatment options.
Posted on March 20, 2017 by Team Medicine after an interview with Dr. Brad Graw
How to diagnose hip pain
Hip Replacement Surgery
More on Dr. Graw
How to diagnose hip pain
When someone comes to see you with hip pain or hip ligaments injury, what’s going through your mind first?
The first thing is quite simply: who is the patient? Beyond the basic facts like age and sex, how do they live their daily life? Do they have a specific occupation or hobbies that will affect my decision-making? In terms of occupation, the general grouping is: do they have more of a desk job, or are they up moving and around during their day? In other words, do they have more of a white-collar type job or are they more of a laborer doing a lot more lifting, pulling, and pushing during the day? It helps me understand two big things: 1) if their daily life increases the load on the hip and constantly worsens it and 2) if I should take into account their livelihood in terms of how aggressive to be with treatment.
With the hip injuries and hip joint pain, what diagnoses are you considering?
My main split is to try and determine if they have arthritis as part of their pathophysiology and the reason that's important is because if arthritis is a driving concern, then the treatment strategies I have for them are a bit different than if they do not have arthritis. The issue around the hip compared to other joints like the shoulder or the knees is that we have more limited ability to actually preserve the joint once arthritis has become significant, and that can even happen for someone in their 20s or 30s. The hip, once it has significantly lost cartilage, we don’t have the same ability to either unload the joint with physical therapy or transport cartilage as we can do in the knee. Also, the surgeries to try and preserve the joint are quite involved and many surgeons and patients are hesitant to go down that path of reorienting the position of the joint.
Given that arthritis is not a great outcome for the hip, when you first see this patient with hip pain, what factors are pushing you towards hip arthritis as the cause versus not?
The family history and history of the person from birth are both important to understand. When we look at all hip arthritis patients historically, we have found a genetic component, but we also found that specific diagnoses predispose a younger person to have arthritis in the hip. These include hip dysplasia, a slipped capital femoral epiphysis called a "skiffy" or (SCFE), and Legg-Calve-Perthes disease, or just Perthes disease. Having any of these can set up young people in their 20s, 30s, and 40s to having hip arthritis, so those questions are very important.
Let's say that the person never had arthritis but comes in with pain in the groin or upper thigh pain, what are you thinking?
I get concerned about arthritis when pain is a driving symptom that comes on after loading the joint through work or exercise, so pain during the activity or pain after the activity, especially in the groin where the hip joint refers to pain, makes me concerned about some degree of arthritis. About 80 percent of the time, hip arthritis will refer to the groin. If the pain is more transient or on the outside of the hip or on the buttock or going down the leg, I'm concerned about other diagnoses. Some of the non-arthritic diagnoses in the hip that we've learned a lot more about over the past 15 years include labral tears, tears of the ligamentum teres, which is a ligament inside the hip, snapping hip, and the general diagnosis that we call femoroacetabular impingement or FAI.
If you have a suspicion of hip arthritis, what's the next step for you?
Physical exam is very important—to look at the person walk and see the degree to which they might be limping or trying to unload the joint. You may have seen people who sway side to side when they walk. We call that a Trendelenburg-type gait, and that is consistent with an intra-articular hip problem like arthritis. The next task is to look at the range of motion of the joint, to what degree the joint may be stiff, and what positions trigger pain. And then, x-rays are the most important imaging study to examine the anatomy and presence of arthritis.
Once you have that x-ray in hand and you have confirmation of hip arthritis, does that also help you grade the severity?
An AP pelvis x-ray (looking from the front to the back), probably gives us more information than any other imaging study about the hip. From that, we can look at the contours and anatomy of the hip and tease out those diagnoses of hip dysplasia, SCFE (slipped capital femoral epiphysis), and predisposition for FAI (femoracetabular impingement), as well as the degree of arthritis that may exist. In terms of hip arthritis, we are looking at simply the amount of cartilage space between the ball and socket of the joint, which on average tends to be about 8 mm. If it's much less than that, then I use that to confirm that arthritis is a driving factor. Another threshold I'll look at is whether the joint space is about half of normal compared to the opposite side. If the joint space and cartilage space is less than half of normal, then joint preservation type procedures become more difficult over time, and I know that that person, for better or for worse, may be looking at a reconstructive surgery on the hip at some point in the near future.
Can you talk a little bit about physical therapy and hip pain exercises and why they are tough to unload the joint once significant cartilage has been lost?
Let me give you the counterexample of the knee to begin. The quadricep muscle sits above your knee, and I look at it as the shock absorber of your knee. If you lose cartilage in that knee, having a nice, strong quadricep and thigh muscles can actually unload your knee somewhat. With your hip being a ball-and-socket joint with major muscle groups traversing it, there is constant pressure pushing that ball into the socket. What we find is that is that if you're working harder to strengthen those muscles, it can often increase the load, in my perspective, across the joint and cause more pain for people. Just last week, I saw someone who was quite eager to revisit physical therapy, but they remembered that a couple years ago, they had undergone physical therapy for hip pain that actually made things quite a bit worse. We took some time to tease out and help describe to that person why physical therapy and doing things more intensely may not actually help them this time around.
How effective is physical therapy for hip pain?
On the other hand, physical therapy does tend to be a mainstay of treatment for someone with a non-arthritic hip, and that is to work on the flexibility of the tissues around the hip and strengthening of the core musculature and the other muscles that traverse the joint, being the hip flexor, the hip abductors, and the hip extensors. For people who have an inflamed hip, perhaps symptomatic labral tear or hip tendonitis, physical therapy can be very effective. I'll often talk with them about different medications like anti-inflammatories that can help. This can be anti-inflammatories like NSAIDS (Ibuprofen, Naproxen, etc.), oral corticosteroids, or sometimes injection of corticosteroids, depending on the severity of the problem. If that person does not respond to physical therapy or has other red flags, I would then generally push them towards getting an MRI of the hip because there can be a handful of things that we don’t pick up so readily, such as a stress fracture of the bone or vascular prostheses of the hip, which can happen in many age groups. The treatment there becomes more nuanced or more specific for those problems.
If the patient has mild arthritis or no arthritis but physical therapy hasn’t worked, what then?
If they have mild arthritis or no arthritis and are suffering from a soft tissue problem of the ligament, tendon, or cartilage inside or around the joint and then they fail non-operative treatments, they then can consider hip arthroscopy, which is a surgical procedure that has gained more favor over the past 10 or 15 years. Arthroscopy of any joint had come along in the 1950s or 1960s and more work had been done on the knee and shoulders because these joints are more accessible. Over time, however, techniques and instruments developed in the late 1990s to treat some of the problems inside the hip joint using an arthroscope. Specifically, small portals about a centimeter in size are placed in the front, side and back of the hip with the surgeon inserting the camera into one of those portals and instruments into the others. They are then able to look at the hip joint, including the cartilage, the bone, the ligaments, and the alignment of the joint, to both assess and treat the problems in a minimally invasive way.
What would that treatment entail once they're in the hip and they can see it?
Of course, it depends on what the problem is. Labral pathology is one that is treated a bit more readily and includes removing a piece of a torn labral cartilage or repairing that labrum. You may be familiar with Alex Rodriguez, the famous baseball player for the NY Yankees who had trouble with his hip. At the end of his career, he underwent hip labral surgery, which was controversial at the time but he ended up returning to baseball after the surgery. Other things that could be treated include removing pieces of loose cartilage inside the joint, taking care of an inflamed lining of the joint or ligament, and treating the underlying anatomy behind FAI, or femoroacetabular impingement.
Hip Replacement Surgery
Let’s talk a little about total hip reconstruction (aka hip replacement). When do you start to finally make the call that reconstruction is something that should be considered?
Always a good question and a very personal decision for the patient in collaboration with the surgeon. Hip replacement surgery sounds like a very big operation and in some ways it very much is. But, it is a very effective one for someone that’s struggling with the symptoms of hip osteoarthritis. That’s why hundreds of thousands of people in the US, probably upwards of 400,000 people get a hip replacement each year. The age of those people getting hip replacements is much younger, partially because a well-done hip replacement can help people be quite active in all low-impact activities and in some higher-impact activities such as skiing or playing tennis. The decision to undergo surgery often comes down to that individual patient's risk tolerance for surgery, as well as how frustrated they are with their life in terms of missing out on things they like to do. For some people, that means not being able to ski. For other people, that means not being able to have a pain-free life during the workday. For other people, that means not being able to walk around their house. Presuming that person has failed non-operative treatments and is adequately frustrated, is medically safe to undergo a one to two-hour surgical procedure, [that person] will often proceed with total hip replacement.
What are the risks of hip replacement surgery?
I tell patients that if they are otherwise healthy, then their chance of a major adverse event is about 2% – some of the most concerning ones being infection, blood clots of the lower extremity, damage to blood vessels or nerves, and mechanical obstruction of the implant include a bone being broken, a hip dislocation, which is when the ball pops out of the socket, long-term wearing down of the prosthesis, and loosening of the prosthesis requiring additional surgery.
Is there a risk window within which most of this 2% happens? After what period of time is the surgery considered largely risk-free or successful?
Some of these complications I mentioned, including infection, dislocation, and nerve/blood vessel damage will happen within 30 days of the procedure. The risk of many of these tails off by about 90 days. This risk of the implant wearing out occurs throughout the life of the prosthesis.
How long is the prosthesis supposed to last would you say?
With better information from joint registries, which monitor implants as they’ve been used across populations, I tell my patients that there's a greater than 90 percent chance that the implant will last greater than 15 years for them. [After 15 years], that patient may be in the category of requiring a revision hip replacement surgery, which means a second time replacement. At that point, it really depends on what the underlying problem is. Historically, there'd been a problem with osteolysis, which is where the body reacted to small particles from the bearing surface of the prosthesis, which led to bone wear and eventual loosening of the prosthesis. That was a very bad problem that we're seeing much less of. When bone is eroded, it requires taking out the existing parts and putting in larger pieces. Thankfully, surgeons and medical device companies have developed prostheses that don’t wear to the same extent and that are not as reactive to the body, so we're seeing problems like infection or dislocation or fracture around the prosthesis as more common reasons for revision.
Let’s talk briefly about the mechanics of a hip replacement surgery. What actually happens during the surgery?
The surgical techniques have changed a lot and become more refined. So the issues that I bring up with a patient are 1) the approach in which the implants will be put in surgically, and 2) the types of implant that will be put in. At the most basic level, what's occurring during surgery is that there's a resurfacing on both sides of the hip joint. On the side of the socket, we use reamers which are like cheese graters to grind down the arthritic socket and place a metal socket, which is sometimes secured with screws, into the pelvis. On the side of the femur, we are making a cut, usually about a centimeter up the neck of the femur, removing the ball of the femur, and then placing a metal component, sometimes with cement, but usually without cement, into the femur. The femoral prosthesis then mates with the acetabular or cup side. Once the patient heals up, they are ready to go.
How would you decide on what type of hospital or what kind of surgeon to choose?
I think there is better information coming out such that people can make that decision. I think better outcomes tend to come from surgeons and facilities that perform enough of these procedures. Any hospital where they go should perform over several hundreds of these procedures over a year. A surgeon could perform more than 50 or a hundred of these procedures every year. Looking at the surgeon's training is relevant; for example, I suggest looking at whether they have done fellowship training, which is advanced training in hip replacement surgery, and if not, they've been doing this for a long, long time. There are some online tools to look up hospital ratings based on complication rates that can be accessed through government websites or Hospital Compare. One caveat is that that data is somewhat limited, but it is getting better, so if a hospital doesn’t have great ratings on the website, it doesn’t mean that they do not do a good job. There's variability across academic institutions just like there are in non-academic institutions, so that’s important to understand. Also, finding a good personality fit between the patient and the surgeon and the surgical team is a very important thing. Going into a major procedure, you want to make sure that the patient is very comfortable and trusting of the situation. Some people want to be in a teaching hospital, other people do not. That age-old method of getting referrals from family and friends is probably a good idea too.Disclaimer: The article does not replace an evaluation by a physician. Information on this page is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes.
More on Dr. Graw
What do you love most about your job?
Getting to know my patients and what their lives are like day-to-day is a hugely fun part of the job. Being able to troubleshoot a really troubling thing in their life, like hip or knee pain or the inability to do something, and then to help them get back to a pain-free life is really fun. Part of that is because I personally look at physical activity as such a necessary and important thing about human existence and to be a part of that is just awesome.
What is one thing you wish your patients knew about you?
I have my own musculoskeletal aches and pains since I've been an active person throughout my life (Brad played lacrosse at Yale as an undergraduate). So when they come to me with their own issues, I wish they knew that I’ve been in their shoes more than they know.
One last question about yourself: if you could describe yourself, what 3 adjectives would you use?
Open-Minded, Collaborative, and Focused.
Dr. Brad Graw
Orthopedic surgeon at Palo Alto Medical Foundation