You have been told your hip joint is "bone on bone." Do you need hip replacement surgery?
Chances are you have a friend, co-worker, or relative that has had a hip replacement surgery recently. Their experience and the success or failure of the procedure has very little relevance to your situation and whether or not surgery is the right option for you. This article is intended to help you objectively determine whether you really need a new hip or if you should pursue a non-surgical option based on your individual circumstances.
How many hip replacements are performed annually?
Total annual hip replacement surgeries in the US are increasing at an alarming rate. Annual hip replacements are predicted to increase from the current level of 500,000 procedures in 2020 to 850,000 procedures in 2030 and an estimated 1,400,000 total hip replacements in 2040. Journal article projected annual hip replacement surgeries.
Is my hip replacement surgery necessary?
A recent article in the Journal of the American Medical Association estimates that up to one-third of the hip and knee replacement surgeries performed annually are unecessary. These surgeries cost Americans approximately $8.3 billion per year. Research indicates unnecessary replacement surgeries cost $8.3 annually
How do I determine if I need surgery?
Simply put, hip replacement surgery may be the only option when degeneration joint disease is so advanced that the ball and socket of the hip joint is so deformed that it causes a “frozen” or “locked” hip. This will usually come along with excessive joint pain, loss of mobility, and an overall decreased of quality of life.
How do I know if my hip pain is from advanced degeneration of the hip joint? I've been told I have "bone on bone."
Many patients diagnosed with "bone on bone" have been told they need to have a total hip replacement. In our experience, approximately 75% of these patients do not need hip replacement surgery. These patient's Xrays often show the cartilage on the the "ball" and the "socket" of the hip joint has an adequate amount of cartilage, they have limited osteophytes (calcification of ligaments, tendons, joint capsule and the "socket" of the joint), and they still have significant range of motion even though they've been told that surgery is their best option.
Is there an accurate way to determine the status of my hip using Xray, MRI, etc?
Xray of the hip and MRI imaging studies are currently the best way to determine the degree of degenerative joint disease (DJD) due to osteoarthritis. The radiology report for an Xray or an MRI will use the following criteria to report a grade of degenerationg. The radiologist will grade the Xray or MRI according to the following changes.
1. The decrease in joint space or cartilage compared to a healthy young joint. This is what is commonly called "bone on bone"
2. The presence of bone spurs (osteophytes), the amount of spurring and the location in the joint and soft tissue.
3. The shape of the femoral head or "ball" portion of the ball and socket joint. A healthy joint has a round regular surface. A diseased head will be flattened or egg-shaped.
Hip Xrays use the following grading scale to determine the severity of hip joint degeneration:
- grade 0: normal hip joint
- grade 1: possible joint space narrowing and subtle osteophytes
- grade 2: definite joint space narrowing, defined osteophytes and some sclerosis, especially in the acetabular region
- grade 3: marked joint space narrowing, small osteophytes, some sclerosis and cyst formation and deformity of femoral head and acetabulum
- grade 4: gross loss of joint space with above features plus large osteophytes and increased deformity of the femoral head and acetabulum
The Xray below is an example of a grade 1 degenerative hip. There is minimal narrowing of the space between the ball and the socket of both joints, indicated by the darker area surrounding the "ball" of the femur. This represents the cartilage of the joint, which acts as a shock absorber and a smooth surface to allow smooth and painless range-of-motion. There are subtle osteophytes identified by the bright white abnormal “fingerlike” projections visible at the outer edges of the “socket”. There are no severe visible lesions or cysts on the ball or socket on the hip on left side of the xRay. The hip on the right side has some slight surface irregularities at approximately 9:00 on the ball joint. The“ball” of the femur head on both hips have maintained their shape. This is an example of an excellent candidate for non-surgical hip regenerative injection therapy and should not pursue surgical hip replacement. Any pain experienced in this patient should be resolved with improving the ligaments, tendons, and the capsule integrity.
XRay GRADE 1 DEGENERATIVE HIP
The Xray below is an example of a grade 4 degenerative hip on both the left and right hip. Compared to the grade 1 degenerative hip, this Xray demonstrates extreme loss of joint space between the “ball” and the “socket” as there is no visible separation between the two. Both joints also have multiple large osteophytes (calcification of soft tissue indicated by bright white fingerlike projections into and surrounding the joint, severe sclerosis and cyst formation on the joint surfaces, and significant deformity of the “ball” of the joint. The “ball” of the joint seems almost fused to the “socket”. Clinically, this patient would predictably have pain with walking or may require a walker. Also, the patient’s range of motion would be predictably restricted. This patient would not be an ideal candidate for non-surgical regenerative joint injection therapy and would be best served by having hip replacement surgery on both hips.
Xray GRADE 4 DEGENERATIVE HIP
MRIs have a similar scale from 0 (normal) to 4 (severe)
If your surgeon or orthopedic specialist orders an Xray and you are told you have "bone on bone," you should ask "what is the grade of degeneration from the radiology report?" If your doctor doesn't know and it's not specifically listed in the radiology report, ask your doctor to request the radiologist for an addendum to the report specifically grading the amount of degeneration.
Our office uses the imaging grading scale as part of our evaluation model to determine who is a good candidate for non-surgical treatment of hip pain for those that have been recommended joint replacement. In addition to the grading of the degeneration on XRay and MRI we consider:
- loss of function and range of motion
- level of pain at rest, standing, while walking
- damage to the soft tissue (ligaments, tendons, joint capsule) which causes an unstable joint
- amount of muscle loss
- degree of low back instability due to disc bulges and ligament laxity of ligaments in the lumbar and sacroiliac (SI) joint.
In short: People with Xray or MRI graded with 0, 1 are usually excellent candidates for non-surgical joint repair. Those with a grade 2 imaging study are usually good candidates. Those with grade 3 and 4 usually require surgical hip replacement. For those that can not undergo surgery or refuse surgery, we may still be able to reduce their hip pain by improving the integrity of the ligaments, tendons and the joint capsule with regenerative orthopedic injections.
It is important to note that patients that require hip replacement surgery may still have post operative pain. Many of these patients may benefit from regenerative injection therapy to strength the ligaments that hold the hip together along with similar treatment to the low back.
What are complications of hip replacement surgery? Is there any reason why I should avoid hip replacement surgery?
While most hip replacement surgeries are successful, possible complications can occur and usually require a second surgery to correct the problem. The most common complications of this invasive surgery include:
- Unequal leg length after surgery. During surgery extra bone material may need to be removed to facilitate success implant of the artificial joint. Even a slight discrepency in leg length can cause a change in posture, causing uneven weight distribution, low back and knee pain and nerve pain.
- Post surgical joint dislocation. Dislocations occur commonly occur after hip replacement due to falling during recovery from surgery. Structural integrity and stability of the joint can be improved by a pre or post regenerative injection procedure to strengthen the ligaments and capsule that hold the joint in place. Regenerative injections for hips
- Post surgical joint infection. Despite using the best surgical methods for preventing infections, a number of hip replacement surgeries result in staphylococcus or MRSA infections. If the infection is inside the joint, most cases will require a surgical revision to eliminate the infection for long term success.
- Post surgical blood clots. Patients may develop blood clots or deep vein thrombosis which can travel to the lungs and cause a pulmonary embolism leading to severe respiratory distress and possibly requiring hospitalization. Complications of hip replacement surgery
Can my hip pain be caused by something other than "bone on bone" or osteoarthritis of the hip joint?
Many of our patients have been told their hip pain is due to "bone on bone", but their pain did not resolve after a cortisone injection or even a total hip replacement. In these cases, their hip pain may be due to:
- Low back disc degeneration. The discs act as a shock absorber between the vertebra (bones in the low back). When this occurs, the spinal nerves that exit between the small openings (foramen) become smaller and the nerves become compressed and can send pain down the leg (sciatica) or to the hip. This can be corrected with regenerative injection therapy to the low back.
- Sacroiliac or SI joint dysfunction. The sacrum, which is the upside triangle shaped shield bone at the base of the spine, is the fulcrum of the low back. Often times, the SI joint which is where the sacrum meets the two hip joints becomes compromised by loose ligaments. When these important ligaments become stretched or slightly torn due to injury, childbirth, or auto accident, the stability of the SI joint can cause low back pain or in many cases pain that radiates into the hip. SI instability can also be treated with regenerative injections.
- Nerve pain from chronic constriction or peripheral nerve entrapment. Nerves that supply the hip area can become compressed, stretched or irritated and can be the cause of hip pain. Our office can relieve this type of pain by a simple non-surgical procedure known as perineural injections or peripheral nerve hydrodisection. This is where the doctor uses his ultrasound to separate the tissues that are compressing the pain causing nerve to release the entrapment and relieving the pain.
All three of these procedures can be performed before or after hip replacement and often is the only way that hip replacement patients can achieve lasting pain relief.
How can I determine if your office can help my hip pain?
Patients with hip pain wondering if we can help can schedule a free 15 minute phone consultation with Dr. William Nelson, hip pain specialist, to determine if we can help resolve your hip pain. Please contact our Scottsdale or Flagstaff, AZ office at 602-692-4626 to schedule your free consultation. We look forward to helping you.