Common issues involving the Hip with Mr Gavin McHugh

Good afternoon, ladies and gentlemen, I am very excited to be part of this UPMC Sports Surgery Clinic webinar. My name is Gavin McHugh. I’m here to talk to you about some common issues involving the hip joint.

First of all, I’m going to try and talk about four aspects of not just the joint in that I want to take it away from the joint a little bit. Number one, the muscle, number two, the joint itself, number three, the tendons around the area and number four, the bone itself and hopefully try and make a little take-home point about all these issues.

The first element I’d like to mention is a thing called sarcopenia, which is a term that most people wouldn’t have heard of and essentially, sarcopenia, unfortunately, is the age-related loss of muscle mass and function that occurs as we get older. Essentially from around the age of about 30 or 40, around eight per cent of your muscle mass is lost and every ten years or so, and after about the age of 70, that accelerates quite a bit to the extent that after by the age of 80, you’re talking about 30, 40 per cent of your muscle mass that is normally present.

This slide demonstrates it quite well. A cross-sectional scan of over a thigh of someone who’s 25 years of age and you can see the difference highlighted in an older individual where there’s been a progressive loss of muscle mass and replacement with fatty tissue.

What is the significance of this? Well, the significance of this is that as you lose muscle mass, you lose strength and as you lose strength, you potentially lose a lot of your independence.

The strength of your quads muscles or your quadriceps muscles are really the important anti-gravity muscle that allows individuals to stand up from us from a seated position. That is what determines how independent you are, essentially and we know from multiple studies, which is quite remarkable, that the strength in your quads determines really how long you stay independent.

It is more important than associated issues such as mental health issues and the deterioration with Alzheimer’s disease, with other comorbidities, such as lung problems and cardiovascular problems, it really boils down to how much muscle you have in the bank, essentially for the future.

We know that if you’re sick and you lose about 10 days in bed, you can lose potentially 50 per cent off that muscle strength. Then that impacts further in the recovery process.

So that the first take-home message is with regards to the muscle is that it’s never too late. There have been some remarkable studies performed in and we are taking cohorts of patients over the age of 90 and put them through an exercise program of six-eight weeks duration and the increase in strength you get when you perform quite simple supervised exercises can be 150/160 per cent increase in strength at six-eight weeks, which is really, really quite dramatic. If bodybuilders could achieve these types of gains, they would be absolutely delighted. But it just highlights the fact that it’s never too late to start that process.

As I said, whilst people are potentially cocooned at home and throughout this current pandemic, very simple little exercises can be performed to, number one, to maintain your strength. and number two, to actually improve it.

And these are simple little exercises that you can get a lot more information on from here in the UPMC Sports Surgery Clinic or indeed, just even touching base with your own local physiotherapist getting a video conference or organise and getting the simple little program.

It really should only take five to 10 minutes in the day. Simple exercises such as even standing up from a sitting position in a chair, performing exercises such as walls slides and bridges. These literally only take a couple of minutes to perform and can really have dramatic improvements and I touch base on how this interrelates to really everything I’m going to talk about regarding the hip.

The next step point is moving on into the joint and it is plain old simple osteoarthritis and really, regarding the hip, this is by far the most common issue that I see on a day to day basis.

What is hip osteoarthritis? Well, essentially, as you get older, wear and tear, as people often call it, you get that sort of pearly cartilage, the pretty white tissue is progressively lost off the surface of the joint.

How does it present? It normally presents with increasing pain, most commonly in the groin area but it can be around the buttock or even over the side of the hip and often that will radiate down to the knee area itself and in fact, quite often people present with just pain in the knee predominately but in fact, that the pain is coming from the hip.

What other impairments do patients note? Things like difficulty with putting on and taking off the shoes and socks, cutting their toenails and difficulty getting in and out of a car and night pain would be particularly common. In fact, night pain would be one of the main determinants that would really pushes us towards considering something like a hip replacement, which I will mention shortly.

Difficulty walking – often times people will notice that, the distance progressively has dropped down from five miles to three to two to one and so on, so forth, to the extent that their normal day to day activities are being significantly impaired.

What tends to be the treatment for a hip replacement? Assuming that and non-operative measures such a simple analgesia, some exercises that I’ve talked about and potentially an injection into the joint to feel that aren’t working well, then the solution is, a hip replacement.

What I often say to people is, that you can pick a lot of worse things to get than a worn hip. Why? Because hip replacement is really the best operation that we do as orthopaedic surgeons. The overall survival of a hip replacement is around 96 per cent to 10 years, which is pretty, pretty impressive and that is increasing all the time so our results are getting better and better.

Essentially what it involves is removing the worn head and the worn socket and replacing both with an implant or a device similar to the one that you see in the picture.

Hip replacements can be either cemented in place or they can be cement-less, which is where the implant has a rough coating that allows the bone to grow onto the surface and that’s how the fixation is gained.

There are pros and cons to both of these that I won’t go into too much detail but either way, both can perform really, really well and essentially from one to two days following the surgery and can lead to really significant improvements in pain to the extent that the majority of people are more or less symptom-free six weeks following their surgery.

The next thing to mention then would be again, something that I see quite commonly and this is moving away from the joint and onto the tendon. It is an issue called Trochanteric bursitis.

I use the term bursitis. What is a bursa? Bursa is a little bag that you can see in the picture that essentially acts to reduce friction around the area of either a joint or bony prominence.

Essentially it is two surfaces that are separated by a tiny drop of fluid to allow very low friction movement and the greater trochanter is the bony prominence that you see on the slide and the trochanter bursa overlies it.

Anything with an ‘itis’ at the end of it essentially means inflammation. So if you have tonsillitis is inflammation in your tonsils and bursitis is the same. It’s inflammation of the bursa.

But to be honest, the vast majority of the times there’s not even a bursitis present. Most of the time, patients have small, little micro-tears in some of the abductor muscles, which are the gluteal muscles that you can see again in the picture and the gluteus minimus and medius that insert onto that bony prominence and essentially perform a very important function in balancing the whole rest of your pelvis as you walk.

How do people present with this bursitis? They tend to get the pain out over the side of their hip and this is something that is really, really common, we see several times a week in the clinic. Quite often people describe that they have pain in bed at night time when they lie on the affected side. In fact, it often stops them from lying on that side.

Sometimes it moves right on the outside of the thigh, towards the knee or just below the knee but it is not usually associated with any numbness. Numbness would be more likely to suggest a spinal cause for this and that a sciatica type pain was the cause.

When I mentioned problems with the back, however, it is worth noting that this is something that does seem to be and exacerbated when patients have a lot of trouble with their lower back as well and I think really one feeds off the other and can make the other worse.

The vast majority of times the bursitis usually responds to a course of physiotherapy. In fact, some of the exercises that I’ve mentioned, along with an exercise called the hip hitch can really often help to try and the cause so that the microscopic tears to heal up themselves.

Quite frequently I will augment that with a steroid injection into the area, in fact, sometimes it might take two if not three injections to the area to fully settle it down.

Rarely does it require a surgical fixation if there’s a significant tear in the muscles and it is really not settling with injections then occasionally it will require surgery and that is ninety-five/Ninety-seven per cent of people will get away without any surgery.

The next thing I’m moving away then from the tendons onto the bone, then just to mention a hip fracture and again, you can see here on the on the X-ray, this is the right side as we are looking at the pelvis from the front, there’s a fracture here, which will be an inter-trochanteric fracture of the right hip.

This is as we get older, it’s often associated with a very, very simple fall, just from standing height. And the key is, is that almost certainly synonymous with osteoporosis.

What is osteoporosis? Osteoporosis is weak bones, essentially and it is the loss of your bone mineral density, so the calcium essentially gets sucked right out of the bones, meaning it loses the strength and its bony architecture and that makes people more and more prone to developing fractures.

It is a little bit like that as we get older that we lose the muscle mass, we also lose bone mineral density and you can see there the striking figure for the mortality rate after a hip fracture. This is something that over the last 30 years hasn’t particularly improved even though the surgery in terms of fixing these fractures has significantly improved. We are still looking at approximately one in four people not being alive one year after their hip fracture, which is really quite striking and up there with the vast majority of cancers and essentially this is to highlight the importance of prevention.

So how do we prevent and hip fractures? Well, we deal with the osteoporosis and one very, very simple way of dealing with the osteoporosis, aside from pharmacological means is weight-bearing exercise.

So again, this all ties into not only do we protect our muscles, not only do we protect our tendons and joints, we protect our bones themselves by performing a weight-bearing exercise.

And again, that can be something simple as getting up, getting out and walking and performing simple little squatting exercises all help to load the bone and increases bone mineral density and bone like the muscle, does remodel and rebuild itself.

You can’t be sure that you’re going to avoid problems such as a fracture or arthritis of the joint or bursitis in the future. But you can be sure that it will stand by you if you have to have any procedure. So, for example, the recovery following a hip replacement and is undoubtedly quicker and people who are fitter from the outset.