Treatment of the hip joint

he International Center for Orthopedics specializes in the treatment of the hip joint. The hip connects the pelvis and the thigh. Since the hip is a ball and socket joint, the legs can be moved very flexibly in all directions.

Learn how a hip injury and hip disease manifests itself by clicking on the different sections. What symptoms should one pay attention to and when is it the best time to go to a specialist? You can also find out what treatment options are available today and what rehabilitation might look like after the surgery.

Hip injuries and diseases

What is coxarthrosis exactly?

Coxarthrosis is the gradual degeneration of the joint cartilage (wear and tear of the joint). The joint cartilage becomes cracked and loses substance. Since it is a gradual process over the years, coxarthrosis is not recognized immediately. Only over the years, when the arthrosis is already advanced, pain and movement restrictions appear.

What symptoms to look out for?

Arthrosis in the hip is often noticed by pain after prolonged sitting or lying down. These typical start-up difficulties are also followed by pain after prolonged exertion. In addition, the leg can no longer be spread or rotated properly. Muscle tension is also a clear sign of coxarthrosis due to the damaged capsule-ligament apparatus.

Most of those affected are already 50 years and older. Physical stress is often the cause of joint wear, but accidents or malformations (dysplasia) are also causes.

How can arthrosis in the hip be clinically diagnosed?

With the help of mobility tests, examination of the gait pattern, posture and palpation, the hip expert already obtains important findings. State-of-the-art imaging such as X-rays also provide information on the condition of the cartilage. MRI provides further details on soft tissue, ligaments and tendons. In this way, other diseases can be ruled out or fluid deposits can be identified.

Can coxarthrosis be treated conservatively?

With initial arthrosis, much can be managed by changing one’s lifestyle. A healthier diet, more exercise and weight reduction can reduce the risk of arthrosis.

Conservative therapies include pain and anti-inflammatory medications, physical therapy (muscle building), and injection therapy.

When is surgery recommended and what treatment options are available?

If coxarthrosis is already advanced, i.e., if the cartilage is already massively damaged, often only surgical interventions can help. Using hip arthroscopy, the joint cartilage can be examined directly. In this way, it is possible to determine whether a cartilage graft is necessary, a correction of malpositions (osteotomy) or a joint replacement.

Of course, joint-preserving measures are preferred. Which is the best therapy must be examined in each individual case and discussed with the patient.

What is remarkable about the hip joint and what happens when it malfunctions?

The hip joint is a ball-and-socket joint that runs along the acetabulum, allowing full movement in all three directions. Disorders of the hip joint can be caused either by malpositions of the head of the femur or the acetabulum and are often manifested by load-dependent pain.

A mechanical problem occurs in both cases due to the head-neck transition of the femoral neck striking the anterior glenoid cup, which can damage both the joint lip (labrum) and the articular cartilage.This leads to joint arthrosis in many cases.

comprehensive examination by a specialist so important?

Besides wear and tear of the hip joint (arthrosis), other damage and diseases close to the joint must be examined. It is not uncommon to find damage to the labrum (joint lip).

What is the function of the labrum (hip joint lip)?

The labrum surrounds the hip joint and protects the free cartilage margin of the hip joint. This allows the joint surface to be increased and keeps the fluid film (synovia) in the joint space. As a result, low-friction movement is possible and wear and tear of the joint is delayed. If the labrum is damaged due to a malposition, it tears, similar to the meniscus tear in the knee joint.

How come groin pain (while sitting) should be taken seriously?

Pain in the groin is noticeable due to the nervous supply to the labrum during loading or certain movements. The labrum becomes irritated. Since most labrum damage is in the anterior (front) acetabular region (62-92%), it is indicated by pain in the groin when sitting during daily activities.

Fig.1: Degenerative labrum damage at the anterior glenoid cup (acetabulum) (left), labrum detached from the glenoid cup (right).

In case this pain occurs, there is often a mechanical problem. In addition to damage to the labrum, the joint cartilage becomes detached and uncovered. The increased shearing forces on the cartilage can cause further damage, which then results in arthrosis of the hip joint.

Fig.2: Loosened articular cartilage from the acetabulum in a severe labral defect with cam impingement.

What examinations are made in the clinic?

If labral damage is suspected, magnetic resonance imaging (MRI) of the affected hip joint should take place during the clinical examination. This involves the injection of a contrast medium into the hip joint (MR arthrography). This method has a much higher sensitivity (92%) compared to standard MRI (62%).

Fig.3: MR arthrography showing labral damage of the hip joint.

Conservative or operative? Why is a surgical intervention recommended?

In the case of labral damage, conservative treatment is usually unsuccessful. The surgical intervention can be realized by arthroscopy without major deformities of the hip joint. The damage is repaired through two to four small skin incisions and by using small instruments. The procedure involves smoothing with removal of degenerative parts of the labrum or reconstruction with suturing of the labrum, depending on the size of the defect and the nature of the labrum.

How much time do you spend in the clinic and when will you be fit again?

Follow-up treatment after arthroscopy of the labrum depends on the initial damage and the surgical therapy that has been done. Nevertheless, in many cases, the patient is able to do pain-adapted and physiotherapeutic exercises on the first day after the surgery. If additional measures were taken on the articular cartilage or bony structures during surgery, partial weight-bearing is often necessary. Aftercare always depends on the individual case.

What are the scientific results? 

The results of clinical studies show that in a large number of cases there is significant improvement with arthroscopic therapy for isolated labral damage. Byrd et al. demonstrated in their research that 83% of treated patients had good to excellent results. Similar results were found by Streich et al, Nepple et al, Yamamoto et al in their patient population where they treated labrum damage arthroscopically.

As a result, arthroscopic treatment of labral damage of the hip joint is today the first choice, giving affected patients very good prospects of improvement.

What is femoroacetabular impingement (FAI)?

Femoro-acetabular impingement (FAI) is a disease of the hip joint in which pain is caused by the femoral neck striking the acetabular cup. Bony abnormalities are often found at the transition from the femoral head to the femoral neck (cam impingement, cam impingement) or at the acetabulum (biting forceps or pincer impingement).

What are the causes?

Possible causes of cam impingement may be bony attachments (bump) at the head-femoral neck junction or malhealed diseases in childhood and adolescence (e.g., Perthes disease, epipyseolysis capitis femoris). Causes of pincer impingement may be congenital (e.g., retroversion of the acetabulum, protrusio acetabuli) or acquired (e.g., degenerative attachments).

Fig. 1: Typical cam impingement with missing contour of the head-neck junction.

Fig.2: A typical pincer impingement with retroversion of the acetabulum (white=anterior acetabular cup, gray= posterior acetabular cup).

What exactly is so critical about it?

In both cases, mechanical problems are caused by the head-neck transition of the femoral neck striking the anterior glenoid cup, which can then damage both the joint lip (labrum) and, in the course, the articular cartilage. In many cases, this results in early joint arthrosis.

Fig.3: Cam impingement (A) or pincer impingement (B) causes the femoral neck to strike the acetabular cup.

And how exactly does an impingement at the hip feels like?

Affected patients often report pain in the groin, which can occur, for example, when sitting for a long period of time or during sports (e.g., hurdlers, volleyball). Classically, the bony pathology does not improve with conservative treatment measures, so that patients often report frustrating physiotherapy treatments.

How to diagnose a FAI?

In the diagnosis of a so-called femoro-acetabular impingement (FAI), both clinical and further diagnostics play a guiding role.

It is noticeable that the patient experiences increased pain especially when the hip joint is flexed with simultaneous internal rotation and spreading of the leg (anterior impingement test). This involves pressing the head-femoral neck junction against the anterior acetabular cup. In the case of malpositions, full and smooth movement of the hip joint is not possible. This test can also provide information about possible damage to the labrum.

How do imaging techniques help?

X-ray images of the affected joint provide an indication of bony malpositions. Furthermore, magnetic resonance imaging (MRI) with injection of a contrast medium into the joint (MR arthrography) is an important additional examination that can detect further pathologies and possible consequential damage before surgery, whereupon the surgical intervention can be planned precisely.

How to operate a FAI? 

Arthroscopic therapy procedures are predominantly used in the treatment of femoroacetabular impingement. Through 2-4 small skin incisions and using special instruments, bony attachments are removed so that the hip joint can continue to move fully in all three directions without causing mechanical problems and pain.

Fig.4: Arthroscopic removal of a cam impingement with repositioning of the head-neck junction.

When is minimally invasive surgery recommended?

More extensive, dorsally extending bony pathologies sometimes require a minimally invasive open approach (MIS, keyhole surgery), as some pathology is very difficult to treat by an arthroscopic approach.Some special cases sometimes implicate a dislocation of the hip joint in order to perform adequate treatment.

How many days do you have to spend in the clinic?

The duration of the hospital stay depends on the type of surgical procedure and can last between three to seven days. Likewise, mobilization and activity depends on the procedure and the extent of the surgery, so each patient receives an individualized physiotherapy and physiotherapy exercise program for further outpatient treatment.

How do you notice cartilage damage in the hip?

The quality of the articular cartilage at the hip joint reduces after a few years due to degenerative processes. The symptoms are manifested in the early phase by load-dependent pain that comes predominantly after long-term stress.

What clinical examinations are made on-site?

The medical history and clinical examination are supported by diagnostic imaging by means of X-rays and MRI.

Does cartilage damage to the hip require surgery?

At this stage, a wealth of conservative treatment options are available, including a nutritional balance, specific exercise activities, and specific medical treatments.

At what point does cartilage damage require surgery?

If the pain becomes more severe and affects the individual’s quality of life (pain at rest, night pain, etc.), further surgical therapy measures are recommended.

What are the treatment options?

Depending on the condition of the cartilage damage, various surgical treatment options are available. In the case of deep defects affecting the articular cartilage on the acetabular side or at the femoral head, microfracturing is often used, in which damaged cartilage is removed and the underlying bone is exposed. The bleeding from the bone, including stem cells, then progressively forms replacement cartilage in the affected area, allowing normal use of the joint. In many cases, microfracture involves covering the defects with a collagen membrane (AMIC, Matrix Associated Chondroneogenesis) so that the migrated blood cells and stem cells remain in place.

Fig.1: AMIC treatment of a cartilage defect on the acetabulum (*ChondroGide lying on top of the defect).

Was genau ist eine Autologe Chondrocyten Transplantation – kurz ACT?

Arthroscopic ACT is a promising method for the treatment of local cartilage defects. The patient’s own cartilage cells (chondrocytes) can be removed during the first surgical procedure.

In einem aufwendigen Verfahren werden dann die Knorpelzellen über eine definierte Zeit angezüchtet und 3-dimensionale Kügelchen (Sphäroide) hergestellt, die etwa 200.000 Knorpelzellen enthalten und einen Durchmesser von 0,5-0,7 mm haben. Diese werden dann in einem zweiten operativen Eingriff in den Knorpeldefekt eingebracht. Auf dieser Seite finden Sie noch mehr Informationen dazu.

Another special feature of this procedure is the multiplication of the cartilage cells and the production of the spheroids exclusively with the patient’s own blood serum. This avoids foreign reactions or side effects.

You should clarify the assumption of costs with the cost unit in advance.

Abb.1: Sphäroide zur Implantation bei einem Knorpeldefekt (©Co.don).

Fig. 2: Arthroscopically inserted chondrospheres into the cartilage defect as part of an ACT.

After the treatment of cartilage damage, what happens next?

Cartilage regenerate is formed under the motion treatment. Passive movement with a so-called motor splint should be performed for at least four to six hours a day over a period of four weeks.

If exercise is useful, what sports are recommended?

Complete rest of the operated leg does not make sense and is also impossible in the case of the hip joint, since the joint is already fully loaded when sitting. As a “cartilage massage” an Ergometer (cycling without great resistance) should be practiced regularly. The patient shouldn’t do sports with load, such as jogging and impact sports, for about nine to twelve months.

Taking glucosamine and chondroitin sulfate orally or injecting them directly into the hip joint for the first twelve months after surgery seems useful.

Further therapy options

In recent years, the attention has been paid to muscle-sparing and joint-preserving orthopedic techniques. The main reason is the young age of the patients and their higher level of activity. After surgery, they want to return to their normal daily activities as quickly as possible. Minimally invasive surgery (MIS) offers the possibility of improving the patient’s quality of life through rapid postoperative mobilization and active recovery.

What is the procedure for minimally invasive surgery of the hip joint?

In surgical hip treatment, an adapted skin incision is chosen that allows access to the hip joint without damaging muscles.

Hip arthroscopy requires only 2-4 small skin incisions to allow treatment of many joint pathologies using adapted instruments. This makes it possible to treat bony protrusions (impingement treatment), labral damage, inflammation of the synovium (synovitis), remove free joint bodies, and conduct cartilage therapies.

Fig.1: Hip joint access option for arthroscopic treatment.

What do extensive pathologies require?

Extensive pathologies sometimes require a short skin incision for adequate treatment. This can be done with arthroscopic assistance in order to minimize the soft tissue trauma during surgery. Thus it is also possible to provide locally outlined cartilage damage with a small cap (HemiCap), so that complete joint replacement is not necessary. These minimally invasive treatments allow early mobilization of the patient and a quick return to normal daily life.

Fig.2: Implantation of a HemiCAP.

Fig.3: Treatment of a local defect with a bone saving HemiCAP prosthesis

What is arthroscopy and why is it performed by only a few orthopedists?

Arthroscopy of the hip joint has become increasingly popular in the treatment of hip disorders in recent years. This procedure has developed significantly in the last decade with regard to approach and surgical techniques, so that special instruments can now be used to treat diseases in and around the joint. Nevertheless, this procedure is only performed by a few orthopedists in Germany, as this type of surgery is very extensive and complex.

What are the advantages of arthroscopy of the hip joint?

The advantage of this minimally invasive technique is the protection of the muscular structures around the hip joint, which can be affected by open surgery. Furthermore, there is less pain in the hip and groin after the operation, so that rapid recovery is possible.

What are typical indications for arthroscopy?

Typical indications for arthroscopy of the hip joint are related to diseases of the labrum (joint lip of the acetabulum), femoro-acetabular impingement (FAI), cartilage damage of the hip joint with cartilage treatment (cartilage cell transplantation, AMIC procedure, microfracturing, etc.) and the structures surrounding the hip joint (tendons, bursa). The symptoms are sometimes expressed by groin pain while sitting in the car or during work, or sports activity.

What clinical examinations must take place in advance?

The exact examination includes special imaging (X-rays, magnetic resonance imaging/MRI with contrast medium) to determine the cause of the complaints. This allows the surgical procedure to be planned and performed precisely.

What are the advantages of arthroscopy during surgery?

During a hip arthroscopy, both the inner part (central compartment) and the outer part of the joint (peripheral compartment) can be visualized during the operation. At the same time, diseases can be treated. Also structures around the hip joint can be repaired (bursitis, tendon pathologies). During the operation, the hip joint is carefully widened under anesthesia so that the X-ray monitoring can be used by enter the joint. With the help of the camera and different instruments, the diseases can then be treated optimally.

An individual aftercare plan is developed for each patient, depending on the operation that has been done. This plan is given to the patient and the physiotherapist who will continue the treatment. This ensures standardized and patient-specific aftercare no matter where the patient lives.

When should you consider endoprosthetic replacement of the hip joint?

If there is arthrosis of the hip joint with damage to the joint cartilage, this often leads to pain at rest or during physical activity. That limits the quality of life. If cartilage-preserving treatments are no longer possible (injection treatments, arthroscopy, etc.), an endoprosthetic replacement of the hip joint should be considered.Arthrosis of the hip joint with damage to the joint cartilage, this often leads to pain at rest or during physical activity. That limits the quality of life. If cartilage-preserving treatments are no longer possible (injection treatments, arthroscopy, etc.), an endoprosthetic replacement of the hip joint should be considered.

Fig.1: Typical arthrosis with loss of cartilage and joint space (left) Postoperative images after hip replacement (center, right)

What are the surgical options?

Currently, there are various surgical procedures to replace both joint components and to reduce pain while improving the patient’s quality of life. Hip arthroplasty is a procedure that has been established for years to treat advanced hip joint arthrosis. For years, uncemented and cemented hip endoprostheses have been implanted with very good results, expecting a 15-20 year durability until replacement surgery may be necessary.

What additional methods have been established in recent years?

Alternative treatment concepts have developed in recent years, so that many hip arthroses can be treated with bone-saving implants. In many cases, implants can be inserted by a minimally invasive anterior/anterior or antero-lateral technique, so allowing for a much faster postoperative mobilization.

What are short-stem prostheses?

Bone-sparing implants are short-shaft prostheses that require less bone resection than standard endoprostheses. These bone-saving implants often allow the implantation of a conventional implant in future replacement operations, so that these types of endoprostheses can be regarded as “prosthesis before prosthesis”.

Fig.2: Modern surgical treatment options for hip arthrosis (left) and two short-shaft prostheses (center, right)

Why has implantation of a surface replacement prosthesis not been advised in the last years?

In recent times, it is not recommended to implant the surface replacement prosthesis. They lead to severe abrasion by the metal-on-metal bearing couple in many cases, resulting in metallosis, pseudotumors, hypersensitivity and neurological problems. Therefore, affected patients should urgently have a control of the metal ion serum concentration and further examinations to identify serious complications at an early stage. We perform such screening examination in affected patients in our center.

What happens after surgery?

Immediately after the surgical procedure, patients are mobilized with a full load on the affected joint and are left to continue their treatment after a few days. With the Fast Recovery or Fast Track procedure, a quick return to normal activity is possible. Likewise, the hospital stay can be reduced to a few days.

When is a partial denture recommended?

In special cases with localized cartilage defects of the femoral head, a partial crowning with a HemiCAP can be performed to cover only the affected part – followed by a return to full activity.

Fig.3: Treatment of a local defect with a bone-saving HemiCAP prosthesis

What are the requirements and what surgical techniques are used?

The precondition for such an intervention is an accurate diagnosis by means of X-ray and MRI, so that the extent of the cartilage damage can be assessed. These can also be implanted using minimally invasive techniques, so that patients can be discharged from inpatient treatment after a few days.

Patients are mobilized with a full load on the affected joint immediately after the surgical procedure. After a few days, they are discharged for further treatment.

What is MAKO Robotics?

“Accurate to the millimeter” – this is important, especially in joint surgery, when operations have to be performed on delicate parts such as the hip or knee joint. Surgery on such complex joint structures, where bones lie close to tendons, ligaments and nerves, requires absolute precision. That is why we rely on the support of state-of-the-art technology in hip surgery. One of the most advanced is the so-called Mako SmartRoboticsTM®. More information on the methodology and advantages can be found on this page.

When does a replacement of the prosthesis be necessary?

As a result of the large number of hip prostheses implanted in recent decades, the number of replacement operations is constantly growing due to the incidence of prosthesis loosening. These can be caused by long service lives of the prostheses or have other causes. After a standing time of about 20 years, in many cases there is no cause of loosening found, so one speaks of an aseptic loosening. A possible reason for an early loosening of the prosthesis is the abrasion particles of the polyethylene plastic of many acetabular cups, which may degrade the bone in the area of the stem or the cups. Rarely, there is septic loosening due to bacterial infection, which may present as an early infection after implantation. However, if this occurs years later, we have a low-grade infection.

What exactly can loosen up?

Generally, the hip stem, the acetabulum or both parts can loosen, which then require replacement surgery. Depending on the size of the bone defect, either conventional endoprostheses or special implants are necessary for a successful replacement operation.

In the acetabular area, these are classic acetabular components that either press into the pelvic bone (press-fit cups), are screwed into the pelvic bone (screw cups) or are cemented in place. For larger defects, the bone fracture is usually filled using bone graft materials or foreign bone and a revision cup with the screw fixation option is selected.

Fig. 1: Aseptic acetabular loosening treated by cup reconstruction with foreign bone and implantation of a revision cup

Fig. 2: Complex revision of a multiple pre-operated acetabular fracture with tilted and loosened revision cup. Change to a modular partial pelvic replacement (Lumic, Implantcast)

In the stem region, standard grade stems are used mostly for smaller defects, and revision systems with longer stems and the possibility of screw anchorage are selected only for larger defects if they affect the proximal part of the femur.

Fig. 3: Early aseptic loosening of a short shaft prosthesis after a period of 4.5 years, which could be changed to a standard grade prosthesis

Fig. 4: Change of a hip prosthesis shaft in the case of a periprosthetic fracture due to a loosening of the shaft

What happens in cases of bacterial infection?

In cases of septic loosening caused by bacterial infection, a two-stage exchange is necessary, involving the insertion of bone cement with antibiotic (as a placeholder) until the defect is healed. After 6-8 weeks, hip arthroplasty can be successfully replaced under antibiotic therapy.

How do the diagnostics look like in this case?

For diagnostic purposes, a 3-phase skeletal scintigraphy is performed in many cases in addition to the conventional radiological examinations (conventional X-rays). If a septic loosening is suspected, an inflammatory scintigraphy (leukocyte scintigraphy) in combination with a puncture of the joint should be discussed for further diagnostics. In addition, the so-called SPECT-CT is also available to enable a highly specialized analysis of the prosthesis pain.

What does mobilization look like?

An early functional mobilization under full load follows in many cases, depending on the size of the defect and the replaced components. For larger defects or a slightly reduced bone quality, partial loading should be done for 6 weeks.

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Prof. Thorey, MD

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