Open access peer-reviewed chapter
Abstract
Hip replacement has evolved over the years, previously considered exclusively for geriatrics. It changed until it became an elective surgery in various pathologies. Certain conditions predominantly affect one age group. Hip dysplasia predominates in pediatrics, hip osteoarthritis in adults, and post-traumatic in geriatrics. Therefore, the indications for carrying out this procedure vary depending on age.
Keywords
- developmental dysplasia of the hip
- legg-calve-perthes disease
- transient hip synovitis
- epiphysiolysis of the femoral head
- arthrosis
1. Introduction
Osteoarthritis is the chief indication for placing a total hip prosthesis (THP) [1]. It is a pathology with multiple and complex etiology, where there are alterations in the physiology of the cartilage and the chondrocyte -one crucial cell in charge of the metabolism of the extracellular matrix-. It is classified into primary, generated by anatomical alterations or joint degeneration without an apparent cause, and secondary, where joint damage is due to aging and related to obesity, diabetes, metabolic syndrome, and chronic and inflammatory diseases [2].
The risk factors for developing secondary osteoarthritis are hip dysplasia, femoroacetabular impingement, avascular necrosis, juvenile arthritis, septic arthritis, slipped capital femoral epiphyseal, hip or acetabular fractures, and Perthes disease [3].
Surgical treatments are advisable under two clinical contexts. In those patients with unicompartmental osteoarthritis and alteration in the axis -in which a surgical intervention (osteotomy or unicompartmental prosthesis) can improve the symptoms and anatomical alteration- in such a way that they manage to reduce the progression to the generalized joint degenerative phenomenon. The other group with surgical indication is those who did not show improvement with conservative treatment, mainly due to pain progression or decreased functionality and loss of range of motion [4].
Rheumatic pathologies are considered an indication to place a total hip prosthesis, mainly affecting the knee and hip. The reported incidence varies from 65–90% for the former and 15–36% for the latter [1, 5, 6].
Patients who develop coxarthrosis caused by rheumatoid arthritis (RA) present with painful hips, decreased mobility, flexion deformity, and external rotation. Approximately 15% will need a total arthroplasty of one or both hips -the gold standard- [5, 6].
Total hip replacement (THR) is a procedure that significantly improves the quality of life of patients with RAwith severe and limiting involvement of their hips [7].
Total hip replacement has evolved, especially in the last 50 years. Previously, it was considered an exclusive procedure for geriatrics with a low expectation of recovery. However, this has evolved and has become the surgery of choice for various hip pathologies [1].
It is considered a dynamic and evolving surgical procedure. Thanks to modern technology and instrumentation, they make this reconstructive procedure, especially in severely disabled patients, is highly predictable and cost-effective [8].
Total hip arthroplasty (THA) is considered one of the most successful reconstructive surgical procedures, consistently rated as an excellent cost-effective surgery [8].
Charnley et al. [9] proposed to treat THA and surgical access through osteotomy of the greater trochanter. Over time, surgical accesses that did not require it were preferred, thus avoiding complications such as nonunion, broken wires, and prolonged operating times [8].
Generally, revision surgery may be necessary mainly during the first or second year (due to infection, dislocation, or periprosthetic fracture) and maintained subsequently with a rate of less than 1% annually. After 20 years, revision rates increase because of osteolysis and aseptic loosening. The high survival rates are supposed to continue for 25–30 years [8].
2. Pediatrics
Regarding pediatric patients, we find diseases associated with developmental disorders such as developmental dysplasia of the hip (DDH), Legg-Calve-Perthes disease, and transient hip synovitis -which has an unknown etiology- [1].
2.1 Developmental dysplasia of the hip
Developmental dysplasia of the hip is considered a condition that can cause significant disability if not correctly treated [10].
The term encompasses different conditions, ranging from instability, dislocation, or subluxation to abnormalities detected by imaging studies such as radiography [10].
There are different types of dysplasia depending on the etiology. Its classification goes from teratological hip luxation, associated with an underlying disease and manifesting prenatally, to typical developmental dysplasia, which can be congenital or have an onset in patients without underlying disease [10].
A total of 90% of patients who do not receive timely detection, and therefore proper treatment, have moderate to severe joint disease in adulthood, requiring hip replacement at an early age, harming their social environment [10].
2.2 Legg-calve-perthes disease
Legg-Calve-Perthes disease is an orthopedic pathology affecting hip development in infants because the irrigation of the capital femoral epiphysis presents ischemic alterations, culminating in necrosis [11].
It consists of necrosis of bone tissue, articular cartilage with the proliferation of chondrocytes in the superficial layers, and dead tissue in the deep layer with the possibility of subchondral fracture of the adjacent bone and a rupture of the growth plate, progressing to bone resorption and re-ossification [11].
All of this is reflected in an X-ray study, which presents with the femoral head in the shape of a mushroom, shortness, and neck thickness; acetabulum reshaping, tilted with the shortened shaft; and metaphyseal rarefaction [11].
The phenotype is described as the elevation of the greater trochanter of the femur and coxa vara [11].
2.3 Septic arthritis and osteomyelitis
Osteoarticular infections (OAI) are more frequent in children under 5 years of age, with septic arthritis (SA) presenting at a lower age than in patients with acute osteomyelitis (OM) [12].
The most frequently affected joints are the knee (56%) and hip (26%), presenting the most common OM in the bones of the foot, femur, and tibia [12].
It usually produces fever, dysregulated general state, localized skeletal pain, and functional impairment in pediatric patients. It is worth noting that not presenting fever does not discard the disease.
2.4 Transient hip synovitis (THS)
It is the most frequent cause of inflammatory arthritis in pediatrics. Its etiology is unknown. It most frequently affects males between 3 and 10 years and is self-limited. It usually presents in children with no significant history, fever, or general condition, such as a sudden onset of the limp, accompanied by pain in the groin or, in 20–30% of patients, in the middle third of the thigh or knee. In 5% of cases, synovitis is bilateral [13].
The examination is characteristic and very important, with painful limitation of the last flexion degrees and, especially, internal rotation of the affected hip. The pain improves with the rest. Mobility is less painful after 48–72 hours [13].
2.5 Epiphysiolysis of the femoral head
It is an inferior and posterior slippage of the proximal femoral epiphysis on the femoral metaphysis of unknown etiology. In 20–50% of patients, it can be bilateral. It characteristically affects adolescents (mean age 12–13 years) who are obese, more frequently males (1.5:1) [13].
The most recent series, however, detect both an increase in its incidence and a decrease in the age of the patients, attributable to the growing epidemic of childhood obesity [13].
Presentation is limping or pain in the groin, thigh, or knee; frequently, patients have presented pain or discomfort in a specific location for months before they become continuous or limiting. On examination, the internal rotation blockage of the affected hip is very characteristic, and – when the hip passively flexes to 90° with the patient supine- the hip deviates into external rotation (Drehmann’s sign) [13].
The confirmation is through an X-ray study of the hips. It is advisable to order an axial view as slippage of the femoral head is more evident on this view than on the AP view. Epiphysiolysis of the femoral head is an orthopedic emergency, so these patients should be immediately referred to traumatology [13].
Treatment for stable epiphysiolysis is
Avascular necrosis is a complication that affects 50% of patients with unstable epiphysiolysis and deforms the femoral head causing pain, joint stiffness, osteoarthritis, and, in the long term, results in THA [16].
3. Teenagers
3.1 Juvenile idiopathic arthritis
It is defined as an inflammatory arthropathy of autoimmune etiology that presents a chronic course of at least six weeks and is considered the leading cause of chronic arthritis in childhood. The onset of the disease, the presence of rheumatoid factors, and the course of the disease are considered fundamental in the prognosis [17].
It is more affected by the female sex. According to its onset form, it can be classified as oligoarticular, which is the most frequent, polyarticular, and systemic [18].
Chronic synovitis causes antalgic postures that promote the development of flexion deformities. It is accompanied by synovial proliferation and invasive pannus deformation producing joint destruction, pericapsular adhesions, local growth alterations, demineralization, and destruction of adjacent bones. These changes generate a muscular imbalance that results in a biomechanical alteration with progressive functional loss and deformities that can progress to bone ankylosis [18].
The diagnosis is fundamentally clinical, and there is no paraclinical examination to rule out or confirm the disease. Synovial fluid analysis indicates a sterile inflammatory process, elevated protein levels, glucose at normal levels, and poor mucin clot formation. The radiological changes at the beginning of the disease are absent, so they are not helpful for early diagnosis [18].
The treatment aims to alleviate joint pain and suppress the inflammatory process. Pharmacological treatment and physiotherapy are given as the first option [17]. However, the presence of traumatic injuries generating damage to the joints is one of the reasons that hip replacement surgery is necessary. Other reasons are deteriorating or destroying joints, having a slow growth rate, uneven growth of a limb, either a leg or an arm, loss of vision, or decreased visual acuity caused by chronic uveitis and pericarditis [19].
4. Adults
In young patients, systemic diseases lead to poor bone quality, acetabular and femoral defects from congenital conditions, post-traumatic osteoarthritis, post-surgical stiffness, osteonecrosis, severe deformities, length discrepancy, pelvic obliquity, and obesity [3].
Hip arthrodesis was previously the surgical treatment of choice since it improved pain. Nevertheless, the patient had limited function. With THA, the aim is to improve the patient’s functionality and quality of life. They have fewer complications. Also, mortality has decreased. Most causes of mortality are secondary to heart disease and thromboembolic pathologies [3].
One of the problems with the hip replacement technique in people aged 20–25 compared to people aged 50 lies mainly in the skeletal maturation time, since it continues after physeal closure, in addition to the fact that bone remodeling occurs faster in younger patients and influences bone-implant interactions, and they have less discipline to control the physical activity they undergo after the period of disability, leading to the need for intervention [20].
It is worth considering that Total Hip Replacement (THR) generates irreversible bone loss, and a surgical revision will probably be necessary when the patient is still young. Therefore, arthroplasty is considered very effective in the short and long term. In the medium term, it should not be advised as the first-line procedure in very young patients [20].
4.1 Arthrosis
Osteoarthritis (OA) is the most common joint disorder worldwide. Approximately 18% of women and 10% of men above 60 years old have symptomatic OA. More than half of people around 65 years old have radiological evidence of OA [21].
Hip osteoarthritis has different causes depending on the age of the patient. In people over 65 years, primary osteoarthritis occurs more frequently, which is of a degenerative type and leads the patient to present progressive joint pain that produces functional limitation to a variable degree. In patients under 40, alterations secondary to complex traumas or severe degrees of childhood pathologies that lead to corrective procedures and later joint degeneration are more frequently found [3].
The United States population suffers from an epidemic of obesity and a prevalence of primary osteoarthritis that has increased significantly. Surgical treatment with THR is recommended when there is a failure in conservative treatment, such as weight loss, increased physical activity, use of a cane, and when the administration of non-steroidal anti-inflammatory drugs fails to relieve pain [1].
The number of obese patients requiring THA has increased, so orthopedic surgeons performing this procedure must be aware of the potential problems and reduce the complications associated with these patients [22].
Secondary osteoarthritis implies greater complexity for the surgeon since patients have higher bone deformities, joint stiffness, shortening, previous surgical procedures, and instability due to muscle, capsular, or bone deficiency [3].
Depending on the stage of the disease, a variety of non-surgical and surgical treatment options are available for the management of hip osteoarthritis. Patient education, exercise therapy, and maintaining physical activity are important during the initial stages of the disease. For mild to moderate clinical data, it is possible to delay THR surgery for a while by combining these two therapies. When symptoms deteriorate in the advanced stage, THR is a successful and effective treatment [23].
Femoral fractures and osteoarthritis of the hip (OA of the hip) are the most common disease of the hip joint, treated by hip replacement surgery [23].
4.2 Post-traumatic arthritis
Post-traumatic arthritis can develop years after an acetabular fracture, impairing joint function and resulting in significant chronic musculoskeletal pain. This study systematically reviewed the literature on THA results in patients with THA and previous acetabular fracture [24].
Post-traumatic osteoarthritis, secondary to fractures and or dislocation of the acetabulum and proximal femur, is a THP indication [1].
Despite the difficulties associated with performing THA in patients with PTA from previous acetabular fracture (including soft tissue scarring, existing hardware, and acetabular bone loss) and the relatively high complication rates, THA in patients with PTA following prior acetabular fracture leads to significant improvement in pain and function at 10-year follow-up. Further high-quality randomized controlled studies are needed to confirm the outcomes after delayed THA in these patients [24].
4.3 Rheumatoid arthritis
Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by polyarthritis with progressive joint wear, increasing physical limitation, and immunological abnormalities.
It is considered an incurable condition of unknown origin, which will have to receive treatment. However, it will not be cured [25].
It affects the female sex in a ratio of 3:1. It is highly prevalent, affecting 1.6% of the Mexican population, which leads to a high economic burden for the public health system and impacts patients’ quality of life [25].
In coxarthrosis secondary to RA, approximately 1 in 6 patients will need a THA [7].
Hip replacement is considered a surgical option for patients with terminal joint destruction secondary to osteoarthritis and RA [25].
Surgical correction is effective for patients with advanced joint destruction [25].
The main goal is to achieve a mobile joint with a pain-free range of motion and mechanical stability [25].
Postoperative surgical complications in replacement and their relationship with risk factors, such as a higher body mass index (BMI), preoperative use of corticosteroids, and a low serum albumin level, increase hospital readmission [25].
The problem of major surgical procedures like hip replacement is not complication-free. Recent studies show an increase in the complication proportion in the population [25].
4.4 Avascular necrosis
Osteonecrosis with the segmental collapse of the femoral head has increased in the United States due to HIV-positive patients receiving highly active antiretroviral therapy, the high rate of alcoholism in the general population, and the use of corticosteroids for various conditions. Therefore, osteonecrosis is a frequent indication for performing a THR [1].
It is considered a multifactorial pathology characterized by the progressive destruction of the bone in the coxofemoral joint due to the alteration of local blood flow. For bone tissue necrosis to develop, ischemic events must be constant [26]. Pain is considered the reason for consultation in most cases, which occurs in the groin, followed by pain in the thighs and buttocks. It is exacerbated or produced by movement and weight bearing [27]. Its incidence increases in adults. Over 75% of patients present it between 30 and 60 years, and the average age of presentation is 36 years [28]. It is most frequent in men [29]. It is associated with trauma such as femur fractures, prolonged use of glucocorticoids, and excessive alcohol consumption.
Treatment aims to preserve the hip for as long as possible. There are two approaches for osteonecrosis: conservative and surgical management [30].
Conservative management is proposed only in early stages that present small lesions or in cases of contraindicated surgical treatment. Weight-bearing restriction, pharmacological treatment, and biophysical modalities are included [31]. Surgical treatment prior to collapse involves procedures such as central decompression and non-vascularized and vascularized bone grafts. In advanced stages with a collapse and arthritic hip, hip prosthetic surgery is considered [32].
Prosthetic hip replacement has a life span of 15 years before it wears out and requires revision. For this reason, it is an optimal option for older patients [33].
Sickle cell anemia is a pathology associated with avascular necrosis of the femoral head. Deformed red blood cells cause vascular congestion, venostasis, and thrombosis of the bone microvasculature. Ischemia is aggravated by increased intraosseous pressure secondary to marrow hyperplasia, producing bone infarcts and necrosis [34]. Non-surgical treatment consists of red blood cell transfusion therapy for preventing manifestations of sickle cell anemia. THA with uncemented components is recommended in patients with sickle cell anemia as this material helps to prevent complications such as aseptic loosening by methyl methacrylate [35].
4.5 Paget’s disease
Paget’s disease of bone is a metabolic bone disease. Its etiology is unclear. It starts with increased resorption followed by a phase of aberrant osteoformation [36].
Approximately 10% of patients with Paget’s disease develop hip osteoarthritis due to the disease itself, mainly to the alterations in the load axes that condition this pathology. Even as the establishment of early treatments decreases the incidence, symptomatic arthritis of the hip continues to be a disabling problem [37].
Hip arthroplasty is the most effective treatment for hip osteoarthritis in a patient with Paget’s. However, in carrying out arthroplasty, multiple complications appear in these patients due to the specific characteristics of their bones [37].
The first difficulty orthopedic surgeons face while implanting a prosthesis is the bone deformity usually generated by the disease. It complicates arthroplasty with standard components or its positioning in varus [37].
5. Geriatrics
Falls are found more frequently in older adults. Approximately 50% occur in institutions, and 30% occur in the community [38].
A total of 90% of hip fractures are due to a fall, but only 14% of a fall results in a fracture [38].
Among the risk factors are mainly age-related changes, due to aging, such as vision alterations, muscle weakness, and proprioception alterations [38].
Pathological processes also play a role, with osteoarthritis being the most common cause, neurological problems such as Parkinson’s disease, and cognitive impairment such as senile dementia, depression, anxiety, and agitation [38].
The environmental factors that influence falls in the home are obstacles to walking (carpets, cables, etc.), poor room lighting, absent bathroom supports, and inappropriate footwear [39].
There is an increase in the prevalence of hip fractures secondary to falls in patients older than 65, mainly affecting women. Women after 50 have twice the risk of suffering a hip fracture. The most frequent treatments are osteosynthesis and partial or total arthroplasty [40].
5.1 Osteoporosis
It is a disease characterized by decreased bone mass, with alteration in the bone microarchitecture, so that fragility increases and, consequently, the tendency to a possible fracture [38].
The factors related to developing osteoporosis are age, diet, environment, hereditary, and hormonal [38].
After the trauma generated by a fall, the hip fracture presents mainly with localized pain in the inguinal region, sometimes presenting irradiation toward the knee [38].
Usually, femoral head fractures, which are also displaced, present intense pain and walking impairment. There is a disability to move the hips. The affected limb is in external rotation with shortening and muscle weakness [38].
There are two options for treating hip fractures: conservative or surgical. Both aim to reduce pain and recover the patient’s functional capacity [38].
Conservative treatment consists of immobilizing the patient for several months, sometimes with traction, but generating complications such as pressure ulcers, thromboembolic ulcers, and urinary and respiratory infections, so, with the introduction of osteosynthesis, this treatment had less relevance [38].
Surgical treatment must be performed within the first 48 hours of the hip fracture. Osteosynthesis or partial or THR is considered [41].
THA is indicated for patients with a displaced intracapsular hip fracture, patients of 70 years or older with a femoral neck fracture, and those over 65 years without a prior reduction, coxarthrosis, and in case osteosynthesis has failed [41].
THR has been shown to have better functional results and fewer complications for displaced femoral neck fractures versus traditional internal fixation techniques or hernioplasty in patients older than 60 years [42].
This procedure allows patients early loading, lowers the risk of requiring a second intervention, prevents failed fixation and union, and avoids avascular necrosis [41].
6. Total hip arthroplasty
Let us remember that the hip is a congruent joint, where the acetabulum and the femoral head have a symmetry that allows rotation around an axis and favors the action of the muscles [43].
Prosthesis success depends on factors related to the patient, such as age, gender, height or weight, medical history, underlying hip condition, and previous surgeries [43].
Certain surgical factors also play a role, such as the experience of the orthopedic surgeon, surgical approach, prosthesis design, component orientation, limb length inequality, and trochanteric non-union [43].
Therefore, evaluating the performance of the prosthesis becomes difficult. In any case, the average lifespan is 20 years [43].
7. Conclusions
Some various pathologies and complications lead to a THR. These pathologies occur throughout the patients’ lives according to the etiology.
THR is a procedure that significantly improves the patient’s quality of life.
Previously, it was thought exclusively for geriatrics with a low expectation of recovery. However, this evolved until it became the surgery of choice for various hip pathologies.
At present, it is considered a dynamic and evolving surgical procedure, which according to the different age groups, some pathologies predispose to this surgery, such as the case of pediatrics with developmental dysplasia of the hip, adults with osteoarthritis of the hip, in older adults or geriatrics with post-traumatic injuries.
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