Contemporary Non-Surgical Considerations in the Management of People with Extra- and Intra-Articular Hip Pathologies

*Fiona Dobson, Kim Allison, Laura Diamond and Michelle Hall*

## **Abstract**

The hip joint can often be affected by extra- and intra-articular pathologies including gluteal tendinopathy, femoroacetabular impingement syndrome and hip osteoarthritis. Understanding alterations associated with these pathologies will provide greater insight into developing and optimising patient-specific treatments. A number of biomechanical and neuromuscular impairment are associated with Femoracetabular impingement (FAI), gluteal tendinopathy (GT) and hip osteoarthritis (OA) conditions including but not limited to muscle weakness, altered postural control, restricted range of motion and altered tendon/joint loading. These alterations can present differently in sub-groups of patients and result directly from the pathological process and/or indirectly from pain and its consequences (e.g. reduced activity). These impairments are often targets for conservative interventions but there is currently little clinical trial evidence to show that treatments can modify these impairments. Clinical trial evidence does, however, support conservative treatment options for each of the pathologies reviewed. Clinical outcome tools used to evaluate the effects of treatment and track change over time are recommended.

**Keywords:** hip osteoarthritis, femoroacetabular impingement, gluteal tendinopathy, exercise, biomechanics, outcome measurement

## **1. Introduction**

This chapter will present contemporary conservative considerations for the management of extra- and intra-articular hip pathologies including gluteal tendinopathy (GT), femoroacetabular impingement (FAI) syndrome and hip osteoarthritis (OA). The clinical presentation of hip pathology is frequent and can be complex. Over the past decade research has uncovered new insights into biomechanical alterations associations with GT, FAI and hip OA that enables clinicians to better understand the condition and management options. We provide an overview of the most significant discoveries as well as unpack the evidence for effective conservative management. Clinical outcome tools used to evaluate the effectiveness of treatments and track change over time in these hip conditions are reviewed.

## **2. Gluteal tendinopathy**

Gluteal tendinopathy, also referred to as "greater trochanteric pain syndrome", is a chronic, debilitating musculoskeletal condition affecting the tendinous insertion of the gluteus medius and/or minimus muscles at or above their attachments into the greater trochanter of the femur [1]. The hallmark features of this extra-articular hip condition are pain and tenderness to palpation at or around the region of the greater trochanter [1–3]. Prevalence rates of GT have been reported at 18% of those aged 50–79 years presenting to general practitioners [3]. Individuals with GT are most frequently over the age of 40 years [4] and typically experience pain during walking, stair climbing and/or lying on the affected side [1–3].

#### **2.1 Biomechanical considerations in gluteal tendinopathy**

#### *2.1.1 Important anatomical and biomechanical considerations*

The trochanteric bursae were previously considered the primary structure implicated in greater trochanteric pain [5]. However, new evidence from magnetic resonance imaging (MRI) [6, 7], ultrasound [8, 9] and surgical case series' [7, 10] has led to a contemporary understanding of the pathological mechanisms of the gluteal tendons underpinning greater trochanter pain. This progressive understanding of tendon involvement has necessitated important advances regarding biomechanical considerations associated with GT.

The gluteal tendons are vulnerable to anatomical compression against the (i) underlying greater trochanter, as they wrap over the borders of its bony facets into their respective insertions [11], and (ii) from the overlying iliotibial band (ITB), particularly as the hip moves into adduction. With increasing adduction of the femur relative to the pelvis, the insertion of the gluteus minimus and medius muscles on the greater trochanter are moved away from their respective origins on the ilium, placing longitudinal tensile and transverse tensile strain through the tendon fibres passing over the greater trochanter. In addition, the ITB exerts progressively higher compressive forces at the greater trochanter as the hip moves into hip adduction (4 N at 0°, increased by nine-fold to 36 N at 10° and 106 N at 40°) [12], which has direct consequences for gluteal tendon loading. Excessive tensile and compressive loads are accepted to be detrimental for tendon health and particularly relevant for the development and perpetuation of tendinopathy [13]. Thus, dynamic control of hip adduction is pertinent in the assessment and management of GT [14].

#### *2.1.2 Hip abductor muscle weakness and clinical relevance to loading biomechanics*

Like other tendinopathies, muscle weakness is a feature of GT [15]. Strength deficiencies of 32% of the hip abductor muscles on the symptomatic hip and 23% on the asymptomatic hip have been identified in individuals with clinically and MRI diagnosed GT compared to age- and sex-comparable controls [15]. The primary functional role of the hip abductor muscles is to maintain alignment of the pelvis in the frontal plane during gait, to eccentrically control the provocative position of hip adduction [16]. The relationship between hip adduction angle and hip abductor tendon loading in GT highlights the importance of abductor muscle strength for adequate eccentric control of hip adduction in this patient group [16]. Clinicians often evaluate hip abductor function by visually evaluating a patient's ability to maintain and control position of the pelvis in single leg stance (SLS) [17]. Further, SLS kinematics are considered relevant for control of single leg loading during gait.

**33**

**Figure 1.**

*Contemporary Non-Surgical Considerations in the Management of People…*

Data from three-dimensional motion capture analysis identified that individuals with GT exhibit greater lateral pelvic shift and hip adduction in preparation for SLS, and more hip adduction and less contralateral pelvic elevation during SLS in the frontal plane when compared to age and sex matched controls [18] (**Figure 1**). Though these findings may be, in part, explained by hip abductor muscle weakness [18], they also provide important insight into why single leg stance is provocative for many individuals with GT. Specifically, the increased potential tensile and compressive load through the gluteal tendons as the muscles work to control the position of the pelvis on the femur, is a likely relevant mechanism for tendon overload and

To date, only one study has evaluated *walking* kinematics and kinetics in individuals with GT compared to healthy controls. In contrast to pain-free controls, individuals with GT exhibit a significantly greater external hip adduction moment during the stance phase of walking [19] and during *stair climbing* [20]. These observations are thought to have distinct clinical relevance, given the external hip adduction moment represents an internal hip abductor moment contributed to by active and passive tension in the primary hip abductor muscles (i.e. the gluteus minimus and medius) [21]. Of importance to clinicians who use visual observation as part of their assessment in GT, contralateral pelvic drop is associated with a greater magnitude of the external hip adduction moment [19]. While data has shown that individuals with GT exhibit greater contralateral pelvic drop during late stance compared to controls, with implications for hip adduction angles and tendon loading, this between-group difference during walking was small on average (1.4 degrees), with questionable clinical relevance [19]. This small mean difference may be explained by variation in walking strategies utilised by participants in the GT group. A secondary analysis identified distinct subgroups in those with GT [19]. This novel and clinically relevant observation highlights that people with GT can compensate for hip abductor weakness in different ways, which coincide with compensations reported in individuals with intra-articular hip pain [22] and

*In preparation for single leg stance (SLS) individuals with gluteal tendinopathy exhibit greater lateral pelvic shift over the stance limb (and subsequently greater hip adduction angle) and maintain a position of single leg* 

*stance with greater contralateral pelvic drop (and subsequently hip adduction angle).*

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

pain.

*2.1.3 Gait biomechanics*

*Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

Data from three-dimensional motion capture analysis identified that individuals with GT exhibit greater lateral pelvic shift and hip adduction in preparation for SLS, and more hip adduction and less contralateral pelvic elevation during SLS in the frontal plane when compared to age and sex matched controls [18] (**Figure 1**). Though these findings may be, in part, explained by hip abductor muscle weakness [18], they also provide important insight into why single leg stance is provocative for many individuals with GT. Specifically, the increased potential tensile and compressive load through the gluteal tendons as the muscles work to control the position of the pelvis on the femur, is a likely relevant mechanism for tendon overload and pain.

#### *2.1.3 Gait biomechanics*

*Hip Surgeries*

**2. Gluteal tendinopathy**

Gluteal tendinopathy, also referred to as "greater trochanteric pain syndrome", is a chronic, debilitating musculoskeletal condition affecting the tendinous insertion of the gluteus medius and/or minimus muscles at or above their attachments into the greater trochanter of the femur [1]. The hallmark features of this extra-articular hip condition are pain and tenderness to palpation at or around the region of the greater trochanter [1–3]. Prevalence rates of GT have been reported at 18% of those aged 50–79 years presenting to general practitioners [3]. Individuals with GT are most frequently over the age of 40 years [4] and typically experience pain during

The trochanteric bursae were previously considered the primary structure implicated in greater trochanteric pain [5]. However, new evidence from magnetic resonance imaging (MRI) [6, 7], ultrasound [8, 9] and surgical case series' [7, 10] has led to a contemporary understanding of the pathological mechanisms of the gluteal tendons underpinning greater trochanter pain. This progressive understanding of tendon involvement has necessitated important advances regarding biome-

The gluteal tendons are vulnerable to anatomical compression against the (i) underlying greater trochanter, as they wrap over the borders of its bony facets into their respective insertions [11], and (ii) from the overlying iliotibial band (ITB), particularly as the hip moves into adduction. With increasing adduction of the femur relative to the pelvis, the insertion of the gluteus minimus and medius muscles on the greater trochanter are moved away from their respective origins on the ilium, placing longitudinal tensile and transverse tensile strain through the tendon fibres passing over the greater trochanter. In addition, the ITB exerts progressively higher compressive forces at the greater trochanter as the hip moves into hip adduction (4 N at 0°, increased by nine-fold to 36 N at 10° and 106 N at 40°) [12], which has direct consequences for gluteal tendon loading. Excessive tensile and compressive loads are accepted to be detrimental for tendon health and particularly relevant for the development and perpetuation of tendinopathy [13]. Thus, dynamic control

of hip adduction is pertinent in the assessment and management of GT [14].

*2.1.2 Hip abductor muscle weakness and clinical relevance to loading biomechanics*

Like other tendinopathies, muscle weakness is a feature of GT [15]. Strength deficiencies of 32% of the hip abductor muscles on the symptomatic hip and 23% on the asymptomatic hip have been identified in individuals with clinically and MRI diagnosed GT compared to age- and sex-comparable controls [15]. The primary functional role of the hip abductor muscles is to maintain alignment of the pelvis in the frontal plane during gait, to eccentrically control the provocative position of hip adduction [16]. The relationship between hip adduction angle and hip abductor tendon loading in GT highlights the importance of abductor muscle strength for adequate eccentric control of hip adduction in this patient group [16]. Clinicians often evaluate hip abductor function by visually evaluating a patient's ability to maintain and control position of the pelvis in single leg stance (SLS) [17]. Further, SLS kinematics are considered relevant for control of single leg loading

walking, stair climbing and/or lying on the affected side [1–3].

**2.1 Biomechanical considerations in gluteal tendinopathy**

*2.1.1 Important anatomical and biomechanical considerations*

chanical considerations associated with GT.

**32**

during gait.

To date, only one study has evaluated *walking* kinematics and kinetics in individuals with GT compared to healthy controls. In contrast to pain-free controls, individuals with GT exhibit a significantly greater external hip adduction moment during the stance phase of walking [19] and during *stair climbing* [20]. These observations are thought to have distinct clinical relevance, given the external hip adduction moment represents an internal hip abductor moment contributed to by active and passive tension in the primary hip abductor muscles (i.e. the gluteus minimus and medius) [21]. Of importance to clinicians who use visual observation as part of their assessment in GT, contralateral pelvic drop is associated with a greater magnitude of the external hip adduction moment [19]. While data has shown that individuals with GT exhibit greater contralateral pelvic drop during late stance compared to controls, with implications for hip adduction angles and tendon loading, this between-group difference during walking was small on average (1.4 degrees), with questionable clinical relevance [19]. This small mean difference may be explained by variation in walking strategies utilised by participants in the GT group. A secondary analysis identified distinct subgroups in those with GT [19]. This novel and clinically relevant observation highlights that people with GT can compensate for hip abductor weakness in different ways, which coincide with compensations reported in individuals with intra-articular hip pain [22] and

#### **Figure 1.**

*In preparation for single leg stance (SLS) individuals with gluteal tendinopathy exhibit greater lateral pelvic shift over the stance limb (and subsequently greater hip adduction angle) and maintain a position of single leg stance with greater contralateral pelvic drop (and subsequently hip adduction angle).*

with extra-articular hip pathology, such as GT [19]. Specifically, two subgroups were identified in those with GT: (1) individuals demonstrating an uncompensated Trendelenburg (contralateral pelvic drop and associated contralateral trunk lean where no compensation is made for hip abductor weakness and the position of the pelvis cannot be maintained in the frontal plane); and (2) individuals demonstrating a compensated Trendelenburg (ipsilateral trunk lean in an attempt to bring the centre of mass closer to the base of support, resulting in reduced hip abductor muscle requirements and maintenance of the position of the pelvis in the frontal plane) (**Figure 2**).

### **2.2 Non-surgical management for gluteal tendinopathy**

Evidence for the management of gluteal tendinopathy is continuing to emerge. Historically, as a result of limited understanding of the pathology and associated impairments in GT, treatment had been simplistic, targeting symptoms or the presumed pathological involvement of the trochanteric bursae. More recently, drawing from contemporary evidence in other tendinopathies and an understanding of tendon structure and function, exercise interventions for GT have been refined and are beginning to be tested in randomised controlled trials with promising results. The most recent systematic review at the time of print concluded that poor quality and insufficient data prevented any conclusions to be drawn regarding optimal treatment for greater trochanteric pain syndrome including GT [23]. Studies in this review and others describe interventions of surgical tendon repair, ITB release and bursectomy, corticosteroid injection, home exercise, shock wave therapy and dry needling [23]. Issues arise when interpreting the collective results of these studies with respect to GT, as the samples are diverse with respect to co-morbidities (e.g. hip OA, lumbar pathology), symptom duration, and most importantly, clinical and

#### **Figure 2.**

*Subgroups have been identified in individuals with gluteal tendinopathy during walking [19]. Some individuals walk with an uncompensated Trendelenburg (contralateral pelvic drop and trunk lean, increasing the centre of mass from the hip joint centre and subsequently influencing the magnitude of the external adduction moment), while some adopt a compensated Trendelenburg (ipsilateral trunk lean, bringing the centre of mass closer to the hip joint centre, a strategy to reduce the magnitude of the external hip adduction moment and requirement for the hip abductor muscles, maintaining alignment of the pelvis in the frontal plane).*

**35**

address this goal [14].

*Contemporary Non-Surgical Considerations in the Management of People…*

imaging diagnosis specific to GT. Further, very few interventions have been evalu-

The strong focus on corticosteroid injection in GT arises from the original theory that trochanteric pain was due to an inflammatory process within the trochanteric bursae. However, the effectiveness and safety of the use of corticosteroid injection in tendinopathy is debatable. Evidence from a high quality systematic review pooling 41 studies evaluating the effect of corticosteroid injection on upper limb, patella and Achilles tendinopathies suggests that while cortisone improves symptoms in the short term, there are no long term effects at 13–26 weeks or ≥ 52 weeks [24]. While these findings cannot be directly inferred to GT, a similar attenuation effect of symptom relief in response to corticosteroid injection has been demonstrated in three clinical trials in greater trochanteric pain syndrome [25–27],

Given that tendon is a metabolically active tissue that maintains its integrity in response to tensile loading, exercise and load modification appear to be important aspects of effective treatment in management of tendinopathy [28]. In order to modify tendon load in the lower limb, addressing lower limb biomechanics and neuromuscular control is considered an effective clinical strategy [14]. Specific to GT, modifying compressive load at the greater trochanter is thought to be particularly relevant [5, 27]. *Load modification* can be achieved my reducing time spent in sustained positions of hip adduction where the gluteal tendons are vulnerable to compressive loading against the greater trochanter below and iliotibial band above (e.g. sitting cross legged, standing 'hanging on one hip', sleeping on the affected side or the unaffected side with the affected limb crossing into hip adduction) or dynamic adduction during gait [14]. The latter is thought to be best achieved by including (1) *functional weight bearing hip abductor muscle exercises* (e.g. bridging, squat, side-stepping) *focusing on pelvic alignment control* in the frontal and transverse planes double to single leg loading and by focusing on (2) *hip abductor strengthening exercises* to address muscle weakness and increase loading capacity of the gluteal tendons [15] (e.g. side-stepping with band, reformer based sliders). A fundamental principle in tendinopathy management which must be applied in this exercise prescription context is that of *progressive graduated overload* to enable tendon remodelling and adaptation [14]. It is essential that exercise difficulty is gradually increased as tolerated to ensure optimal muscle activation to enable gains in muscle strength and function without significant aggravation of pain. Finally specific to the context of GT, (3) *motor control of the entire hip abductor muscle mechanism* thought to be important to reduce overactivity of tensor fascia lata (and subsequent ITB tension) relative to the deeper segments of the gluteus minimus and medius muscles [29] to facilitate gluteal tendon tensile loading and avoid compressive loads, known to be detrimental to tendon health. Patient tactile feedback over the tensor fascia lata and gluteal muscles is thought to be a useful clinical strategy to

A recent clinical trial demonstrated that a progressive exercise program incorporating functional training, targeted strengthening and dynamic motor control of the pelvis, delivered with patient education over 8-weeks under supervision of a physiotherapist, was superior to a wait-and-see approach or corticosteroid injection [27]. These results are promising and contribute to the body of evidence for treatment of GT. Importantly, they also add to the contemporary conversation that emphasises the need for patient education in management. As outlined, it is evident that hip abductor muscle strength, biomechanical and neuromuscular patterns be considered in the assessment and management of GT. However, data from individuals with GT highlights that the kinematic presentation of GT is heterogeneous [19, 20]. Thus a 'one size fits all' approach to assessment and management

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

questioning the efficacy of corticosteroid use in GT.

ated in randomised controlled trials.

#### *Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

*Hip Surgeries*

plane) (**Figure 2**).

with extra-articular hip pathology, such as GT [19]. Specifically, two subgroups were identified in those with GT: (1) individuals demonstrating an uncompensated Trendelenburg (contralateral pelvic drop and associated contralateral trunk lean where no compensation is made for hip abductor weakness and the position of the pelvis cannot be maintained in the frontal plane); and (2) individuals demonstrating a compensated Trendelenburg (ipsilateral trunk lean in an attempt to bring the centre of mass closer to the base of support, resulting in reduced hip abductor muscle requirements and maintenance of the position of the pelvis in the frontal

Evidence for the management of gluteal tendinopathy is continuing to emerge. Historically, as a result of limited understanding of the pathology and associated impairments in GT, treatment had been simplistic, targeting symptoms or the presumed pathological involvement of the trochanteric bursae. More recently, drawing from contemporary evidence in other tendinopathies and an understanding of tendon structure and function, exercise interventions for GT have been refined and are beginning to be tested in randomised controlled trials with promising results. The most recent systematic review at the time of print concluded that poor quality and insufficient data prevented any conclusions to be drawn regarding optimal treatment for greater trochanteric pain syndrome including GT [23]. Studies in this review and others describe interventions of surgical tendon repair, ITB release and bursectomy, corticosteroid injection, home exercise, shock wave therapy and dry needling [23]. Issues arise when interpreting the collective results of these studies with respect to GT, as the samples are diverse with respect to co-morbidities (e.g. hip OA, lumbar pathology), symptom duration, and most importantly, clinical and

*Subgroups have been identified in individuals with gluteal tendinopathy during walking [19]. Some individuals walk with an uncompensated Trendelenburg (contralateral pelvic drop and trunk lean, increasing the centre of mass from the hip joint centre and subsequently influencing the magnitude of the external adduction moment), while some adopt a compensated Trendelenburg (ipsilateral trunk lean, bringing the centre of mass closer to the hip joint centre, a strategy to reduce the magnitude of the external hip adduction moment and requirement for* 

*the hip abductor muscles, maintaining alignment of the pelvis in the frontal plane).*

**2.2 Non-surgical management for gluteal tendinopathy**

**34**

**Figure 2.**

imaging diagnosis specific to GT. Further, very few interventions have been evaluated in randomised controlled trials.

The strong focus on corticosteroid injection in GT arises from the original theory that trochanteric pain was due to an inflammatory process within the trochanteric bursae. However, the effectiveness and safety of the use of corticosteroid injection in tendinopathy is debatable. Evidence from a high quality systematic review pooling 41 studies evaluating the effect of corticosteroid injection on upper limb, patella and Achilles tendinopathies suggests that while cortisone improves symptoms in the short term, there are no long term effects at 13–26 weeks or ≥ 52 weeks [24]. While these findings cannot be directly inferred to GT, a similar attenuation effect of symptom relief in response to corticosteroid injection has been demonstrated in three clinical trials in greater trochanteric pain syndrome [25–27], questioning the efficacy of corticosteroid use in GT.

Given that tendon is a metabolically active tissue that maintains its integrity in response to tensile loading, exercise and load modification appear to be important aspects of effective treatment in management of tendinopathy [28]. In order to modify tendon load in the lower limb, addressing lower limb biomechanics and neuromuscular control is considered an effective clinical strategy [14]. Specific to GT, modifying compressive load at the greater trochanter is thought to be particularly relevant [5, 27]. *Load modification* can be achieved my reducing time spent in sustained positions of hip adduction where the gluteal tendons are vulnerable to compressive loading against the greater trochanter below and iliotibial band above (e.g. sitting cross legged, standing 'hanging on one hip', sleeping on the affected side or the unaffected side with the affected limb crossing into hip adduction) or dynamic adduction during gait [14]. The latter is thought to be best achieved by including (1) *functional weight bearing hip abductor muscle exercises* (e.g. bridging, squat, side-stepping) *focusing on pelvic alignment control* in the frontal and transverse planes double to single leg loading and by focusing on (2) *hip abductor strengthening exercises* to address muscle weakness and increase loading capacity of the gluteal tendons [15] (e.g. side-stepping with band, reformer based sliders). A fundamental principle in tendinopathy management which must be applied in this exercise prescription context is that of *progressive graduated overload* to enable tendon remodelling and adaptation [14]. It is essential that exercise difficulty is gradually increased as tolerated to ensure optimal muscle activation to enable gains in muscle strength and function without significant aggravation of pain. Finally specific to the context of GT, (3) *motor control of the entire hip abductor muscle mechanism* thought to be important to reduce overactivity of tensor fascia lata (and subsequent ITB tension) relative to the deeper segments of the gluteus minimus and medius muscles [29] to facilitate gluteal tendon tensile loading and avoid compressive loads, known to be detrimental to tendon health. Patient tactile feedback over the tensor fascia lata and gluteal muscles is thought to be a useful clinical strategy to address this goal [14].

A recent clinical trial demonstrated that a progressive exercise program incorporating functional training, targeted strengthening and dynamic motor control of the pelvis, delivered with patient education over 8-weeks under supervision of a physiotherapist, was superior to a wait-and-see approach or corticosteroid injection [27]. These results are promising and contribute to the body of evidence for treatment of GT. Importantly, they also add to the contemporary conversation that emphasises the need for patient education in management. As outlined, it is evident that hip abductor muscle strength, biomechanical and neuromuscular patterns be considered in the assessment and management of GT. However, data from individuals with GT highlights that the kinematic presentation of GT is heterogeneous [19, 20]. Thus a 'one size fits all' approach to assessment and management

is unlikely to be effective. Clinicians should evaluate patients who present with GT with respect to specific biomechanical and neuromuscular impairments, and tailor treatment and load modification based on the principles of tendinopathy treatment.

## **3. Femoroacetabular impingement syndrome**

FAI syndrome is a motion related condition of the hip joint and is associated with hip pain and impaired function in younger active adults [30]. FAI is characterised by abnormally shaped hip bones (i.e. head of femur and/or acetabulum), which can lead to mechanical impingement during movement [30]. Repetitive mechanical impingement is thought to lead to chondral stresses that cause irreversible structural pathology [31]. FAI syndrome is considered a principal determinant of future development of hip osteoarthritis [32].

### **3.1 Biomechanical considerations in femoroacetabular impingement syndrome**

### *3.1.1 Hip joint biomechanics*

Evidence for altered hip joint biomechanics during movement in individuals with FAI syndrome is mounting [33]. Gait has been well studied in this population. Findings from systematic reviews [31, 33] and empirical studies provide moderate evidence for less sagittal plane hip range of motion (ROM) [34], primarily driven by a lower peak hip extension angle [35], during gait in individuals with FAI syndrome compared to healthy controls. Lower peak hip internal rotation angle [35, 36] and lower peak hip external rotation joint torque [35] have also be reported during stance in FAI syndrome compared to healthy controls. However, the biomechanical adaptations exhibited by individuals with FAI syndrome during gait are generally small on average, and consequently of uncertain clinical significance.

Hip joint biomechanics during squatting [37–39] in FAI syndrome also differs only subtly from individuals without pain or FAI morphology. Though some studies report that individuals with FAI syndrome are unable to squat as deep as controls [37, 39], hip flexion range is not significantly reduced during task completion [37–39]. Individuals with FAI syndrome place the hip in a more adducted position during squatting [38] and step ascent [40], which may be secondary to hip abductor muscle weakness commonly reported in FAI syndrome cohorts [41]. Biomechanical comparisons during these more demanding tasks targeting positions of impingement (i.e. squatting and step ascent) have extended knowledge regarding altered hip joint biomechanics in individuals with FAI syndrome. Nevertheless, the implications of these alterations, including any relationship with pain and/or function and/or joint structure remain unclear.

### *3.1.2 Biomechanics of adjacent segments*

Individual variation in movement strategy and interaction between adjacent body segments (i.e. pelvis, trunk) may account for the small between-group differences observed in hip joint biomechanics when comparing individuals with FAI syndrome to healthy controls. Failure to consider such factors may explain the modest effects of conservative treatment [42] and the unrestored hip function observed post-operatively [36]. Reduced sagittal plane pelvis range of motion has been identified during squatting in FAI syndrome compared to healthy controls

**37**

*Contemporary Non-Surgical Considerations in the Management of People…*

[39], and has been proposed as a risk factor for symptom presentation [43]. Greater anterior pelvic tilt has also been reported in FAI syndrome during squatting [37] and step descent [44] compared to healthy controls. This biomechanical alteration may be counterproductive for pathology since an increase in anterior pelvic position

Few studies have considered pelvic and trunk control in the frontal plane despite the implications for hip joint loading [45]. Control of frontal plane pelvic alignment during single leg support is necessary to prevent movement into impingement. Pain and/or hip abductor muscle weakness, both features of FAI syndrome, could hinder control of the pelvis in the frontal plane. On the other hand, altered frontal plane control of the trunk may moderate provocative hip joint contact forces (i.e. reduced demand on hip abductor muscles), and has been observed in cohorts with hip osteoarthritis [22, 46]. Recent findings from a step ascent task corroborate that control of adjacent segments may play an important role in symptom management in FAI syndrome [40]. When individuals with FAI syndrome were sub-grouped based on trunk and pelvis dominant strategies, those who exhibited lateral trunk lean and maintained neutral pelvis alignment reported no pain and prevented the hip from moving towards an impinging position. It is reasonable to suggest that this strategy may alleviate load on the abnormal hip joint structures. In direct contrast to this, 86% of participants who exhibited poor pelvis control, inherently moving the hip into an impinging position, reported moderate levels of pain [40]. Control of—and interaction between—adjacent body segments may play an important role in symptomatic and structural preservation or deterioration in FAI syndrome. Further, altered hip joint function remains unresolved post-operatively [36], suggesting that a hip-only treatment focus may be misguided. Functional biomechanics is modifiable, and could be changed by conservative interventions and

FAI syndrome is a complex condition [48] with no common pathological pathway [30]. Patient presentation is heterogeneous, which may explain the modest treatment effects [42]. Different biomechanical strategies are used by separate subgroups of participants to perform a task [38, 49], albeit some more advantageous than others for symptoms and function. As with established hip OA [50], no conservative treatment is likely to be effective for all individuals with FAI syndrome. Maximum efficacy will only be attained with interventions catered to the individual. More research must be done to improve understanding of the patientspecific biomechanical alterations associated with FAI syndrome in order to better

Biomechanical alterations in individuals with FAI syndrome are subtle but may relate to enhanced protection for the hip, albeit with possible long-term consequences. It comes as no surprise that individuals with FAI syndrome exhibit less prominent biomechanical alterations than individuals with structural damage and hip OA [51]. Individuals with FAI syndrome have less severe morphological deformities and accordingly, exhibit more subtle biomechanical modifications. The absence of longitudinal studies means that it is not known whether these small biomechanical alterations are precursors to the larger deviations observed in those

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

rehabilitation programs [47].

manage the disease and its consequences.

*3.1.4 Implications for joint structure*

with established hip OA.

*3.1.3 Patient subgrouping*

will promote hip flexion and thus impingement.

*Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

[39], and has been proposed as a risk factor for symptom presentation [43]. Greater anterior pelvic tilt has also been reported in FAI syndrome during squatting [37] and step descent [44] compared to healthy controls. This biomechanical alteration may be counterproductive for pathology since an increase in anterior pelvic position will promote hip flexion and thus impingement.

Few studies have considered pelvic and trunk control in the frontal plane despite the implications for hip joint loading [45]. Control of frontal plane pelvic alignment during single leg support is necessary to prevent movement into impingement. Pain and/or hip abductor muscle weakness, both features of FAI syndrome, could hinder control of the pelvis in the frontal plane. On the other hand, altered frontal plane control of the trunk may moderate provocative hip joint contact forces (i.e. reduced demand on hip abductor muscles), and has been observed in cohorts with hip osteoarthritis [22, 46]. Recent findings from a step ascent task corroborate that control of adjacent segments may play an important role in symptom management in FAI syndrome [40]. When individuals with FAI syndrome were sub-grouped based on trunk and pelvis dominant strategies, those who exhibited lateral trunk lean and maintained neutral pelvis alignment reported no pain and prevented the hip from moving towards an impinging position. It is reasonable to suggest that this strategy may alleviate load on the abnormal hip joint structures. In direct contrast to this, 86% of participants who exhibited poor pelvis control, inherently moving the hip into an impinging position, reported moderate levels of pain [40]. Control of—and interaction between—adjacent body segments may play an important role in symptomatic and structural preservation or deterioration in FAI syndrome. Further, altered hip joint function remains unresolved post-operatively [36], suggesting that a hip-only treatment focus may be misguided. Functional biomechanics is modifiable, and could be changed by conservative interventions and rehabilitation programs [47].

#### *3.1.3 Patient subgrouping*

*Hip Surgeries*

treatment.

is unlikely to be effective. Clinicians should evaluate patients who present with GT with respect to specific biomechanical and neuromuscular impairments, and tailor treatment and load modification based on the principles of tendinopathy

FAI syndrome is a motion related condition of the hip joint and is associated with hip pain and impaired function in younger active adults [30]. FAI is characterised by abnormally shaped hip bones (i.e. head of femur and/or acetabulum), which can lead to mechanical impingement during movement [30]. Repetitive mechanical impingement is thought to lead to chondral stresses that cause irreversible structural pathology [31]. FAI syndrome is considered a principal determinant of future

**3.1 Biomechanical considerations in femoroacetabular impingement syndrome**

Evidence for altered hip joint biomechanics during movement in individuals with FAI syndrome is mounting [33]. Gait has been well studied in this population. Findings from systematic reviews [31, 33] and empirical studies provide moderate evidence for less sagittal plane hip range of motion (ROM) [34], primarily driven by a lower peak hip extension angle [35], during gait in individuals with FAI syndrome compared to healthy controls. Lower peak hip internal rotation angle [35, 36] and lower peak hip external rotation joint torque [35] have also be reported during stance in FAI syndrome compared to healthy controls. However, the biomechanical adaptations exhibited by individuals with FAI syndrome during gait are generally

Hip joint biomechanics during squatting [37–39] in FAI syndrome also differs only subtly from individuals without pain or FAI morphology. Though some studies report that individuals with FAI syndrome are unable to squat as deep as controls [37, 39], hip flexion range is not significantly reduced during task completion [37–39]. Individuals with FAI syndrome place the hip in a more adducted position during squatting [38] and step ascent [40], which may be secondary to hip abductor muscle weakness commonly reported in FAI syndrome cohorts [41]. Biomechanical comparisons during these more demanding tasks targeting positions of impingement (i.e. squatting and step ascent) have extended knowledge regarding altered hip joint biomechanics in individuals with FAI syndrome. Nevertheless, the implications of these alterations, including any relationship with pain and/or function

Individual variation in movement strategy and interaction between adjacent body segments (i.e. pelvis, trunk) may account for the small between-group differences observed in hip joint biomechanics when comparing individuals with FAI syndrome to healthy controls. Failure to consider such factors may explain the modest effects of conservative treatment [42] and the unrestored hip function observed post-operatively [36]. Reduced sagittal plane pelvis range of motion has been identified during squatting in FAI syndrome compared to healthy controls

small on average, and consequently of uncertain clinical significance.

**3. Femoroacetabular impingement syndrome**

development of hip osteoarthritis [32].

and/or joint structure remain unclear.

*3.1.2 Biomechanics of adjacent segments*

*3.1.1 Hip joint biomechanics*

**36**

FAI syndrome is a complex condition [48] with no common pathological pathway [30]. Patient presentation is heterogeneous, which may explain the modest treatment effects [42]. Different biomechanical strategies are used by separate subgroups of participants to perform a task [38, 49], albeit some more advantageous than others for symptoms and function. As with established hip OA [50], no conservative treatment is likely to be effective for all individuals with FAI syndrome. Maximum efficacy will only be attained with interventions catered to the individual. More research must be done to improve understanding of the patientspecific biomechanical alterations associated with FAI syndrome in order to better manage the disease and its consequences.

#### *3.1.4 Implications for joint structure*

Biomechanical alterations in individuals with FAI syndrome are subtle but may relate to enhanced protection for the hip, albeit with possible long-term consequences. It comes as no surprise that individuals with FAI syndrome exhibit less prominent biomechanical alterations than individuals with structural damage and hip OA [51]. Individuals with FAI syndrome have less severe morphological deformities and accordingly, exhibit more subtle biomechanical modifications. The absence of longitudinal studies means that it is not known whether these small biomechanical alterations are precursors to the larger deviations observed in those with established hip OA.

#### **3.2 Non-surgical management for femoroacetabular impingement syndrome**

Arthroscopic hip surgery is the most common treatment for FAI syndrome [52]. Despite a dramatic upsurge in the number of surgeries performed over the past decade [52], surgical intervention for FAI syndrome does not completely restore hip joint function to that of healthy controls [36] or uniformly improve pain [53], despite correction of the hip's bony abnormalities. This may be because surgery corrects the local mechanical issue (i.e. correction of the bony abnormalities until impingement free motion is obtained), but without resolution of the altered movement strategies adopted pre-operatively.

Findings from the only large randomised controlled trial comparing hip arthroscopy and best conservative care for the treatment of FAI syndrome support the short-term efficacy of arthroscopic hip surgery [54]. However, patients in both groups reported significant improvements in hip-related quality of life at 12-months, and the costs associated with surgery were higher than with conservative care [54]. Non-surgical treatments for FAI syndrome, such as exercise, activity adaptation and education, are globally recommended [48], and attractive given the relatively low harmful risks and associated costs. Identification of non-surgical interventions to reduce the burden of hip OA in its early stages, including FAI syndrome, is an important public health priority [55]. At present, conservative treatment effects for FAI syndrome are also modest [42, 56], likely due, in part, to a lack of understanding regarding the underlying mechanisms associated with clinical and structural decline.

#### *3.2.1 Conservative care*

Theoretically, an adequately designed, evidence-based, appropriately administered conservative management program may have the potential to alleviate symptoms, and in turn prevent disease progression, thus postponing or negating the need for surgery [56]. Current clinical practice entails combinations of physiotherapist-led rehabilitation, education, and activity modification for the management of FAI syndrome [48, 56]. There is little evidence from randomised control trials to guide conservative care for FAI syndrome, which means that conservative treatments are largely based on clinical theory and/or extrapolation of evidence from other clinical conditions.

Potential targets for conservative treatment include the abnormal movement patterns and hip muscle weakness seen in patients with FAI syndrome [31]. Gait assessment alone is unlikely to provide clear information to guide treatment of FAI syndrome. However, the biomechanical alterations at the hip joint and adjacent segments apparent during more demanding tasks (e.g. squatting, step ascent and descent) may be relevant in the clinical management of this patient population. Altered movement patterns in the form of altered hip joint biomechanics have been identified during tasks with similar demands in these patients post-operatively [36]. Pre-operative treatments addressing these biomechanical abnormalities may also have scope to improve surgical outcomes.

Retraining of deep hip muscle function (e.g. quadratus femoris, obturator internus) is a common objective of non-operative management [57] and post-operative rehabilitation [58] for FAI syndrome. Conservative care commonly targets deep hip external rotator muscle strengthening and neuromuscular retraining with the aim of improving dynamic hip joint stability [57]. Although experimental evidence suggests that activation of these deep muscles may contribute to dynamic stability in a healthy hip [59], it is less clear if adaptations in neuromuscular control are associated with FAI syndrome. Cross-sectional data acquired during gait provide

**39**

*Contemporary Non-Surgical Considerations in the Management of People…*

preliminary evidence of the extent and nature of FAI-related changes to deep hip muscle activation [49]. However, an improved understanding of deep hip muscle function during more demanding, provocative tasks is needed to provide a compre-

Hip strength assessment may be important in the clinical management of FAI syndrome. Evaluation of agonist/antagonist and/or between-limb strength ratios could be particularly beneficial clinically, as body size normalisation and control normative data for individual movement directions are not required. Reduced abduction strength in FAI patients [41] may have important implications as the abductor muscles control the position of the pelvis relative to the femur [60]. This is critical to prevent movement (i.e. contralateral pelvic drop) into a position that impinges the hip joint during single leg weight bearing tasks, such as those commonly required in sport where FAI syndrome has been identified (e.g. soccer, dancing, football) [61]. Treatment programs targeting the primary abductor muscles may improve pelvic-femoral stability during single leg task performance in individuals with FAI syndrome, though any implications of such treatments for

Clinical interventions to restore normal musculoskeletal function around the hip joint may be beneficial, but future research is needed to determine whether these features can and should be changed, and whether this improves outcomes. Cam impingement has been proposed as a modifiable risk factor for hip OA [32]. Optimising treatments relies on the identification of novel treatment targets to slow femoral lesion progression and prolong the development of structural damage and

A critical step in the clinical management of individuals with FAI syndrome is to identify which biomechanical and neuromuscular features are: (i) positive and should be encouraged; (ii) negative and should be discouraged; and (iii) potentially positive prior to surgery to compensate for the abnormal morphology but should be a target for treatment following surgery to prevent further impairments. It would be precipitous to categorise these features without the support of longitudinal data. Nevertheless, it is abundantly clear that the widespread implications for FAI-related clinical practice depend on the appropriate classification of any modifiable targets

The evaluation of conservative management programs, that include a range of techniques to modify joint motion/loading/function such as joint mobilisation techniques, hip bracing, and targeted exercise programs (including range of motion, strengthening, and/or neuromuscular retraining) are required on a range of outcomes in FAI syndrome (including any modifiable risk factors). Though the evidence underpinning these treatments is still in its infancy, the development of conservative treatments, including post-operative rehabilitation strategies and pre-operative training programs that aim to improve surgical outcomes, is a critical

Hip OA is a major public health problem and affects one in four adults over their lifetime [62]. The condition substantially impairs quality of life and causes pain and physical dysfunction. Around the world, hip replacement surgery for hip OA is on the rise, and the burden of OA on society and health care cost will continue to rise

component as we move towards improving treatment outcomes.

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

hensive recommendation for retraining.

symptoms and joint structure are not yet clear.

*3.2.2 Optimising treatment*

early hip OA.

for treatment.

**4. Hip osteoarthritis**

*Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

preliminary evidence of the extent and nature of FAI-related changes to deep hip muscle activation [49]. However, an improved understanding of deep hip muscle function during more demanding, provocative tasks is needed to provide a comprehensive recommendation for retraining.

Hip strength assessment may be important in the clinical management of FAI syndrome. Evaluation of agonist/antagonist and/or between-limb strength ratios could be particularly beneficial clinically, as body size normalisation and control normative data for individual movement directions are not required. Reduced abduction strength in FAI patients [41] may have important implications as the abductor muscles control the position of the pelvis relative to the femur [60]. This is critical to prevent movement (i.e. contralateral pelvic drop) into a position that impinges the hip joint during single leg weight bearing tasks, such as those commonly required in sport where FAI syndrome has been identified (e.g. soccer, dancing, football) [61]. Treatment programs targeting the primary abductor muscles may improve pelvic-femoral stability during single leg task performance in individuals with FAI syndrome, though any implications of such treatments for symptoms and joint structure are not yet clear.

#### *3.2.2 Optimising treatment*

*Hip Surgeries*

ment strategies adopted pre-operatively.

clinical and structural decline.

from other clinical conditions.

have scope to improve surgical outcomes.

*3.2.1 Conservative care*

**3.2 Non-surgical management for femoroacetabular impingement syndrome**

Despite a dramatic upsurge in the number of surgeries performed over the past decade [52], surgical intervention for FAI syndrome does not completely restore hip joint function to that of healthy controls [36] or uniformly improve pain [53], despite correction of the hip's bony abnormalities. This may be because surgery corrects the local mechanical issue (i.e. correction of the bony abnormalities until impingement free motion is obtained), but without resolution of the altered move-

Findings from the only large randomised controlled trial comparing hip arthroscopy and best conservative care for the treatment of FAI syndrome support the short-term efficacy of arthroscopic hip surgery [54]. However, patients in both groups reported significant improvements in hip-related quality of life at 12-months, and the costs associated with surgery were higher than with conservative care [54]. Non-surgical treatments for FAI syndrome, such as exercise, activity adaptation and education, are globally recommended [48], and attractive given the relatively low harmful risks and associated costs. Identification of non-surgical interventions to reduce the burden of hip OA in its early stages, including FAI syndrome, is an important public health priority [55]. At present, conservative treatment effects for FAI syndrome are also modest [42, 56], likely due, in part, to a lack of understanding regarding the underlying mechanisms associated with

Theoretically, an adequately designed, evidence-based, appropriately administered conservative management program may have the potential to alleviate symptoms, and in turn prevent disease progression, thus postponing or negating the need for surgery [56]. Current clinical practice entails combinations of physiotherapist-led rehabilitation, education, and activity modification for the management of FAI syndrome [48, 56]. There is little evidence from randomised control trials to guide conservative care for FAI syndrome, which means that conservative treatments are largely based on clinical theory and/or extrapolation of evidence

Potential targets for conservative treatment include the abnormal movement patterns and hip muscle weakness seen in patients with FAI syndrome [31]. Gait assessment alone is unlikely to provide clear information to guide treatment of FAI syndrome. However, the biomechanical alterations at the hip joint and adjacent segments apparent during more demanding tasks (e.g. squatting, step ascent and descent) may be relevant in the clinical management of this patient population. Altered movement patterns in the form of altered hip joint biomechanics have been identified during tasks with similar demands in these patients post-operatively [36]. Pre-operative treatments addressing these biomechanical abnormalities may also

Retraining of deep hip muscle function (e.g. quadratus femoris, obturator internus) is a common objective of non-operative management [57] and post-operative rehabilitation [58] for FAI syndrome. Conservative care commonly targets deep hip external rotator muscle strengthening and neuromuscular retraining with the aim of improving dynamic hip joint stability [57]. Although experimental evidence suggests that activation of these deep muscles may contribute to dynamic stability in a healthy hip [59], it is less clear if adaptations in neuromuscular control are associated with FAI syndrome. Cross-sectional data acquired during gait provide

Arthroscopic hip surgery is the most common treatment for FAI syndrome [52].

**38**

Clinical interventions to restore normal musculoskeletal function around the hip joint may be beneficial, but future research is needed to determine whether these features can and should be changed, and whether this improves outcomes. Cam impingement has been proposed as a modifiable risk factor for hip OA [32]. Optimising treatments relies on the identification of novel treatment targets to slow femoral lesion progression and prolong the development of structural damage and early hip OA.

A critical step in the clinical management of individuals with FAI syndrome is to identify which biomechanical and neuromuscular features are: (i) positive and should be encouraged; (ii) negative and should be discouraged; and (iii) potentially positive prior to surgery to compensate for the abnormal morphology but should be a target for treatment following surgery to prevent further impairments. It would be precipitous to categorise these features without the support of longitudinal data. Nevertheless, it is abundantly clear that the widespread implications for FAI-related clinical practice depend on the appropriate classification of any modifiable targets for treatment.

The evaluation of conservative management programs, that include a range of techniques to modify joint motion/loading/function such as joint mobilisation techniques, hip bracing, and targeted exercise programs (including range of motion, strengthening, and/or neuromuscular retraining) are required on a range of outcomes in FAI syndrome (including any modifiable risk factors). Though the evidence underpinning these treatments is still in its infancy, the development of conservative treatments, including post-operative rehabilitation strategies and pre-operative training programs that aim to improve surgical outcomes, is a critical component as we move towards improving treatment outcomes.

#### **4. Hip osteoarthritis**

Hip OA is a major public health problem and affects one in four adults over their lifetime [62]. The condition substantially impairs quality of life and causes pain and physical dysfunction. Around the world, hip replacement surgery for hip OA is on the rise, and the burden of OA on society and health care cost will continue to rise

due to the ageing population and escalation in obesity rates [63]. Therefore, treatments that reduce symptoms and delay the need for joint replacement are critical.

#### **4.1 Biomechanical considerations in hip osteoarthritis**

Kinematic and kinetic alterations are reported in people with hip OA compared to healthy controls. There is marked interest in hip joint loading as a culprit for disease progression, arguably due to the evidence in knee OA. Higher knee joint loading has been implicated in structural joint degeneration in middle-aged people at risk of early knee OA [64] and in individuals with established with knee OA [65]. However, few longitudinal studies have evaluated the association between hip joint biomechanics during gait and alterations in hip joint structure [66, 67]. A 12-month longitudinal study of women concluded that higher cumulative hip joint loading assessed as the number of steps per day, in the frontal plane, was associated with joint space narrowing at the hip joint [67]. However, there is insufficient evidence regarding which direction of loading magnitude change is detrimental for joint health (i.e. under- or over-loading). Recent investigations have highlighted the effect of sex, stage of disease and symptom severity on measures of joint loading, as well as the intricate relationships between these measures and hip joint load. Similar to other hip pathologies, hip OA is a heterogeneous disease, and exploration of patient and disease characteristics are needed to better understand moderators of *hip joint load*, a potential disease modifier. For the clinician, 'joint loading' is not examinable or visible in the clinical setting. However, the trunk and pelvis, together are major contributors to the centre of mass, the position of which (relative to the hip joint centre) influences hip joint loading. Thus, visual examination of trunk and pelvic kinematics during functional tasks is an important part of assessment.

#### *4.1.1 Sex and joint loading*

Measures of frontal plane loading appear to be dependent on sex. For example, in disease-free individuals the external hip adduction moment is typically greater in females as compared to males [68]. Between-sex differences in anatomy may explain these differences, at least in part. Females typically have a wider pelvis than males [69], which inherently increases the lateral distance of the centre of mass from the hip joint centre, and thus increases the hip adduction moment. However, any underlying anatomical differences appear secondary to disease stage when explaining difference in frontal plane moments. A series of cross-sectional studies indicate that between-sex differences in frontal plane loading are apparent in those with unilateral mild-to-moderate hip OA [70], while measures of hip joint loading are not different between men and women with end-stage hip OA [68]. The indirect effect of sex on hip joint loading earlier in the disease process was also detected in meta-regression analysis of a systematic review. Studies with a greater proportion of men demonstrated a greater average standardised mean difference for reduced frontal plane loading between people with hip OA compared to controls [71]. Given that loading may be relevant for disease progression, it may be clinically pertinent to consider sex-specific interventions for hip OA.

#### *4.1.2 Stage of disease and joint loading*

Measures of hip joint loading are also dependent on disease severity. A recent systematic review and meta-analysis of 13 studies suggests that people with hip OA appear to underload compared to controls [72]. Moreover, the sub-group analysis indicates that people awaiting total hip replacement (i.e. greater disease

**41**

*Contemporary Non-Surgical Considerations in the Management of People…*

imperative to guide conservative hip OA management.

between symptoms and joint loading is intricate.

for exercise in these individuals.

**4.2 Conservative management for hip osteoarthritis**

"*What can I do myself to decrease OA symptoms and prevent the OA from getting worse?"* These were prioritised as the most important questions by patients and health professionals in relation to hip and knee OA [80]. Treatments to reduce hip OA symptoms and delay the need for joint replacement are critical. Joint replacement is costly and is only reserved for end-stage disease when nonsurgical treatments are no longer effective. Current clinical guidelines [55, 81, 82], including the recent update by the Royal Australian College of General Practitioners [83], emphasise that a healthy lifestyle consisting of regular exercise and weight management are the core management strategies for hip OA. Interestingly, there are no clinical trials for weight management in people with hip OA [83], and consequently the subsequent overview explores evidence

severity) underload the hip joint compared to controls; whereas people with less severe disease have comparable measures of joint loading in the sagittal and frontal plane [73]. These observations are consistent with empirical investigations determining the influence of disease severity on measures of hip joint loading [71]. Understanding the effect of joint loading on joint structure and symptoms is

Slow walking speed is a risk factor for mortality [74] and chronic functional limitation in older adults [75]. A systematic review of 17 studies estimated that people with hip OA have a self-selected walking speed of 0.95 m/s, a markedly 26% slower than controls [76]. In light of critical walking speed estimates of 1.0 m/s [72], the observation that people with hip OA walk slower than critical walking speed estimates is alarming. Slower walking speed can be attributable to symptoms and a reduction in stride length in people with hip OA [76]. However, a recent cross-sectional study [73] investigating people with moderate radiographic hip OA with and without symptoms found that irrespective of symptoms, people with radiographic hip OA walk slower than disease-free individuals. These data question symptoms as a cause for reduced walking speed and instead, appear to reflect a longer-term adaptation hip joint degeneration. In addition to being an important marker of function [74, 75], walking speed also influences measures of hip joint loading. Investigators grapple with understanding whether alteration in measures of joint loading are predominately reflections of alterations in walking speed [77]. It appears that in addition to slower walking speed, neuromuscular adaptations are likely to underpin the reduction in hip joint loading in individuals with hip OA. Evidence regarding pain during walking and how it influences movement strategies is emerging in OA literature [78]. In hip OA, the overall evidence supports the contention that people with hip OA, particularly at end-stage of the disease, underload during walking compared to controls [79]. The premise being that symptoms potentially cause people to walk slower. However, recent cross-sectional findings refute this logic [72], highlighting the complexities between symptoms and joint loading. In a study of people with unilateral mild-to-moderate radiographic hip OA, those who reported moderate pain during walking had higher frontal plane joint loading compared to people who reported less pain during walking [72]. These data suggest that people with mild or no pain during walking modified their gait biomechanics to exert lower frontal hip joint loading. Evidently, the relationship

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

*4.1.3 Relevance of pain and symptoms*

#### *Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

severity) underload the hip joint compared to controls; whereas people with less severe disease have comparable measures of joint loading in the sagittal and frontal plane [73]. These observations are consistent with empirical investigations determining the influence of disease severity on measures of hip joint loading [71]. Understanding the effect of joint loading on joint structure and symptoms is imperative to guide conservative hip OA management.

### *4.1.3 Relevance of pain and symptoms*

*Hip Surgeries*

due to the ageing population and escalation in obesity rates [63]. Therefore, treatments that reduce symptoms and delay the need for joint replacement are critical.

Kinematic and kinetic alterations are reported in people with hip OA compared to healthy controls. There is marked interest in hip joint loading as a culprit for disease progression, arguably due to the evidence in knee OA. Higher knee joint loading has been implicated in structural joint degeneration in middle-aged people at risk of early knee OA [64] and in individuals with established with knee OA [65]. However, few longitudinal studies have evaluated the association between hip joint biomechanics during gait and alterations in hip joint structure [66, 67]. A 12-month longitudinal study of women concluded that higher cumulative hip joint loading assessed as the number of steps per day, in the frontal plane, was associated with joint space narrowing at the hip joint [67]. However, there is insufficient evidence regarding which direction of loading magnitude change is detrimental for joint health (i.e. under- or over-loading). Recent investigations have highlighted the effect of sex, stage of disease and symptom severity on measures of joint loading, as well as the intricate relationships between these measures and hip joint load. Similar to other hip pathologies, hip OA is a heterogeneous disease, and exploration of patient and disease characteristics are needed to better understand moderators of *hip joint load*, a potential disease modifier. For the clinician, 'joint loading' is not examinable or visible in the clinical setting. However, the trunk and pelvis, together are major contributors to the centre of mass, the position of which (relative to the hip joint centre) influences hip joint loading. Thus, visual examination of trunk and pelvic

**4.1 Biomechanical considerations in hip osteoarthritis**

kinematics during functional tasks is an important part of assessment.

to consider sex-specific interventions for hip OA.

*4.1.2 Stage of disease and joint loading*

Measures of frontal plane loading appear to be dependent on sex. For example, in disease-free individuals the external hip adduction moment is typically greater in females as compared to males [68]. Between-sex differences in anatomy may explain these differences, at least in part. Females typically have a wider pelvis than males [69], which inherently increases the lateral distance of the centre of mass from the hip joint centre, and thus increases the hip adduction moment. However, any underlying anatomical differences appear secondary to disease stage when explaining difference in frontal plane moments. A series of cross-sectional studies indicate that between-sex differences in frontal plane loading are apparent in those with unilateral mild-to-moderate hip OA [70], while measures of hip joint loading are not different between men and women with end-stage hip OA [68]. The indirect effect of sex on hip joint loading earlier in the disease process was also detected in meta-regression analysis of a systematic review. Studies with a greater proportion of men demonstrated a greater average standardised mean difference for reduced frontal plane loading between people with hip OA compared to controls [71]. Given that loading may be relevant for disease progression, it may be clinically pertinent

Measures of hip joint loading are also dependent on disease severity. A recent systematic review and meta-analysis of 13 studies suggests that people with hip OA appear to underload compared to controls [72]. Moreover, the sub-group analysis indicates that people awaiting total hip replacement (i.e. greater disease

*4.1.1 Sex and joint loading*

**40**

Slow walking speed is a risk factor for mortality [74] and chronic functional limitation in older adults [75]. A systematic review of 17 studies estimated that people with hip OA have a self-selected walking speed of 0.95 m/s, a markedly 26% slower than controls [76]. In light of critical walking speed estimates of 1.0 m/s [72], the observation that people with hip OA walk slower than critical walking speed estimates is alarming. Slower walking speed can be attributable to symptoms and a reduction in stride length in people with hip OA [76]. However, a recent cross-sectional study [73] investigating people with moderate radiographic hip OA with and without symptoms found that irrespective of symptoms, people with radiographic hip OA walk slower than disease-free individuals. These data question symptoms as a cause for reduced walking speed and instead, appear to reflect a longer-term adaptation hip joint degeneration. In addition to being an important marker of function [74, 75], walking speed also influences measures of hip joint loading. Investigators grapple with understanding whether alteration in measures of joint loading are predominately reflections of alterations in walking speed [77]. It appears that in addition to slower walking speed, neuromuscular adaptations are likely to underpin the reduction in hip joint loading in individuals with hip OA.

Evidence regarding pain during walking and how it influences movement strategies is emerging in OA literature [78]. In hip OA, the overall evidence supports the contention that people with hip OA, particularly at end-stage of the disease, underload during walking compared to controls [79]. The premise being that symptoms potentially cause people to walk slower. However, recent cross-sectional findings refute this logic [72], highlighting the complexities between symptoms and joint loading. In a study of people with unilateral mild-to-moderate radiographic hip OA, those who reported moderate pain during walking had higher frontal plane joint loading compared to people who reported less pain during walking [72]. These data suggest that people with mild or no pain during walking modified their gait biomechanics to exert lower frontal hip joint loading. Evidently, the relationship between symptoms and joint loading is intricate.

#### **4.2 Conservative management for hip osteoarthritis**

"*What can I do myself to decrease OA symptoms and prevent the OA from getting worse?"* These were prioritised as the most important questions by patients and health professionals in relation to hip and knee OA [80]. Treatments to reduce hip OA symptoms and delay the need for joint replacement are critical. Joint replacement is costly and is only reserved for end-stage disease when nonsurgical treatments are no longer effective. Current clinical guidelines [55, 81, 82], including the recent update by the Royal Australian College of General Practitioners [83], emphasise that a healthy lifestyle consisting of regular exercise and weight management are the core management strategies for hip OA. Interestingly, there are no clinical trials for weight management in people with hip OA [83], and consequently the subsequent overview explores evidence for exercise in these individuals.

Exercise is advised for all people with hip OA irrespective of age, disease severity, symptoms and co-morbidities [81]. A recent meta-analyses in people with hip OA identified 12 RCTs and showed small-to-modest beneficial effects of exercise on pain (standardised mean difference [SMD] −0.28, 95% CI: −0.45 to −0.10) and physical function (−0.34 SMD, 95% CI: −0.50 to −0.18) compared to no exercise [84]. Notably, two trials including 154 people scheduled for total hip replacement [85, 86], had large improvements in pain (−0.63 SMD, 95% CI: −0.95 to −0.30) and physical function (−0.71 SMD, 95% CI: −1.04 to −0.39) following 8–10 weeks of exercise. In addition to beneficial effects on symptoms, exercise can potentially delay total hip replacement. A long-term follow-up of a clinical trial found that exercise combined with patient education can potentially reduce the need for total hip replacement by 44% in people with hip OA [87].

Evidence strongly supports the use of exercise as treatment for hip OA symptoms and can potentially prevent disease progression. In line with high quality evidence and clinical guidelines, physiotherapists in the UK [88] and Australia [89] typically recommend exercise in the management of hip OA. However, knowledge on the specifics of exercise prescription is a recognised barrier to exercise uptake [90]. Reintahl [91] eloquently likens exercise prescription to drug prescription. For example, the physician determines the type of medication, the amount or intensity, the frequency of intake and the duration of use. Exercise prescription typically follows the frequency, intensity, type, time, volume and progression (FITT-VP) principles [92], but evidence on best exercise prescription is lacking for treatment of hip OA symptoms. Below, we provide an update on the current evidence for dosage and type of exercise.

#### *4.2.1 Exercise dosage*

Meta-analyses from trials with high compliance to the American College of Sports Medicine (ACSM) exercise guidelines with respect to dosage was −0.42 SMD (95% CI: −0.58 to −0.26) for pain, and studies with uncertain compliance to ACSM dosage was −0.05 SMD (95% CI, −0.35 to −0.25) for pain. Improvement in physical function of −0.41 SMD (95% CI −0.58, −0.24) was comparable to pain in trials with high compliance to the ACSM dosage guidelines while effect from trials with uncertain compliance was −0.23 SMD (95% CI, −0.52, 0.06) [84]. These data support the prescription of exercise in accordance with ACSM guidelines, particularly in relation to pain. A Cochrane review revealed that patients with OA are confused about their cause of pain, and they do not know what they should and should not do, and as a consequence, they avoid activity for fear of causing harm [93]. Collectively, health professionals can use existing evidence to reassure patients about the value of exercise to safely manage symptoms.

#### *4.2.2 Exercise type*

All clinical trials to date include lower-limb strengthening [85, 86, 94–103], which is unsurprising given that hip and knee muscle weakness is widely established in people with hip OA [104]. However, only a few clinical trials in people with hip OA include aerobic exercise [96, 101, 103]. People with hip OA often present with co-morbidities, such as poor cardiovascular fitness and low psychological wellbeing, and these are associated with greater hip OA symptom severity [105, 106]. Aerobic exercise and muscle strengthening exercise address different impairments associated with hip OA symptoms and the adaptations people experience are distinctly different for each exercise type. Aerobic exercise may enhance the effects of strengthening exercise on hip OA symptoms by targeting

**43**

**Figure 3.**

*Contemporary Non-Surgical Considerations in the Management of People…*

cardiovascular fitness and psychological well-being [107]. In our own analysis, pain and physical function scores before and after exercise interventions in people with mild-to-moderate hip OA were sourced through publications and direct author contact. Changes in pain and physical function in studies that used a combination of aerobic and strengthening exercise are compared to those studies that used strengthening exercise only (**Figure 3**). This preliminary comparison provides support that greater effects on hip OA-related pain and physical dysfunction occur when a combination of aerobic and strengthening exercise is prescribed rather than strengthening exercise alone (**Figure 3**). Despite the clear rationale to support the premise that a combination of aerobic and muscle strengthening exercise could be more beneficial for hip OA symptoms then either exercise on its own, no clinical

*Change in pain (top plot) and physical function (bottom plot) in people with mild to moderate hip osteoarthritis after a combination of aerobic and strengthening exercise or strengthening exercise alone.*

Measuring patient-specific outcomes following an intervention or over a course of care is important for clinical research and best evidence-based practice. Outcomes that are most meaningful from the patient's perspective, such as those that measure symptoms of pain and physical function during activities of daily living, are imperative [108, 109]. Other outcomes of impairments, such as strength, flexibility, range of motion are also important for clinicians and researchers to assess and monitor, but are more often used for clinical differential diagnosis or

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

trials have directly tested this hypothesis.

**5. Outcome measures**

#### *Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

#### **Figure 3.**

*Hip Surgeries*

Exercise is advised for all people with hip OA irrespective of age, disease severity, symptoms and co-morbidities [81]. A recent meta-analyses in people with hip OA identified 12 RCTs and showed small-to-modest beneficial effects of exercise on pain (standardised mean difference [SMD] −0.28, 95% CI: −0.45 to −0.10) and physical function (−0.34 SMD, 95% CI: −0.50 to −0.18) compared to no exercise [84]. Notably, two trials including 154 people scheduled for total hip replacement [85, 86], had large improvements in pain (−0.63 SMD, 95% CI: −0.95 to −0.30) and physical function (−0.71 SMD, 95% CI: −1.04 to −0.39) following 8–10 weeks of exercise. In addition to beneficial effects on symptoms, exercise can potentially delay total hip replacement. A long-term follow-up of a clinical trial found that exercise combined with patient education can potentially reduce the need for total

Evidence strongly supports the use of exercise as treatment for hip OA symptoms and can potentially prevent disease progression. In line with high quality evidence and clinical guidelines, physiotherapists in the UK [88] and Australia [89] typically recommend exercise in the management of hip OA. However, knowledge on the specifics of exercise prescription is a recognised barrier to exercise uptake [90]. Reintahl [91] eloquently likens exercise prescription to drug prescription. For example, the physician determines the type of medication, the amount or intensity, the frequency of intake and the duration of use. Exercise prescription typically follows the frequency, intensity, type, time, volume and progression (FITT-VP) principles [92], but evidence on best exercise prescription is lacking for treatment of hip OA symptoms. Below, we provide an update on the current evidence for dos-

Meta-analyses from trials with high compliance to the American College of Sports Medicine (ACSM) exercise guidelines with respect to dosage was −0.42 SMD (95% CI: −0.58 to −0.26) for pain, and studies with uncertain compliance to ACSM dosage was −0.05 SMD (95% CI, −0.35 to −0.25) for pain. Improvement in physical function of −0.41 SMD (95% CI −0.58, −0.24) was comparable to pain in trials with high compliance to the ACSM dosage guidelines while effect from trials with uncertain compliance was −0.23 SMD (95% CI, −0.52, 0.06) [84]. These data support the prescription of exercise in accordance with ACSM guidelines, particularly in relation to pain. A Cochrane review revealed that patients with OA are confused about their cause of pain, and they do not know what they should and should not do, and as a consequence, they avoid activity for fear of causing harm [93]. Collectively, health professionals can use existing evidence to reassure patients about the value of

All clinical trials to date include lower-limb strengthening [85, 86, 94–103], which is unsurprising given that hip and knee muscle weakness is widely established in people with hip OA [104]. However, only a few clinical trials in people with hip OA include aerobic exercise [96, 101, 103]. People with hip OA often present with co-morbidities, such as poor cardiovascular fitness and low psychological well-

being, and these are associated with greater hip OA symptom severity

[105, 106]. Aerobic exercise and muscle strengthening exercise address different impairments associated with hip OA symptoms and the adaptations people experience are distinctly different for each exercise type. Aerobic exercise may enhance the effects of strengthening exercise on hip OA symptoms by targeting

hip replacement by 44% in people with hip OA [87].

age and type of exercise.

exercise to safely manage symptoms.

*4.2.1 Exercise dosage*

*4.2.2 Exercise type*

**42**

*Change in pain (top plot) and physical function (bottom plot) in people with mild to moderate hip osteoarthritis after a combination of aerobic and strengthening exercise or strengthening exercise alone.*

cardiovascular fitness and psychological well-being [107]. In our own analysis, pain and physical function scores before and after exercise interventions in people with mild-to-moderate hip OA were sourced through publications and direct author contact. Changes in pain and physical function in studies that used a combination of aerobic and strengthening exercise are compared to those studies that used strengthening exercise only (**Figure 3**). This preliminary comparison provides support that greater effects on hip OA-related pain and physical dysfunction occur when a combination of aerobic and strengthening exercise is prescribed rather than strengthening exercise alone (**Figure 3**). Despite the clear rationale to support the premise that a combination of aerobic and muscle strengthening exercise could be more beneficial for hip OA symptoms then either exercise on its own, no clinical trials have directly tested this hypothesis.

#### **5. Outcome measures**

Measuring patient-specific outcomes following an intervention or over a course of care is important for clinical research and best evidence-based practice. Outcomes that are most meaningful from the patient's perspective, such as those that measure symptoms of pain and physical function during activities of daily living, are imperative [108, 109]. Other outcomes of impairments, such as strength, flexibility, range of motion are also important for clinicians and researchers to assess and monitor, but are more often used for clinical differential diagnosis or

prognosis and are usually secondary outcome measures to pain and physical function [109–111].

Measurement of pain and physical function are complex and cover multiple dimensions. For example, pain can be measured in multiple contexts including intensity, duration, type and location. Physical functioning can not only be measured in many contexts but it also crosses multiple domains. According to the International Classification of Functioning, Disability and Health (ICF), physical function spans *body functions and structure, activity* and *participation* domains [112].

Many outcome tools for pain and physical function have been described for hip conditions and a selection of tools with the best level of measurement evidence is recommended [109]. Ideally, measure outcomes should be suitably valid, reliable and responsive to change. Known values of the minimum important difference (MID) are important for interpreting meaningful change and are useful to help set individual targets and goals with patients [113].

Patient outcomes can be measured using patient-reported outcome measures (PROMs) and performance-based tests measured by the clinician/researcher. Pain is usually measured with PROMs, such as pain scales and questionnaires, however physical functioning can be measured with both PROMs and performance-based tests. Performance-based tests reflect what patients can do rather than what they think they can do, which is usually captured with PROMs. When assessing physical function, it is recommended that both PROMs and performance-based tests are used as they can encapsulate different information as they test different constructs of function [114].

Patient outcomes can be measured using individual-specific, condition-specific and/or generic outcome tools. There are several condition-generic, individualspecific PROMs that are useful in assessing and monitoring symptoms and function in people with a variety of hip conditions.

#### **5.1 Condition-generic, individual-specific patient-reported outcome measures**

The 11-point Numerical Pain Rating Scale (NPRS) can be used to track pain symptoms and can be customised to individual dimensions of pain. For example, average, current or greatest pain in the previous 24-hours or week can be measured ranging from 0 (no pain) to 10 (worst possible pain). Similarly, pain during an activity such as walking can be measured ranging from 0 (no pain on walking) to 10 (severe pain on walking). The MID for the NPRS (scale 0–10) in musculoskeletal conditions ranges from 1.5 points (small change) to 3.5 points (large change) [115] and in hip OA is defined as a change in pain during walking of 1.8 points [116].

The Patient-reported functional scale (PRFS) [117] assesses current level of difficulty associated with 3–5 activities that the individual identifies as being important, each measured on an 11-point scale, where 0 is unable to perform the activity and 10 is able to perform the activity as normal. The MID for the PSFS ranges from 1.3 points (small change) to 2.7 points (large change [115].

Patient-perceived change following an intervention over time can be measured on a Global Rating of Change (GROC) scale, customised to the outcome to be measured, and used by the patient to rate their perceived overall change as worse, no change or better. If worse, the patient is asked to indicate how much worse, from very much worse to slightly worse. If better, then they are asked how much better, from slightly better to very much better. An example is the 11-point GROC [118] with a change scale ranging from −5 to +5. The GROC scale can be very useful to set individual levels of acceptable change over a stated time frame and to set individual treatment goals [119].

**45**

*Contemporary Non-Surgical Considerations in the Management of People…*

There are also several condition-generic PROMs useful for assessing quality of life in a variety of hip conditions. These include the Medical Outcome Study 36 questions short form (SF-36) [120], the EuroQol (EQ-5D) [121] and the Assessment of quality of life (AQOL) [122]. Patient-specific quality of life questionnaires have also been developed for hip OA such as the Osteoarthritis Knee and Hip Quality of

The following sections will outline condition-specific PROMs and performancebased tests used to measure pain and physical function in the hip conditions outlined previously in this chapter. Outcomes are selected based on available clinical practice guideline recommendations, measurement property evidence and reported use within clinical trials. A summary of the outcomes presented across the three hip conditions including the outcome domains, scoring method, and where known,

A number of valid and reliable measures used in recent clinical trials to measure

change in pain and function in patients following corticosteroid injections and exercise [129] and recommended in a systematic review [130] are promising suitable outcomes for people with gluteal tendinopathies. These include the Victorian Institute of Sport Assessment-Gluteal tendon (VISA-G) questionnaire [131] that evaluates the severity of disability using 8 items about current pain and function. Regarding performance-based tests, the single-leg stance test with light fingertip support is useful to assess provocation of pain during a 30-second period. A report of pain over the greater trochanteric region indicates a positive test. This test has excellent sensitivity (100%) and specificity (97.3%), making it an ideal screening out test when pain is negative [2]. Additionally, the pain-free time and the time the patient can maintain a level pelvis in single-leg stance can also be recorded to measure change over time. Other performance-based tests include the single leg squat test where the ability to single leg squat as far as possible 5 times with the non-support leg out front and arms folded across the chest is rated on 5 criteria as good, fair or poor [132] and the star-excursion balance test that evaluates the ability to stand on one leg

and reach the other leg into eight directions as far as possible [133].

A number of specifically designed, reliable and well-validated PROMs are recommended for measuring outcomes in people with FAI by an international, multidisciplinary consensus statement endorsed by 25 clinical societies worldwide [48]. The International Hip Outcome Tool (iHOT-33) is a patient-derived questionnaire designed to measure hip-related quality of life in young adults with nonarthritic hip pain over four domains: symptoms and functional limitations; sports and recreational physical activities; job related concerns; and social, emotional and lifestyle concerns [124]. The hip and groin outcome score (HAGOS) was developed for physically active young to middle-aged adults [134] and contains 37 questions, covering six domains of pain; symptoms; physical function in daily living, sport and recreation; participation in physical function, sports and recreation, and hip and/or groin related QOL. The hip outcome score (HOS) [126] was developed to assess treatment outcomes of hip arthroscopy in young to middle-aged individuals

and contains 28 questions, covering activities of daily living, and sport.

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

Life questionnaire (OAKHQOL) [123].

**5.2 Condition-specific outcomes**

MID values are provided in **Table 1**.

*5.2.2 Femoroacetabular impingement*

*5.2.1 Gluteal tendinopathy*

*Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

There are also several condition-generic PROMs useful for assessing quality of life in a variety of hip conditions. These include the Medical Outcome Study 36 questions short form (SF-36) [120], the EuroQol (EQ-5D) [121] and the Assessment of quality of life (AQOL) [122]. Patient-specific quality of life questionnaires have also been developed for hip OA such as the Osteoarthritis Knee and Hip Quality of Life questionnaire (OAKHQOL) [123].

#### **5.2 Condition-specific outcomes**

*Hip Surgeries*

tion [109–111].

of function [114].

points [116].

individual targets and goals with patients [113].

in people with a variety of hip conditions.

prognosis and are usually secondary outcome measures to pain and physical func-

Measurement of pain and physical function are complex and cover multiple dimensions. For example, pain can be measured in multiple contexts including intensity, duration, type and location. Physical functioning can not only be measured in many contexts but it also crosses multiple domains. According to the International Classification of Functioning, Disability and Health (ICF), physical function spans *body functions and structure, activity* and *participation* domains [112]. Many outcome tools for pain and physical function have been described for hip conditions and a selection of tools with the best level of measurement evidence is recommended [109]. Ideally, measure outcomes should be suitably valid, reliable and responsive to change. Known values of the minimum important difference (MID) are important for interpreting meaningful change and are useful to help set

Patient outcomes can be measured using patient-reported outcome measures (PROMs) and performance-based tests measured by the clinician/researcher. Pain is usually measured with PROMs, such as pain scales and questionnaires, however physical functioning can be measured with both PROMs and performance-based tests. Performance-based tests reflect what patients can do rather than what they think they can do, which is usually captured with PROMs. When assessing physical function, it is recommended that both PROMs and performance-based tests are used as they can encapsulate different information as they test different constructs

Patient outcomes can be measured using individual-specific, condition-specific

and/or generic outcome tools. There are several condition-generic, individualspecific PROMs that are useful in assessing and monitoring symptoms and function

**5.1 Condition-generic, individual-specific patient-reported outcome measures**

The 11-point Numerical Pain Rating Scale (NPRS) can be used to track pain symptoms and can be customised to individual dimensions of pain. For example, average, current or greatest pain in the previous 24-hours or week can be measured ranging from 0 (no pain) to 10 (worst possible pain). Similarly, pain during an activity such as walking can be measured ranging from 0 (no pain on walking) to 10 (severe pain on walking). The MID for the NPRS (scale 0–10) in musculoskeletal conditions ranges from 1.5 points (small change) to 3.5 points (large change) [115] and in hip OA is defined as a change in pain during walking of 1.8

The Patient-reported functional scale (PRFS) [117] assesses current level of difficulty associated with 3–5 activities that the individual identifies as being important, each measured on an 11-point scale, where 0 is unable to perform the activity and 10 is able to perform the activity as normal. The MID for the PSFS ranges from

Patient-perceived change following an intervention over time can be measured

on a Global Rating of Change (GROC) scale, customised to the outcome to be measured, and used by the patient to rate their perceived overall change as worse, no change or better. If worse, the patient is asked to indicate how much worse, from very much worse to slightly worse. If better, then they are asked how much better, from slightly better to very much better. An example is the 11-point GROC [118] with a change scale ranging from −5 to +5. The GROC scale can be very useful to set individual levels of acceptable change over a stated time frame and to set individual

1.3 points (small change) to 2.7 points (large change [115].

**44**

treatment goals [119].

The following sections will outline condition-specific PROMs and performancebased tests used to measure pain and physical function in the hip conditions outlined previously in this chapter. Outcomes are selected based on available clinical practice guideline recommendations, measurement property evidence and reported use within clinical trials. A summary of the outcomes presented across the three hip conditions including the outcome domains, scoring method, and where known, MID values are provided in **Table 1**.

#### *5.2.1 Gluteal tendinopathy*

A number of valid and reliable measures used in recent clinical trials to measure change in pain and function in patients following corticosteroid injections and exercise [129] and recommended in a systematic review [130] are promising suitable outcomes for people with gluteal tendinopathies. These include the Victorian Institute of Sport Assessment-Gluteal tendon (VISA-G) questionnaire [131] that evaluates the severity of disability using 8 items about current pain and function. Regarding performance-based tests, the single-leg stance test with light fingertip support is useful to assess provocation of pain during a 30-second period. A report of pain over the greater trochanteric region indicates a positive test. This test has excellent sensitivity (100%) and specificity (97.3%), making it an ideal screening out test when pain is negative [2]. Additionally, the pain-free time and the time the patient can maintain a level pelvis in single-leg stance can also be recorded to measure change over time. Other performance-based tests include the single leg squat test where the ability to single leg squat as far as possible 5 times with the non-support leg out front and arms folded across the chest is rated on 5 criteria as good, fair or poor [132] and the star-excursion balance test that evaluates the ability to stand on one leg and reach the other leg into eight directions as far as possible [133].

#### *5.2.2 Femoroacetabular impingement*

A number of specifically designed, reliable and well-validated PROMs are recommended for measuring outcomes in people with FAI by an international, multidisciplinary consensus statement endorsed by 25 clinical societies worldwide [48]. The International Hip Outcome Tool (iHOT-33) is a patient-derived questionnaire designed to measure hip-related quality of life in young adults with nonarthritic hip pain over four domains: symptoms and functional limitations; sports and recreational physical activities; job related concerns; and social, emotional and lifestyle concerns [124]. The hip and groin outcome score (HAGOS) was developed for physically active young to middle-aged adults [134] and contains 37 questions, covering six domains of pain; symptoms; physical function in daily living, sport and recreation; participation in physical function, sports and recreation, and hip and/or groin related QOL. The hip outcome score (HOS) [126] was developed to assess treatment outcomes of hip arthroscopy in young to middle-aged individuals and contains 28 questions, covering activities of daily living, and sport.


**47**

**Table 1.**

*Contemporary Non-Surgical Considerations in the Management of People…*

physical function

function

function, balance

GT Pain,

GT Physical

GT Physical

All Physical

Hip OA Physical

Hip OA Physical

Hip OA Physical

function

function

function

function, aerobic capacity

*Patient-reported outcome measures and performance-based tests for hip conditions.*

Hip OA 1 Faster time

**Condition Outcome Items Scoring MID**

1 Pain free; hold pelvis level up to 30 s

1 Rated as good, fair, poor

1 Distance

1 Faster time

1 Great number

1 Faster time

1 Greater

in seconds indicates higher level of physical function

of repetitions indicates higher level of physical function

in seconds or greater speed in metres/second indicates higher level of physical function

in seconds indicates higher level of physical function

distance covered in metres indicates higher level of physical function and aerobic capacity

2–3 repetitions in people with hip OA [128]

0.2–0.3 m/s in people with hip OA [128]

0.8–1.4 s in people with hip OA [128]

reached in centimetres normalised to leg length with larger distances indicating greater balance and higher physical function

A clear recommendation of which performance-based tests should be used for this condition is yet to be made, however tests that are reliable and best discriminate between individuals with FAI and those without have been described [135]. This

*ADL, activities of daily living; FAI, femoroacetabular impingement; MID, minimum important difference; OA,* 

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

*Performance-based tests*

30-sec single leg stance

Single leg squat test

Stair Climb test

30-sec chair stand test

40-m fast paced walk test

Timed Up and Go test

6-minute walk test

*osteoarthritis; VAS, visual analogue scale.*

Starexcursion balance test


#### *Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

*ADL, activities of daily living; FAI, femoroacetabular impingement; MID, minimum important difference; OA, osteoarthritis; VAS, visual analogue scale.*

#### **Table 1.**

*Hip Surgeries*

*Patient-reported outcomes*

Numeric Pain Rating Scale (NPRS)

Patient-Specific Functional Scale (PSFS)

Global Rating of Change (GROC) Scale

Victorian Institute of Sport Assessment-Gluteal tendon (VISA-G)

International Hip Outcome Tool (iHOT-33)

Hip and Groin Outcome Score (HAGOS)

Hip Outcome Score (HOS)

Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)

Hip disability and Osteoarthritis Outcome Score (HOOS)

**Condition Outcome Items Scoring MID**

Higher scores indicate worst pain

Higher scores indicate higher function

scales e.g. −5 to +5, higher scores indicate improvement

3–5 0–10 scale

1 Variable

8 0–100 mm VAS Higher scores indicate less pain and higher function

33 0–100 mm

37 0–100 mm

28 0–100 mm VAS

32 0–4 point scale

40 0–4 point

VAS, where 100 indicates better quality of life score

VAS where 100 indicates no problems

Higher scores on each subscale indicates higher levels of physical function

Higher scores on each of subscale indicate greater disability.

scale where 0 indicates extreme symptoms and 4 indicates no symptoms

1.5–3.5 points in musculoskeletal conditions [115]; 1.8 points for hip OA [116]

1.3–2.7 points in musculoskeletal conditions [115]

Individualised e.g. moderately better/ somewhat worse

Between 6 mm [124] and 10 mm [125] in young adults after hip arthroscopy

Less than 10 mm (10%) on each subscale in young adults after hip arthroscopy [125]

5-9 mm for ADL subscale; 6 mm for sports subscale in young adults after arthroscopic surgery [125, 126]

6/68 points on the physical function subscale in people with hip OA [127]

All Pain 1 0–10 scale

All Physical

All Change in

GT Pain,

FAI Pain,

FAI Pain,

FAI Physical

Hip OA Pain,

Hip OA Pain,

function

condition

physical function

physical function, quality of life

physical function, quality of life

function

stiffness, physical function

physical function, quality of life

**46**

*Patient-reported outcome measures and performance-based tests for hip conditions.*

A clear recommendation of which performance-based tests should be used for this condition is yet to be made, however tests that are reliable and best discriminate between individuals with FAI and those without have been described [135]. This

includes the 5-times sit-to-stand test where the time taken to transition from sitting to standing from a standard chair five times is recorded in seconds; and the stair ascend test where the time taken to ascend a flight of stairs as quickly as possible without using a handrail is recorded in seconds.

## *5.2.3 Hip osteoarthritis*

Numerous clinical practice guidelines, for example [83, 108, 111], and recommendations, for example [110, 136, 137] informed from high level measurement property evidence and expert consensus strongly recommend a number of condition-specific PROMs. The Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index [138] measures pain, stiffness and physical function The Hip disability and Osteoarthritis Outcome Score (HOOS) [139] consists of five subscales; pain, other symptoms, function in daily living, function in sport and recreation, and hip related quality of life. This scale incorporates items from the WOMAC scale so can also be extracted from this questionnaire.

The Osteoarthritis Research Society International (OARSI) recommend performance-based measures of physical function representing typical activities relevant to individuals diagnosed with hip or knee OA [136, 137]. Comprehensive descriptions, including set up, equipment, preparation (environment, participant, and tester), procedures, verbal instructions and scoring are available on the OARSI website: http://oarsi.org/research/physical-performance-measures along with videos of each recommended test. The full set includes five tests and the first three were recommended as the minimum core set: (i) *30 s chair stand test* where the number of full stands a person can perform in a 30 s period is recorded in seconds; (ii) *40 m fast-paced walk test* where the time taken to walk 4 × 10 m as quickly but as safely as possible is recorded in seconds which can be converted to speed recorded in metres per second; (iii) *stair climb test* where the time taken to ascend and descend a flight of stairs (with optional use of handrail) is recorded in seconds; (iv) *timed up and go* where the time taken to stand up from a standard chair with arm-rests, walk at regular pace to a line 3 m away, turn around and return to the seated position is recorded in seconds; and (v) s*ix-minute walk test* where the maximum possible distance walked in 6 min is recorded in metres covered.

## **6. Conclusion**

Evidence supports exercise as a promising solution to the most important questions asked by patients with extra- and intra-articular hip pathologies and health professionals. Exercise can reduce hip symptoms and potentially prevent disease progression. Stakeholders, including but not limited to, health care professionals, research communities, consumer organisations, and local and national policy makers must make a deliberate effort to translate the positive message of exercise as a treatment for hip conditions. Research is ongoing to further empower patients and clinicians with evidence around best-prescription for exercise.

**49**

**Author details**

Fiona Dobson1

provided the original work is properly cited.

\*, Kim Allison1

University of Melbourne, Carlton, Australia

\*Address all correspondence to: fdobson@unimelb.edu.au

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

, Laura Diamond2

2 School of Allied Health Sciences, Griffith University, Gold Coast, Australia

1 Department of Physiotherapy, Centre for Health, Exercise and Sports Medicine,

and Michelle Hall1

*Contemporary Non-Surgical Considerations in the Management of People…*

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

*Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

## **Author details**

*Hip Surgeries*

*5.2.3 Hip osteoarthritis*

questionnaire.

covered.

**6. Conclusion**

for exercise.

includes the 5-times sit-to-stand test where the time taken to transition from sitting to standing from a standard chair five times is recorded in seconds; and the stair ascend test where the time taken to ascend a flight of stairs as quickly as possible

Numerous clinical practice guidelines, for example [83, 108, 111], and recommendations, for example [110, 136, 137] informed from high level measurement property evidence and expert consensus strongly recommend a number of condition-specific PROMs. The Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index [138] measures pain, stiffness and physical function The Hip disability and Osteoarthritis Outcome Score (HOOS) [139] consists of five subscales; pain, other symptoms, function in daily living, function in sport and recreation, and hip related quality of life. This scale incorporates items from the WOMAC scale so can also be extracted from this

The Osteoarthritis Research Society International (OARSI) recommend performance-based measures of physical function representing typical activities relevant to individuals diagnosed with hip or knee OA [136, 137]. Comprehensive descriptions, including set up, equipment, preparation (environment, participant, and tester), procedures, verbal instructions and scoring are available on the OARSI website: http://oarsi.org/research/physical-performance-measures along with videos of each recommended test. The full set includes five tests and the first three were recommended as the minimum core set: (i) *30 s chair stand test* where the number of full stands a person can perform in a 30 s period is recorded in seconds; (ii) *40 m fast-paced walk test* where the time taken to walk 4 × 10 m as quickly but as safely as possible is recorded in seconds which can be converted to speed recorded in metres per second; (iii) *stair climb test* where the time taken to ascend and descend a flight of stairs (with optional use of handrail) is recorded in seconds; (iv) *timed up and go* where the time taken to stand up from a standard chair with arm-rests, walk at regular pace to a line 3 m away, turn around and return to the seated position is recorded in seconds; and (v) s*ix-minute walk test* where the maximum possible distance walked in 6 min is recorded in metres

Evidence supports exercise as a promising solution to the most important questions asked by patients with extra- and intra-articular hip pathologies and health professionals. Exercise can reduce hip symptoms and potentially prevent disease progression. Stakeholders, including but not limited to, health care professionals, research communities, consumer organisations, and local and national policy makers must make a deliberate effort to translate the positive message of exercise as a treatment for hip conditions. Research is ongoing to further empower patients and clinicians with evidence around best-prescription

without using a handrail is recorded in seconds.

**48**

Fiona Dobson1 \*, Kim Allison1 , Laura Diamond2 and Michelle Hall1

1 Department of Physiotherapy, Centre for Health, Exercise and Sports Medicine, University of Melbourne, Carlton, Australia

2 School of Allied Health Sciences, Griffith University, Gold Coast, Australia

\*Address all correspondence to: fdobson@unimelb.edu.au

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **References**

[1] Fearon AM, Scarvell JM, Neeman T, et al. Greater trochanteric pain syndrome: Defining the clinical syndrome. British Journal of Sports Medicine. 2013;**47**(10):649-653

[2] Lequesne M, Mathieu P, Vuillemin-Bodaghi V, et al. Gluteal tendinopathy in refractory greater trochanter pain syndrome: Diagnostic value of two clinical tests. Arthritis and Rheumatism. 2008;**59**(2):241-246

[3] Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: Epidemiology and associated factors. Archives of Physical Medicine & Rehabilitation. 2007;**88**(8):988-992

[4] Glyn-Jones S, Palmer A, Price A, et al. Osteoarthritis. The Lancet. 2015;**386**(9991):376-387

[5] Grimaldi A, Mellor R, Hodges PW, et al. Gluteal tendinopathy: A review of mechanisms. Assessment and Management. Sports Medicine. 2015;**48**(8):1107-1119

[6] Woodley S, Nicholson H, Livingstone V, et al. Lateral hip pain: Findings from magnetic resonance imaging and clinical examination. Journal of Orthopaedic & Sports Physical Therapy. 2008;**38**(6):313-328

[7] Lequesne M, Djian P, Vuillemin V, et al. Prospective study of refractory greater trochanter pain syndrome. MRI findings of gluteal tendon tears seen at surgery. Clinical and MRI results of tendon repair. Joint, Bone, Spine. 2008;**75**(4):458-464

[8] Long SS, Surrey DE, Nazarian LN. Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis. American Journal of Roentgenology. 2013;**201**(5):1083-1086

[9] Fearon AM, Scarvell JM, Cook JL, et al. Does ultrasound correlate with surgical or histologic findings in greater trochanteric pain syndrome? A pilot study. Clinical Orthopaedics and Related Research. 2010;**468**(7):1838-1844

[10] Domb BG, Carreira DS. Endoscopic repair of full-thickness gluteus medius tears. Arthroscopy Techniques. 2013;**2**(2):e77-e81

[11] Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy? British Journal of Sports Medicine. 2011;**46**(3):163-168

[12] Birnbaum K, Siebert CH, Pandorf T, et al. Anatomical and biomechanical investigations of the iliotibial tract. Surgical and Radiologic Anatomy: SRA. 2004;**26**(6):433-446

[13] Cook J, Rio E, Purdam C, et al. Revisiting the continuum model of tendon pathology: What is its merit in clinical practice and research? British Journal of Sports Medicine. 2016;**50**(19):1187-1191

[14] Grimaldi A, Fearon AM. Gluteal tendinopathy: Integrating pathomechanics and clinical features in its management. Journal of Orthopaedic & Sports Physical Therapy. 2015;**45**(11):910-922

[15] Allison K, Vicenzino B, Wrigley TV, et al. Hip abductor muscle weakness in individuals with gluteal tendinopathy. Medicine and Science in Sports and Exercise. 2016;**48**(3):346-352

[16] Al-Hayani A. The functional anatomy of hip abductors. Folia Morphologica. 2009;**68**(2):98-103

[17] Grimaldi A. Assessing lateral stability of the hip and pelvis. Manual Therapy. 2011;**16**(1):26-32

**51**

*Contemporary Non-Surgical Considerations in the Management of People…*

[27] Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: Prospective, single blinded, randomised clinical trial. BMJ. 2018;**361**:k1162

[28] Larsson MH, Käll I, Nilsson-Helander K. Treatment of patellar tendinopathy—A systematic review of randomized controlled trials. Knee Surgery, Sports Traumatology, Arthroscopy. 2012;**20**(8):1632-1646

[29] Allison K, Salomoni SE, Bennell KL, et al. Hip abductor muscle activity during walking in individuals with gluteal tendinopathy. Scandinavian Journal of Medicine & Science in Sports.

[30] Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clinical Orthopaedics and Related Research. 2003;**417**:112-120

[31] Diamond LE, Dobson FL, Bennell KL, et al. Physical impairments and activity limitations in people with femoroacetabular impingement: A systematic review. British Journal of Sports Medicine. 2015;**49**(4):230-242

[32] Agricola R, Heijboer MP, Bierma-Zeinstra SM, et al. Cam impingement causes osteoarthritis of the hip: A nationwide prospective cohort study (CHECK). Annals of the Rheumatic

[33] King MG, Lawrenson PR, Semciw AI, et al. Lower limb biomechanics in femoroacetabular impingement syndrome: A systematic review and meta-analysis. British Journal of Sports

[34] Diamond LE, Wrigley TV, Bennell KL, et al. Hip joint biomechanics during gait in people with and without symptomatic femoroacetabular

Diseases. 2013;**72**(6):918-923

Medicine. 2018;**52**(9):566-580

2018;**28**(2):686-695

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

[18] Allison K, Bennell KL, Grimaldi A, et al. Single leg stance control in individuals with symptomatic gluteal tendinopathy. Gait & Posture.

[19] Allison K, Wrigley TV, Vicenzino B, et al. Kinematics and kinetics during walking in individuals with gluteal tendinopathy. Clinical Biomechanics.

[20] Allison K, Vicenzino B, Bennell KL, et al. Kinematics and kinetics during stair ascent in individuals with gluteal tendinopathy. Clinical Biomechanics.

[21] Yoon YS, Mansour JM. The passive elastic moment at the hip. Journal of Biomechanics. 1982;**15**(12):905-910

[22] Thurston A. Spinal and pelvic kinematics in osteoarthrosis of the hip joint. Spine. 1985;**10**(5):467-471

[23] Del Buono A, Papalia R, Khanduja V, et al. Management of the greater trochanteric pain syndrome: A systematic review. British Medical

[24] Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomised controlled trials. Lancet (London, England). 2010;**376**(9754):1751-1767

Bulletin. 2012;**102**:115-131

[25] Denman M. Corticosteroid injections improved short-term, but not long-term, recovery and pain in the greater trochanteric pain syndrome. Annals of Internal Medicine.

[26] Rompe JD, Segal NA, Cacchio A, et al. Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. American Journal of Sports Medicine.

2011;**155**(8)JC4

2009;**37**(10):1981-1990

2016;**49**:108-113

2016;**32**:56-63

2016;**40**:37-44

*Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

[18] Allison K, Bennell KL, Grimaldi A, et al. Single leg stance control in individuals with symptomatic gluteal tendinopathy. Gait & Posture. 2016;**49**:108-113

[19] Allison K, Wrigley TV, Vicenzino B, et al. Kinematics and kinetics during walking in individuals with gluteal tendinopathy. Clinical Biomechanics. 2016;**32**:56-63

[20] Allison K, Vicenzino B, Bennell KL, et al. Kinematics and kinetics during stair ascent in individuals with gluteal tendinopathy. Clinical Biomechanics. 2016;**40**:37-44

[21] Yoon YS, Mansour JM. The passive elastic moment at the hip. Journal of Biomechanics. 1982;**15**(12):905-910

[22] Thurston A. Spinal and pelvic kinematics in osteoarthrosis of the hip joint. Spine. 1985;**10**(5):467-471

[23] Del Buono A, Papalia R, Khanduja V, et al. Management of the greater trochanteric pain syndrome: A systematic review. British Medical Bulletin. 2012;**102**:115-131

[24] Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomised controlled trials. Lancet (London, England). 2010;**376**(9754):1751-1767

[25] Denman M. Corticosteroid injections improved short-term, but not long-term, recovery and pain in the greater trochanteric pain syndrome. Annals of Internal Medicine. 2011;**155**(8)JC4

[26] Rompe JD, Segal NA, Cacchio A, et al. Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. American Journal of Sports Medicine. 2009;**37**(10):1981-1990

[27] Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: Prospective, single blinded, randomised clinical trial. BMJ. 2018;**361**:k1162

[28] Larsson MH, Käll I, Nilsson-Helander K. Treatment of patellar tendinopathy—A systematic review of randomized controlled trials. Knee Surgery, Sports Traumatology, Arthroscopy. 2012;**20**(8):1632-1646

[29] Allison K, Salomoni SE, Bennell KL, et al. Hip abductor muscle activity during walking in individuals with gluteal tendinopathy. Scandinavian Journal of Medicine & Science in Sports. 2018;**28**(2):686-695

[30] Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clinical Orthopaedics and Related Research. 2003;**417**:112-120

[31] Diamond LE, Dobson FL, Bennell KL, et al. Physical impairments and activity limitations in people with femoroacetabular impingement: A systematic review. British Journal of Sports Medicine. 2015;**49**(4):230-242

[32] Agricola R, Heijboer MP, Bierma-Zeinstra SM, et al. Cam impingement causes osteoarthritis of the hip: A nationwide prospective cohort study (CHECK). Annals of the Rheumatic Diseases. 2013;**72**(6):918-923

[33] King MG, Lawrenson PR, Semciw AI, et al. Lower limb biomechanics in femoroacetabular impingement syndrome: A systematic review and meta-analysis. British Journal of Sports Medicine. 2018;**52**(9):566-580

[34] Diamond LE, Wrigley TV, Bennell KL, et al. Hip joint biomechanics during gait in people with and without symptomatic femoroacetabular

**50**

*Hip Surgeries*

**References**

[1] Fearon AM, Scarvell JM, Neeman T, et al. Greater trochanteric pain syndrome: Defining the clinical syndrome. British Journal of Sports Medicine. 2013;**47**(10):649-653

[9] Fearon AM, Scarvell JM, Cook JL, et al. Does ultrasound correlate with surgical or histologic findings

[10] Domb BG, Carreira DS. Endoscopic repair of full-thickness gluteus medius

[11] Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy? British Journal of Sports

[12] Birnbaum K, Siebert CH, Pandorf T, et al. Anatomical and biomechanical investigations of the iliotibial tract. Surgical and Radiologic Anatomy: SRA.

[13] Cook J, Rio E, Purdam C, et al. Revisiting the continuum model of tendon pathology: What is its merit in clinical practice and research? British Journal of Sports Medicine.

[14] Grimaldi A, Fearon AM. Gluteal

pathomechanics and clinical features in its management. Journal of

Orthopaedic & Sports Physical Therapy.

[15] Allison K, Vicenzino B, Wrigley TV, et al. Hip abductor muscle weakness in individuals with gluteal tendinopathy. Medicine and Science in Sports and Exercise. 2016;**48**(3):346-352

[16] Al-Hayani A. The functional anatomy of hip abductors. Folia Morphologica. 2009;**68**(2):98-103

[17] Grimaldi A. Assessing lateral stability of the hip and pelvis. Manual

Therapy. 2011;**16**(1):26-32

tears. Arthroscopy Techniques.

Medicine. 2011;**46**(3):163-168

in greater trochanteric pain syndrome? A pilot study. Clinical Orthopaedics and Related Research.

2010;**468**(7):1838-1844

2013;**2**(2):e77-e81

2004;**26**(6):433-446

2016;**50**(19):1187-1191

2015;**45**(11):910-922

tendinopathy: Integrating

[2] Lequesne M, Mathieu P, Vuillemin-Bodaghi V, et al. Gluteal tendinopathy in refractory greater trochanter pain syndrome: Diagnostic value of two clinical tests. Arthritis and Rheumatism.

[3] Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: Epidemiology and associated factors. Archives of Physical Medicine & Rehabilitation.

[4] Glyn-Jones S, Palmer A, Price A, et al. Osteoarthritis. The Lancet.

[5] Grimaldi A, Mellor R, Hodges PW, et al. Gluteal tendinopathy: A review of mechanisms. Assessment and Management. Sports Medicine.

[6] Woodley S, Nicholson H, Livingstone V, et al. Lateral hip pain: Findings from magnetic resonance imaging and clinical examination. Journal of Orthopaedic & Sports Physical Therapy.

[7] Lequesne M, Djian P, Vuillemin V, et al. Prospective study of refractory greater trochanter pain syndrome. MRI findings of gluteal tendon tears seen at surgery. Clinical and MRI results of tendon repair. Joint, Bone, Spine.

[8] Long SS, Surrey DE, Nazarian LN. Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis. American Journal of Roentgenology.

2008;**59**(2):241-246

2007;**88**(8):988-992

2015;**386**(9991):376-387

2015;**48**(8):1107-1119

2008;**38**(6):313-328

2008;**75**(4):458-464

2013;**201**(5):1083-1086

impingement. Gait & Posture. 2016;**43**:198-203

[35] Hunt MA, Guenther JR, Gilbart MK. Kinematic and kinetic differences during walking in patients with and without symptomatic femoroacetabular impingement. Clinical Biomechanics (Bristol, Avon). 2013;**28**(5):519-523

[36] Rylander J, Shu B, Favre J, et al. Functional testing provides unique insights into the pathomechanics of femoroacetabular impingement and an objective basis for evaluating treatment outcome. Journal of Orthopaedic Research: Official Publication of the Orthopaedic Research Society. 2013;**31**(9):1461-1468

[37] Bagwell JJ, Snibbe J, Gerhardt M, et al. Hip kinematics and kinetics in persons with and without cam femoroacetabular impingement during a deep squat task. Clinical Biomechanics. 2016;**31**:87-92

[38] Diamond LE, Bennell KL, Wrigley TV, et al. Squatting biomechanics in individuals with symptomatic femoroacetabular impingement. Medicine and Science in Sports and Exercise. 2017;**49**(8):1520-1529

[39] Lamontagne M, Kennedy MJ, Beaule PE. The effect of cam FAI on hip and pelvic motion during maximum squat. Clinical Orthopaedics and Related Research. 2009;**467**(3):645-650

[40] Diamond LE, Bennell KL, Wrigley TV, et al. Trunk, pelvis and hip biomechanics in individuals with femoroacetabular impingement syndrome: Strategies for step ascent. Gait & Posture. 2018;**61**:176-182

[41] Diamond LE, Wrigley TV, Hinman RS, et al. Isometric and isokinetic hip strength and agonist/antagonist ratios in symptomatic femoroacetabular impingement. Journal of Science and Medicine in Sport. 2016;**19**(9):696-701

[42] Reiman MP, Thorborg K. Femoroacetabular impingement surgery: Are we moving too fast and too far beyond the evidence? British Journal of Sports Medicine. 2015;**49**(12):782-784

[43] Ng KC, Lamontagne M, Adamczyk AP, et al. Patient-specific anatomical and functional parameters provide new insights into the pathomechanism of cam FAI. Clinical Orthopaedics and Related Research. 2015;**473**(4):1289-1296

[44] Lewis CL, Loverro KL, Khuu A. Kinematic differences during singleleg step-down between individuals with femoroacetabular impingement syndrome and individuals without hip pain. The Journal of Orthopaedic and Sports Physical Therapy. 2018;**48**(4):270-279

[45] Bergmann G, Deuretzbacher G, Heller M, et al. Hip contact forces and gait patterns from routine activities. Journal of Biomechanics. 2001;**34**(7):859-871

[46] Meyer CAG, Corten K, Fieuws S, et al. Evaluation of stair motion contributes to new insights into hip osteoarthritis-related motion pathomechanics. Journal of Orthopaedic Research. 2015;**34**(2):187-196

[47] Kemp J. Hip-related pain. In: Brukner P, Khan KM, editors. Clinical Sports Medicine. Sydney: McGraw-Hill; 2012. pp. 510-544

[48] Griffin DR, Dickenson EJ, O'Donnell J, et al. The Warwick agreement on femoroacetabular impingement syndrome (FAI syndrome): An international consensus statement. British Journal of Sports Medicine. 2016;**50**(19):1169-1176

[49] Diamond LE, Van den Hoorn W, Bennell KL, et al. Coordination of deep hip muscle activity is altered

**53**

*Contemporary Non-Surgical Considerations in the Management of People…*

systematic review of the literature. PM & R: The Journal of Injury, Function, and Rehabilitation.

[57] Kemp JL, Moore K, Fransen M, et al. A phase II trial for the efficacy of physiotherapy intervention for earlyonset hip osteoarthritis: Study protocol for a randomised controlled trial. Trials.

[58] Bennell KL, O�Donnell JM, Takla A, et al. Efficacy of a physiotherapy rehabilitation program for individuals undergoing arthroscopic management of femoroacetabular impingement—The FAIR trial: A randomised controlled trial protocol. BMC Musculoskeletal

2013;**5**(5):418-426

Disorders. 2014;**15**:58

2014;**24**(4):489-496

1989;**166**:179-189

2007;**15**(7):908-914

[59] Hodges PW, McLean L, Hodder J. Insight into the function of the obturator internus muscle in humans: Observations with development and validation of an electromyography recording

technique. Journal of Electromyography and Kinesiology: Official Journal of the International Society of Electrophysiological Kinesiology.

[60] Gottschalk F, Kourosh S, Leveau B. The functional anatomy of tensor fasciae latae and gluteus medius and minimus. Journal of Anatomy.

[61] Philippon M, Schenker M, Briggs K, et al. Femoroacetabular impingement in 45 professional athletes: Associated pathologies and return to sport following arthroscopic

decompression. Knee Surgery, Sports Traumatology, Arthroscopy.

[62] Murphy LB, Helmick CG, Schwartz TA, et al. One in four people may develop symptomatic hip osteoarthritis in his or her lifetime. Osteoarthritis and Cartilage. 2010;**18**(11):1372-1379

2015;**16**:26

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

in symptomatic femoroacetabular impingement. Journal of Orthopaedic Research. 2017;**35**(7):1494-1504

[50] Driban JB, Sitler MR, Barbe MF, et al. Is osteoarthritis a heterogeneous disease that can be stratified into subsets? Clinical Rheumatology.

[51] Kumar D, Wyatt C, Chiba K, et al. Anatomic correlates of reduced hip extension during walking in individuals with mild-moderate radiographic hip osteoarthritis. Journal of Orthopaedic Research: Official Publication of the Orthopaedic Research Society.

2010;**29**(2):123-131

2015;**33**(4):527-534

(8 Suppl):140-143

[53] Clohisy JC, St John LC, Schutz AL. Surgical treatment of femoroacetabular impingement: A systematic review of the literature. Clinical Orthopaedics and Related Research. 2010;**468**(2):555-564

[54] Griffin DR, Dickenson EJ, Wall PDH, et al. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): A multicentre randomised controlled trial. Lancet (London, England). 2018;**391**(10136):2225-2235

[55] Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: Part III: Changes in evidence following systematic

cumulative update of research published through January 2009. Osteoarthritis and Cartilage. 2010;**18**(4):476-499

[56] Wall PD, Fernandez M, Griffin D, et al. Nonoperative treatment for femoroacetabular impingement: A

[52] Bozic KJ, Chan V, Valone FH 3rd, et al. Trends in hip arthroscopy utilization in the United States. The Journal of Arthroplasty. 2013;**28**

*Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

in symptomatic femoroacetabular impingement. Journal of Orthopaedic Research. 2017;**35**(7):1494-1504

*Hip Surgeries*

2016;**43**:198-203

impingement. Gait & Posture.

[35] Hunt MA, Guenther JR, Gilbart MK. Kinematic and kinetic differences during walking in patients with and without symptomatic femoroacetabular impingement. Clinical Biomechanics (Bristol, Avon). 2013;**28**(5):519-523

[42] Reiman MP, Thorborg K. Femoroacetabular impingement surgery: Are we moving too fast and too far beyond the evidence? British Journal of Sports Medicine.

[43] Ng KC, Lamontagne M,

provide new insights into the

2015;**473**(4):1289-1296

Adamczyk AP, et al. Patient-specific anatomical and functional parameters

pathomechanism of cam FAI. Clinical Orthopaedics and Related Research.

[44] Lewis CL, Loverro KL, Khuu A. Kinematic differences during singleleg step-down between individuals with femoroacetabular impingement syndrome and individuals without hip pain. The Journal of Orthopaedic

and Sports Physical Therapy.

[45] Bergmann G, Deuretzbacher G, Heller M, et al. Hip contact forces and gait patterns from routine activities. Journal of Biomechanics.

[46] Meyer CAG, Corten K, Fieuws S, et al. Evaluation of stair motion contributes to new insights into hip osteoarthritis-related motion

Research. 2015;**34**(2):187-196

[47] Kemp J. Hip-related pain. In: Brukner P, Khan KM, editors. Clinical Sports Medicine. Sydney: McGraw-Hill;

[48] Griffin DR, Dickenson EJ, O'Donnell J, et al. The Warwick agreement on femoroacetabular impingement syndrome (FAI

syndrome): An international consensus statement. British Journal of Sports Medicine. 2016;**50**(19):1169-1176

[49] Diamond LE, Van den Hoorn W, Bennell KL, et al. Coordination of deep hip muscle activity is altered

pathomechanics. Journal of Orthopaedic

2018;**48**(4):270-279

2001;**34**(7):859-871

2012. pp. 510-544

2015;**49**(12):782-784

[36] Rylander J, Shu B, Favre J, et al. Functional testing provides unique insights into the pathomechanics of femoroacetabular impingement and an objective basis for evaluating treatment outcome. Journal of Orthopaedic Research: Official Publication of the Orthopaedic Research Society.

[37] Bagwell JJ, Snibbe J, Gerhardt M, et al. Hip kinematics and kinetics in persons with and without cam

femoroacetabular impingement during a deep squat task. Clinical Biomechanics.

[38] Diamond LE, Bennell KL, Wrigley TV, et al. Squatting biomechanics in individuals with symptomatic femoroacetabular impingement. Medicine and Science in Sports and Exercise. 2017;**49**(8):1520-1529

[39] Lamontagne M, Kennedy MJ, Beaule PE. The effect of cam FAI on hip and pelvic motion during maximum squat. Clinical Orthopaedics and Related Research. 2009;**467**(3):645-650

[40] Diamond LE, Bennell KL, Wrigley TV, et al. Trunk, pelvis and hip biomechanics in individuals with femoroacetabular impingement syndrome: Strategies for step ascent. Gait & Posture. 2018;**61**:176-182

[41] Diamond LE, Wrigley TV, Hinman RS, et al. Isometric and isokinetic hip strength and agonist/antagonist ratios in symptomatic femoroacetabular impingement. Journal of Science and Medicine in Sport. 2016;**19**(9):696-701

2013;**31**(9):1461-1468

2016;**31**:87-92

**52**

[50] Driban JB, Sitler MR, Barbe MF, et al. Is osteoarthritis a heterogeneous disease that can be stratified into subsets? Clinical Rheumatology. 2010;**29**(2):123-131

[51] Kumar D, Wyatt C, Chiba K, et al. Anatomic correlates of reduced hip extension during walking in individuals with mild-moderate radiographic hip osteoarthritis. Journal of Orthopaedic Research: Official Publication of the Orthopaedic Research Society. 2015;**33**(4):527-534

[52] Bozic KJ, Chan V, Valone FH 3rd, et al. Trends in hip arthroscopy utilization in the United States. The Journal of Arthroplasty. 2013;**28** (8 Suppl):140-143

[53] Clohisy JC, St John LC, Schutz AL. Surgical treatment of femoroacetabular impingement: A systematic review of the literature. Clinical Orthopaedics and Related Research. 2010;**468**(2):555-564

[54] Griffin DR, Dickenson EJ, Wall PDH, et al. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): A multicentre randomised controlled trial. Lancet (London, England). 2018;**391**(10136):2225-2235

[55] Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: Part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis and Cartilage. 2010;**18**(4):476-499

[56] Wall PD, Fernandez M, Griffin D, et al. Nonoperative treatment for femoroacetabular impingement: A

systematic review of the literature. PM & R: The Journal of Injury, Function, and Rehabilitation. 2013;**5**(5):418-426

[57] Kemp JL, Moore K, Fransen M, et al. A phase II trial for the efficacy of physiotherapy intervention for earlyonset hip osteoarthritis: Study protocol for a randomised controlled trial. Trials. 2015;**16**:26

[58] Bennell KL, O�Donnell JM, Takla A, et al. Efficacy of a physiotherapy rehabilitation program for individuals undergoing arthroscopic management of femoroacetabular impingement—The FAIR trial: A randomised controlled trial protocol. BMC Musculoskeletal Disorders. 2014;**15**:58

[59] Hodges PW, McLean L, Hodder J. Insight into the function of the obturator internus muscle in humans: Observations with development and validation of an electromyography recording technique. Journal of Electromyography and Kinesiology: Official Journal of the International Society of Electrophysiological Kinesiology. 2014;**24**(4):489-496

[60] Gottschalk F, Kourosh S, Leveau B. The functional anatomy of tensor fasciae latae and gluteus medius and minimus. Journal of Anatomy. 1989;**166**:179-189

[61] Philippon M, Schenker M, Briggs K, et al. Femoroacetabular impingement in 45 professional athletes: Associated pathologies and return to sport following arthroscopic decompression. Knee Surgery, Sports Traumatology, Arthroscopy. 2007;**15**(7):908-914

[62] Murphy LB, Helmick CG, Schwartz TA, et al. One in four people may develop symptomatic hip osteoarthritis in his or her lifetime. Osteoarthritis and Cartilage. 2010;**18**(11):1372-1379

[63] GBD 2016 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet (London, England). 2017;**390**(10100):1260-1344

[64] Hall M, Wrigley TV, Metcalf BR, et al. Do moments and strength predict cartilage changes after partial meniscectomy? Medicine and Science in Sports and Exercise. 2015;**47**(8):1549-1556

[65] Bennell KL, Bowles KA, Wang Y, et al. Higher dynamic medial knee load predicts greater cartilage loss over 12 months in medial knee osteoarthritis. Annals of the Rheumatic Diseases. 2011;**70**(10):1770-1774

[66] Kumar D, Wyatt C, Lee S, et al. Sagittal plane walking patterns are related to MRI changes over 18-months in people with and without mildmoderate hip osteoarthritis. Journal of Orthopaedic Research: Official Publication of the Orthopaedic Research Society. 2018;**36**(5):1472-1477

[67] Tateuchi H, Koyama Y, Akiyama H, et al. Daily cumulative hip moment is associated with radiographic progression of secondary hip osteoarthritis. Osteoarthritis and Cartilage. 2017;**25**(8):1291-1298

[68] Foucher KC. Sex-specific hip osteoarthritis-associated gait abnormalities: Alterations in dynamic hip abductor function differ in men and women. Clinical Biomechanics (Bristol, Avon). 2017;**48**:24-29

[69] Wang SC, Brede C, Lange, Poster CS, Lange AW, Kohoyda-Inglis C, et al. Gender differences in hip anatomy: Possible implications for injury tolerance in frontal collisions. Annual Proceedings. Association for the

Advancement of Automotive Medicine. 2004;**48**:287-301

[70] Allison K, Hall M, Wrigley TV, et al. Sex-specific walking kinematics and kinetics in individuals with unilateral, symptomatic hip osteoarthritis: A cross sectional study. Gait & Posture. 2018;**65**:234-239

[71] Foucher KC. In: Aaron R, editor. Gait Pathomechanics in Hip Disease. Cham: Springer; 2015

[72] Hall M, Allison K, Wrigley TV, et al. Frontal plane hip joint loading according to pain severity in people with hip osteoarthritis. Journal of Orthopaedic Research: Official Publication of the Orthopaedic Research Society. 2018;**36**(6):1637-1644

[73] Hall MCS, Shakoor N, Leurgans SE, Foucher KC. Hip joint loading according to symptoms in people with mild radiographic osteoarthritis. Under revision

[74] Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. Journal of the American Medical Association. 2011;**305**(1):50-58

[75] Cesari M, Kritchevsky SB, Penninx BW, et al. Prognostic value of usual gait speed in well-functioning older people—Results from the Health, Aging and Body Composition Study. Journal of the American Geriatrics Society. 2005;**53**(10):1675-1680

[76] Constantinou M, Barrett R, Brown M, et al. Spatial-temporal gait characteristics in individuals with hip osteoarthritis: A systematic literature review and meta-analysis. The Journal of Orthopaedic and Sports Physical Therapy. 2014;**44**(4):291-2B7

[77] Astephen Wilson JL. Challenges in dealing with walking speed in knee osteoarthritis gait analyses. Clinical Biomechanics (Bristol, Avon). 2012;**27**(3):210-212

**55**

*Contemporary Non-Surgical Considerations in the Management of People…*

explosive-type resistance training is feasible and effective in patients with hip osteoarthritis scheduled for total hip arthroplasty—A randomized controlled trial. Osteoarthritis and Cartilage.

[86] Villadsen A, Overgaard S,

Holsgaard-Larsen A, et al. Immediate efficacy of neuromuscular exercise in patients with severe osteoarthritis of the hip or knee: A secondary analysis from a randomized controlled trial. The Journal of Rheumatology.

[87] Svege I, Nordsletten L, Fernandes L, et al. Exercise therapy may postpone total hip replacement surgery in patients with hip osteoarthritis: A long-term follow-up of a randomised trial. Annals of the Rheumatic Diseases. 2015;**74**(1):164-169

[88] Holden MA, Bennell KL, Whittle R, et al. How do physical therapists in the United Kingdom manage patients with hip osteoarthritis? Results of a crosssectional survey. Physical Therapy.

2016;**24**(1):91-98

2014;**41**(7):1385-1394

2018;**98**(6):461-470

2010;**96**(4):289-295

2016;**95**(5):372-389

Physiotherapies. 2017;**7**:e147

[92] American College of Sports Medicine ACSM's Health-Related Physical Fitness Assessment Manual.

[89] Cowan SM, Blackburn MS, McMahon K, et al. Current Australian physiotherapy management of hip osteoarthritis. Physiotherapy.

[90] Dobson F, Bennell KL, French SD, et al. Barriers and facilitators to exercise participation in people with hip and/or knee osteoarthritis: Synthesis of the literature using behavior change theory. American Journal of Physical Medicine & Rehabilitation.

[91] Reinthal A. Getting the dosage right in balance exercise prescription: The intensity problem. Journal of Novel

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

[78] Boyer KA. Biomechanical response

[79] Diamond LE, Allison K, Dobson F, et al. Hip joint moments during walking in people with hip osteoarthritis: A systematic review and metaanalysis. Osteoarthritis Cartilage.

[80] Claassen A, Kremers-van de K, van den Hoogen FHJ, et al. The most important frequently asked questions of patients with hip or knee osteoarthritis: A best-worst scaling exercise. Arthritis Care & Research (Hoboken). 2018; Jul 28. DOI: 10.1002/acr.23719. [Epub ahead of print]

[81] Fernandes L, Hagen KB, Bijlsma JW, et al. EULAR recommendations for the non-pharmacological core management

[82] National Clinical Guideline Centre. Osteoarthritis. Care and Management in Adults. National Institiute for Health and Care in Excellence

[84] Moseng T, Dagfinrud H, Smedslund

analysis. Osteoarthritis and Cartilage.

[85] Hermann A, Holsgaard-Larsen A, Zerahn B, et al. Preoperative progressive

G, et al. The importance of dose in land-based supervised exercise for people with hip osteoarthritis. A systematic review and meta-

2017;**25**(10):1563-1576

of hip and knee osteoarthritis. Annals of the Rheumatic Diseases.

[83] Royal Australian College of General Practitioners. Royal Australian College of General Practitioners. 2nd ed. 2018. Available from: https://www. racgp.org.au/your-practice/ guidelines/musculoskeletal/ hipandkneeosteoarthritis/

2013;**72**(7):1125-1135

[Internet]. 2014

to osteoarthritis pain treatment may impair long-term efficacy. Exercise and Sport Sciences Reviews.

2018;**46**(2):121-128

2018;**26**(11):1415-1424

*Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

[78] Boyer KA. Biomechanical response to osteoarthritis pain treatment may impair long-term efficacy. Exercise and Sport Sciences Reviews. 2018;**46**(2):121-128

*Hip Surgeries*

[63] GBD 2016 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet (London, England). 2017;**390**(10100):1260-1344

Advancement of Automotive Medicine.

[70] Allison K, Hall M, Wrigley TV, et al. Sex-specific walking kinematics and kinetics in individuals with unilateral, symptomatic hip osteoarthritis: A cross sectional study. Gait & Posture.

[71] Foucher KC. In: Aaron R, editor. Gait Pathomechanics in Hip Disease.

[72] Hall M, Allison K, Wrigley TV, et al. Frontal plane hip joint loading according to pain severity in people with hip osteoarthritis. Journal of Orthopaedic Research: Official Publication of the Orthopaedic Research

Society. 2018;**36**(6):1637-1644

[73] Hall MCS, Shakoor N, Leurgans SE, Foucher KC. Hip joint loading according to symptoms in people with mild

radiographic osteoarthritis. Under revision

[75] Cesari M, Kritchevsky SB, Penninx BW, et al. Prognostic value of usual gait speed in well-functioning older people—Results from the Health, Aging and Body Composition Study. Journal of the American Geriatrics Society.

[74] Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. Journal of the American Medical

Association. 2011;**305**(1):50-58

2005;**53**(10):1675-1680

2012;**27**(3):210-212

[76] Constantinou M, Barrett R, Brown M, et al. Spatial-temporal gait characteristics in individuals with hip osteoarthritis: A systematic literature review and meta-analysis. The Journal of Orthopaedic and Sports Physical Therapy. 2014;**44**(4):291-2B7

[77] Astephen Wilson JL. Challenges in dealing with walking speed in knee osteoarthritis gait analyses. Clinical Biomechanics (Bristol, Avon).

2004;**48**:287-301

2018;**65**:234-239

Cham: Springer; 2015

[64] Hall M, Wrigley TV, Metcalf BR, et al. Do moments and strength predict cartilage changes after partial meniscectomy? Medicine and Science in Sports and Exercise.

[65] Bennell KL, Bowles KA, Wang Y, et al. Higher dynamic medial knee load predicts greater cartilage loss over 12 months in medial knee osteoarthritis. Annals of the Rheumatic Diseases.

[66] Kumar D, Wyatt C, Lee S, et al. Sagittal plane walking patterns are related to MRI changes over 18-months in people with and without mildmoderate hip osteoarthritis. Journal of Orthopaedic Research: Official Publication of the Orthopaedic Research

Society. 2018;**36**(5):1472-1477

is associated with radiographic progression of secondary hip osteoarthritis. Osteoarthritis and Cartilage. 2017;**25**(8):1291-1298

[68] Foucher KC. Sex-specific hip osteoarthritis-associated gait abnormalities: Alterations in dynamic hip abductor function differ in men and women. Clinical Biomechanics (Bristol,

[69] Wang SC, Brede C, Lange, Poster CS, Lange AW, Kohoyda-Inglis C, et al. Gender differences in hip anatomy: Possible implications for injury tolerance in frontal collisions. Annual Proceedings. Association for the

Avon). 2017;**48**:24-29

[67] Tateuchi H, Koyama Y, Akiyama H, et al. Daily cumulative hip moment

2015;**47**(8):1549-1556

2011;**70**(10):1770-1774

**54**

[79] Diamond LE, Allison K, Dobson F, et al. Hip joint moments during walking in people with hip osteoarthritis: A systematic review and metaanalysis. Osteoarthritis Cartilage. 2018;**26**(11):1415-1424

[80] Claassen A, Kremers-van de K, van den Hoogen FHJ, et al. The most important frequently asked questions of patients with hip or knee osteoarthritis: A best-worst scaling exercise. Arthritis Care & Research (Hoboken). 2018; Jul 28. DOI: 10.1002/acr.23719. [Epub ahead of print]

[81] Fernandes L, Hagen KB, Bijlsma JW, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Annals of the Rheumatic Diseases. 2013;**72**(7):1125-1135

[82] National Clinical Guideline Centre. Osteoarthritis. Care and Management in Adults. National Institiute for Health and Care in Excellence [Internet]. 2014

[83] Royal Australian College of General Practitioners. Royal Australian College of General Practitioners. 2nd ed. 2018. Available from: https://www. racgp.org.au/your-practice/ guidelines/musculoskeletal/ hipandkneeosteoarthritis/

[84] Moseng T, Dagfinrud H, Smedslund G, et al. The importance of dose in land-based supervised exercise for people with hip osteoarthritis. A systematic review and metaanalysis. Osteoarthritis and Cartilage. 2017;**25**(10):1563-1576

[85] Hermann A, Holsgaard-Larsen A, Zerahn B, et al. Preoperative progressive explosive-type resistance training is feasible and effective in patients with hip osteoarthritis scheduled for total hip arthroplasty—A randomized controlled trial. Osteoarthritis and Cartilage. 2016;**24**(1):91-98

[86] Villadsen A, Overgaard S, Holsgaard-Larsen A, et al. Immediate efficacy of neuromuscular exercise in patients with severe osteoarthritis of the hip or knee: A secondary analysis from a randomized controlled trial. The Journal of Rheumatology. 2014;**41**(7):1385-1394

[87] Svege I, Nordsletten L, Fernandes L, et al. Exercise therapy may postpone total hip replacement surgery in patients with hip osteoarthritis: A long-term follow-up of a randomised trial. Annals of the Rheumatic Diseases. 2015;**74**(1):164-169

[88] Holden MA, Bennell KL, Whittle R, et al. How do physical therapists in the United Kingdom manage patients with hip osteoarthritis? Results of a crosssectional survey. Physical Therapy. 2018;**98**(6):461-470

[89] Cowan SM, Blackburn MS, McMahon K, et al. Current Australian physiotherapy management of hip osteoarthritis. Physiotherapy. 2010;**96**(4):289-295

[90] Dobson F, Bennell KL, French SD, et al. Barriers and facilitators to exercise participation in people with hip and/or knee osteoarthritis: Synthesis of the literature using behavior change theory. American Journal of Physical Medicine & Rehabilitation. 2016;**95**(5):372-389

[91] Reinthal A. Getting the dosage right in balance exercise prescription: The intensity problem. Journal of Novel Physiotherapies. 2017;**7**:e147

[92] American College of Sports Medicine ACSM's Health-Related Physical Fitness Assessment Manual. lippincott Williams & Wilkins Philadelphia, USA; 2013

[93] Hurley M, Dickson K, Hallett R, et al. Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: A mixed methods review. The Cochrane Database of Systematic Reviews. 2018;**4**:Cd010842

[94] Abbott JH, Robertson MC, Chapple C, et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: A randomized controlled trial. 1: Clinical effectiveness. Osteoarthritis and Cartilage. 2013;**21**(4):525-534

[95] Fernandes L, Storheim K, Sandvik L, et al. Efficacy of patient education and supervised exercise vs patient education alone in patients with hip osteoarthritis: A single blind randomized clinical trial. Osteoarthritis and Cartilage. 2010;**18**(10):1237-1243

[96] French HP, Cusack T, Brennan A, et al. Exercise and manual physiotherapy arthritis research trial (EMPART) for osteoarthritis of the hip: A multicenter randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2013;**94**(2):302-314

[97] Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: A randomized clinical trial. Arthritis and Rheumatism. 2004;**51**(5):722-729

[98] Hopman-Rock M, Westhoff MH. The effects of a health educational and exercise program for older adults with osteoarthritis for the hip or knee. The Journal of Rheumatology. 2000;**27**(8):1947-1954

[99] Juhakoski R, Tenhonen S, Malmivaara A, et al. A pragmatic randomized controlled study of the effectiveness and cost consequences of exercise therapy in hip osteoarthritis. Clinical Rehabilitation. 2011;**25**(4):370-383

[100] Krauss I, Steinhilber B, Haupt G, et al. Exercise therapy in hip osteoarthritis—A randomized controlled trial. Deutsches Arzteblatt International. 2014;**111**(35-36): 592-599

[101] Carlson NL. A pilot study on the effects of strength and aerobic coniditioning in patients with hip osteoarthritis. Osteoarthritis and Cartilage. 2011;**S53**:256

[102] Tak E, Staats P, Van Hespen A, et al. The effects of an exercise program for older adults with osteoarthritis of the hip. The Journal of Rheumatology. 2005;**32**(6):1106-1113

[103] Teirlinck CH, Luijsterburg PA, Dekker J, et al. Effectiveness of exercise therapy added to general practitioner care in patients with hip osteoarthritis: A pragmatic randomized controlled trial. Osteoarthritis and Cartilage. 2016;**24**(1):82-90

[104] Loureiro A, Mills PM, Barrett RS. Muscle weakness in hip osteoarthritis: A systematic review. Arthritis Care & Research (Hoboken). 2013;**65**(3):340-352

[105] Marks R. Comorbid depression and anxiety impact hip osteoarthritis disability. Disability and Health Journal. 2009;**2**(1):27-35

[106] van Dijk GM, Veenhof C, Schellevis F, et al. Comorbidity, limitations in activities and pain in patients with osteoarthritis of the hip or knee. BMC Musculoskeletal Disorders. 2008;**9**:95

[107] Bieler T, Siersma V, Magnusson SP, et al. In hip osteoarthritis, Nordic walking is superior to strength

**57**

*Contemporary Non-Surgical Considerations in the Management of People…*

[115] Abbott JH, Schmitt J. Minimum important differences for the patientspecific functional scale, 4 regionspecific outcome measures, and the numeric pain rating scale. The Journal of Orthopaedic and Sports Physical Therapy. 2014;**44**(8):560-564

[116] Tubach F, Ravaud P, Baron G, et al. Evaluation of clinically relevant changes in patient reported outcomes in knee and hip osteoarthritis: The minimal clinically important improvement. Annals of the Rheumatic Diseases.

[117] Horn KK, Jennings S, Richardson G, et al. The patient-specific functional scale: Psychometrics, clinimetrics, and application as a clinical outcome measure. The Journal of Orthopaedic

and Sports Physical Therapy.

[118] Kamper SJ, Maher CG, Mackay G. Global rating of change scales: A review of strengths and weaknesses and considerations for design. The Journal of Manual & Manipulative Therapy.

[119] ten Klooster PM, Drossaers-Bakker KW, Taal E, et al. Patient-perceived satisfactory improvement (PPSI): Interpreting meaningful change in pain from the patient�s perspective. Pain.

2005;**64**(1):29-33

2012;**42**(1):30-42

2009;**17**(3):163-170

2006;**121**(1-2):151-157

1993;**31**(3):247-263

1990;**16**(3):199-208

[120] McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical Care.

[121] EuroQol Group. EuroQol—A new facility for the measurement of health-related quality of life. Health Policy (Amsterdam, Netherlands).

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

training and home-based exercise for improving function. Scandinavian Journal of Medicine & Science in Sports.

[108] Cibulka MT, Bloom NJ, Enseki KR, et al. Hip pain and mobility deficits-hip osteoarthritis: Revision 2017. The Journal of Orthopaedic and Sports Physical Therapy.

[109] Messier SP, Callahan LF, Golightly

recommendations: Design and conduct of clinical trials of lifestyle diet and exercise interventions for osteoarthritis.

[110] Lane NE, Hochberg MC, Nevitt MC, et al. OARSI clinical trials

recommendations: Design and conduct of clinical trials for hip osteoarthritis.

YM, et al. OARSI clinical trials

Osteoarthritis and Cartilage.

Osteoarthritis and Cartilage.

Cartilage. 2014;**22**(3):363-388

[112] World Health Organization. International Classification of Functioning, Disability, and Health. Geneva, Switzerland: ICF; 2001

[113] Hefford C, Abbott JH, Baxter GD, et al. Outcome measurement in clinical practice: Practical and theoretical issues for health related quality of life (HRQOL) questionnaires. Physical Therapy Reviews. 2011;**16**(3):155-167

[114] Stratford PW, Kennedy DM, Woodhouse LJ. Performance measures provide assessments of pain and function in people with advanced osteoarthritis of the hip or knee. Physical Therapy.

2006;**86**(11):1489-1496

[111] McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis and

2017;**27**(8):873-886

2017;**47**(6):A1-A37

2015;**23**(5):787-797

2015;**23**(5):761-771

*Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

training and home-based exercise for improving function. Scandinavian Journal of Medicine & Science in Sports. 2017;**27**(8):873-886

*Hip Surgeries*

lippincott Williams & Wilkins Philadelphia, USA; 2013

[93] Hurley M, Dickson K, Hallett R, et al. Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: A mixed methods review. The Cochrane Database of Systematic Reviews. 2018;**4**:Cd010842

of exercise therapy in hip

[100] Krauss I, Steinhilber B, Haupt G, et al. Exercise therapy in hip osteoarthritis—A randomized controlled trial. Deutsches Arzteblatt International. 2014;**111**(35-36):

[101] Carlson NL. A pilot study on the effects of strength and aerobic coniditioning in patients with hip osteoarthritis. Osteoarthritis and

[102] Tak E, Staats P, Van Hespen A, et al. The effects of an exercise program for older adults with osteoarthritis of the hip. The Journal of Rheumatology.

[103] Teirlinck CH, Luijsterburg PA, Dekker J, et al. Effectiveness of exercise therapy added to general practitioner care in patients with hip osteoarthritis: A pragmatic randomized controlled trial. Osteoarthritis and Cartilage.

[104] Loureiro A, Mills PM, Barrett RS. Muscle weakness in hip

osteoarthritis: A systematic review. Arthritis Care & Research (Hoboken).

[105] Marks R. Comorbid depression and anxiety impact hip osteoarthritis disability. Disability and Health Journal.

[106] van Dijk GM, Veenhof C, Schellevis F, et al. Comorbidity, limitations in activities and pain in patients with osteoarthritis of the hip or knee. BMC Musculoskeletal Disorders.

[107] Bieler T, Siersma V, Magnusson SP, et al. In hip osteoarthritis, Nordic walking is superior to strength

Cartilage. 2011;**S53**:256

2005;**32**(6):1106-1113

2016;**24**(1):82-90

2013;**65**(3):340-352

2009;**2**(1):27-35

2008;**9**:95

2011;**25**(4):370-383

592-599

osteoarthritis. Clinical Rehabilitation.

[94] Abbott JH, Robertson MC, Chapple C, et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: A randomized controlled trial. 1: Clinical effectiveness. Osteoarthritis and Cartilage. 2013;**21**(4):525-534

[95] Fernandes L, Storheim K, Sandvik L, et al. Efficacy of patient education and supervised exercise vs patient education alone in patients with hip osteoarthritis: A single blind

randomized clinical trial. Osteoarthritis and Cartilage. 2010;**18**(10):1237-1243

[96] French HP, Cusack T, Brennan A, et al. Exercise and manual

physiotherapy arthritis research trial (EMPART) for osteoarthritis of the hip: A multicenter randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2013;**94**(2):302-314

[97] Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: A randomized clinical trial. Arthritis and Rheumatism.

2004;**51**(5):722-729

2000;**27**(8):1947-1954

[98] Hopman-Rock M, Westhoff

[99] Juhakoski R, Tenhonen S, Malmivaara A, et al. A pragmatic randomized controlled study of the effectiveness and cost consequences

MH. The effects of a health educational and exercise program for older adults with osteoarthritis for the hip or knee. The Journal of Rheumatology.

**56**

[108] Cibulka MT, Bloom NJ, Enseki KR, et al. Hip pain and mobility deficits-hip osteoarthritis: Revision 2017. The Journal of Orthopaedic and Sports Physical Therapy. 2017;**47**(6):A1-A37

[109] Messier SP, Callahan LF, Golightly YM, et al. OARSI clinical trials recommendations: Design and conduct of clinical trials of lifestyle diet and exercise interventions for osteoarthritis. Osteoarthritis and Cartilage. 2015;**23**(5):787-797

[110] Lane NE, Hochberg MC, Nevitt MC, et al. OARSI clinical trials recommendations: Design and conduct of clinical trials for hip osteoarthritis. Osteoarthritis and Cartilage. 2015;**23**(5):761-771

[111] McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis and Cartilage. 2014;**22**(3):363-388

[112] World Health Organization. International Classification of Functioning, Disability, and Health. Geneva, Switzerland: ICF; 2001

[113] Hefford C, Abbott JH, Baxter GD, et al. Outcome measurement in clinical practice: Practical and theoretical issues for health related quality of life (HRQOL) questionnaires. Physical Therapy Reviews. 2011;**16**(3):155-167

[114] Stratford PW, Kennedy DM, Woodhouse LJ. Performance measures provide assessments of pain and function in people with advanced osteoarthritis of the hip or knee. Physical Therapy. 2006;**86**(11):1489-1496

[115] Abbott JH, Schmitt J. Minimum important differences for the patientspecific functional scale, 4 regionspecific outcome measures, and the numeric pain rating scale. The Journal of Orthopaedic and Sports Physical Therapy. 2014;**44**(8):560-564

[116] Tubach F, Ravaud P, Baron G, et al. Evaluation of clinically relevant changes in patient reported outcomes in knee and hip osteoarthritis: The minimal clinically important improvement. Annals of the Rheumatic Diseases. 2005;**64**(1):29-33

[117] Horn KK, Jennings S, Richardson G, et al. The patient-specific functional scale: Psychometrics, clinimetrics, and application as a clinical outcome measure. The Journal of Orthopaedic and Sports Physical Therapy. 2012;**42**(1):30-42

[118] Kamper SJ, Maher CG, Mackay G. Global rating of change scales: A review of strengths and weaknesses and considerations for design. The Journal of Manual & Manipulative Therapy. 2009;**17**(3):163-170

[119] ten Klooster PM, Drossaers-Bakker KW, Taal E, et al. Patient-perceived satisfactory improvement (PPSI): Interpreting meaningful change in pain from the patient�s perspective. Pain. 2006;**121**(1-2):151-157

[120] McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical Care. 1993;**31**(3):247-263

[121] EuroQol Group. EuroQol—A new facility for the measurement of health-related quality of life. Health Policy (Amsterdam, Netherlands). 1990;**16**(3):199-208

[122] Whitfield K, Buchbinder R, Segal L, et al. Parsimonious and efficient assessment of health-related quality of life in osteoarthritis research: Validation of the Assessment of Quality of Life (AQoL) instrument. Health and Quality of Life Outcomes. 2006;**4**:19

[123] Rat A-C, Pouchot J, Coste J, et al. Development and testing of a specific quality-of-life questionnaire for knee and hip osteoarthritis: OAKHQOL (OsteoArthritis of Knee Hip Quality of Life). Joint, Bone, Spine. 2006;**73**(6):697-704

[124] Mohtadi NG, Griffin DR, Pedersen ME, et al. The development and validation of a self-administered quality-of-life outcome measure for young, active patients with symptomatic hip disease: The International Hip Outcome Tool (iHOT-33). Arthroscopy: The Journal of Arthroscopic & Related Surgery: Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2012;**28**(5):595-605 quiz 6-10.e1

[125] Kemp JL, Collins NJ, Roos EM, et al. Psychometric properties of patient-reported outcome measures for hip arthroscopic surgery. The American Journal of Sports Medicine. 2013;**41**(9):2065-2073

[126] Martin RL, Philippon MJ. Evidence of reliability and responsiveness for the hip outcome score. Arthroscopy: The Journal of Arthroscopic & Related Surgery: Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2008;**24**(6):676-682

[127] Bellamy N, Carette S, Ford PM, et al. Osteoarthritis antirheumatic drug trials. III. Setting the delta for clinical trials—Results of a consensus development (Delphi) exercise.

The Journal of Rheumatology. 1992;**19**(3):451-457

[128] Wright AA, Cook CE, Baxter GD, et al. A comparison of 3 methodological approaches to defining major clinically important improvement of 4 performance measures in patients with hip osteoarthritis. The Journal of Orthopaedic and Sports Physical Therapy. 2011;**41**:319-327

[129] Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: Prospective, single blinded, randomised clinical trial. BMJ (Clinical Research Ed). 2018;**361**:k1662

[130] Kivlan BR, Martin RL. Functional performance testing of the hip in athletes: A systematic review for reliability and validity. International Journal of Sports Physical Therapy. 2012;**7**(4):402-412

[131] Fearon AM, Ganderton C, Scarvell JM, et al. Development and validation of a VISA tendinopathy questionnaire for greater trochanteric pain syndrome, the VISA-G. Manual Therapy. 2015;**20**(6):805-813

[132] Crossley KM, Zhang WJ, Schache AG, et al. Performance on the single-leg squat task indicates hip abductor muscle function. The American Journal of Sports Medicine. 2011;**39**(4):866-873

[133] Kinzey SJ, Armstrong CW. The reliability of the star-excursion test in assessing dynamic balance. The Journal of Orthopaedic and Sports Physical Therapy. 1998;**27**(5):356-360

[134] Thorborg K, Hölmich P, Christensen R, et al. The Copenhagen Hip and Groin Outcome Score (HAGOS): Development and validation according to the COSMIN checklist.

**59**

*Contemporary Non-Surgical Considerations in the Management of People…*

*DOI: http://dx.doi.org/10.5772/intechopen.81821*

[135] Sheean AJ, Schmitz MR, Ward CL, et al. Assessment of disability related to femoroacetabular impingement syndrome by use of the patient-

reported outcome measure information

system (PROMIS) and objective measures of physical performance. The American Journal of Sports Medicine.

[136] Dobson F, Hinman RS, Hall M, et al. Reliability and measurement error of the Osteoarthritis Research Society International (OARSI) recommended performance-based tests of physical function in people with hip and knee osteoarthritis. Osteoarthritis and Cartilage. 2017;**25**(11):1792-1796

[137] Dobson F, Hinman RS, Roos EM, et al. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthritis and Cartilage.

[138] Bellamy N, Buchanan WW, Goldsmith CH, et al. Validation study of WOMAC: A health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. The Journal of Rheumatology.

[139] Klassbo M, Larsson E, Mannevik E. Hip disability and osteoarthritis outcome score. An extension of the Western Ontario and McMaster Universities Osteoarthritis Index. Scandinavian Journal of Rheumatology.

2013;**21**(8):1042-1052

1988;**15**(12):1833-1840

2003;**32**(1):46-51

2017;**45**(11):2476-2482

British Journal of Sports Medicine.

2011;**45**(6):478-491

*Contemporary Non-Surgical Considerations in the Management of People… DOI: http://dx.doi.org/10.5772/intechopen.81821*

British Journal of Sports Medicine. 2011;**45**(6):478-491

*Hip Surgeries*

[122] Whitfield K, Buchbinder R, Segal L, et al. Parsimonious and efficient assessment of health-related quality of life in osteoarthritis research: Validation of the Assessment of Quality of Life (AQoL) instrument. Health and Quality The Journal of Rheumatology.

approaches to defining major clinically important improvement of 4 performance measures in patients with hip osteoarthritis. The Journal of Orthopaedic and Sports Physical

Therapy. 2011;**41**:319-327

Ed). 2018;**361**:k1662

2012;**7**(4):402-412

2015;**20**(6):805-813

[128] Wright AA, Cook CE, Baxter GD, et al. A comparison of 3 methodological

[129] Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: Prospective, single blinded, randomised clinical trial. BMJ (Clinical Research

[130] Kivlan BR, Martin RL. Functional performance testing of the hip in athletes: A systematic review for reliability and validity. International Journal of Sports Physical Therapy.

[131] Fearon AM, Ganderton C, Scarvell JM, et al. Development and validation of a VISA tendinopathy questionnaire for greater trochanteric pain syndrome,

[132] Crossley KM, Zhang WJ, Schache AG, et al. Performance on the single-leg squat task indicates hip abductor muscle function. The American Journal of Sports Medicine. 2011;**39**(4):866-873

[133] Kinzey SJ, Armstrong CW. The reliability of the star-excursion test in assessing dynamic balance. The Journal of Orthopaedic and Sports Physical Therapy. 1998;**27**(5):356-360

Christensen R, et al. The Copenhagen

(HAGOS): Development and validation according to the COSMIN checklist.

[134] Thorborg K, Hölmich P,

Hip and Groin Outcome Score

the VISA-G. Manual Therapy.

1992;**19**(3):451-457

of Life Outcomes. 2006;**4**:19

2006;**73**(6):697-704

[123] Rat A-C, Pouchot J, Coste J, et al. Development and testing of a specific quality-of-life questionnaire for knee and hip osteoarthritis: OAKHQOL (OsteoArthritis of Knee Hip Quality of Life). Joint, Bone, Spine.

[124] Mohtadi NG, Griffin DR, Pedersen ME, et al. The development and validation of a self-administered quality-of-life outcome measure for young, active patients with symptomatic hip disease: The International Hip Outcome Tool (iHOT-33). Arthroscopy: The Journal of Arthroscopic & Related Surgery: Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association.

2012;**28**(5):595-605 quiz 6-10.e1

2013;**41**(9):2065-2073

Arthroscopy Association. 2008;**24**(6):676-682

[127] Bellamy N, Carette S, Ford PM, et al. Osteoarthritis antirheumatic drug trials. III. Setting the delta for clinical trials—Results of a consensus development (Delphi) exercise.

[125] Kemp JL, Collins NJ, Roos EM, et al. Psychometric properties of patient-reported outcome measures for hip arthroscopic surgery. The American Journal of Sports Medicine.

[126] Martin RL, Philippon MJ. Evidence of reliability and responsiveness for the hip outcome score. Arthroscopy: The Journal of Arthroscopic & Related Surgery: Official Publication of the Arthroscopy Association of North America and the International

**58**

[135] Sheean AJ, Schmitz MR, Ward CL, et al. Assessment of disability related to femoroacetabular impingement syndrome by use of the patientreported outcome measure information system (PROMIS) and objective measures of physical performance. The American Journal of Sports Medicine. 2017;**45**(11):2476-2482

[136] Dobson F, Hinman RS, Hall M, et al. Reliability and measurement error of the Osteoarthritis Research Society International (OARSI) recommended performance-based tests of physical function in people with hip and knee osteoarthritis. Osteoarthritis and Cartilage. 2017;**25**(11):1792-1796

[137] Dobson F, Hinman RS, Roos EM, et al. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthritis and Cartilage. 2013;**21**(8):1042-1052

[138] Bellamy N, Buchanan WW, Goldsmith CH, et al. Validation study of WOMAC: A health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. The Journal of Rheumatology. 1988;**15**(12):1833-1840

[139] Klassbo M, Larsson E, Mannevik E. Hip disability and osteoarthritis outcome score. An extension of the Western Ontario and McMaster Universities Osteoarthritis Index. Scandinavian Journal of Rheumatology. 2003;**32**(1):46-51

**61**

**Chapter 4**

**Abstract**

Hip Arthroplasty

to the future. We wish you a good reading.

**1. Introduction and history of hip arthroplasty**

*and Fernando Pagnussato*

*Carlos Roberto Galia, Tiango Aguiar Ribeiro,* 

*Cristiano Valter Diesel, Marcelo Reuwsaat Guimarães* 

**Keywords:** bone biology, hip arthroplasty, total hip arthroplasty, orthopedic

of the century by one of the most important medical journals in 2007 [3].

The hip arthroplasty is considered one of the greatest achievements of modern orthopedics [1, 2]. Through this surgery the patient returns to most of his normal life and a life without pain [3]. The primary indication for a hip arthroplasty

remains osteoarthritis (OA). OA is a degenerative disease that affects synovial joints [4]. Because of the rapid recovery and return to most of the activities of daily living, hip arthroplasty was considered one of the few medical procedures with great benefit to the patient as a whole [5], and this surgery was considered the operation

Hip arthroplasty began in Berlin in the late nineteenth century. Themistocles Gluck fashioned heads in ivory to replace the femoral head. This is the first concept of partial hip arthroplasty or hemiarthroplasty prosthesis. Gluck did these experiments in human patients with hip tuberculosis. These experiments demonstrated that the human body is tolerant to foreign bodies [6, 7]. Schmaltz (1817) and White (1821) underwent hip resection arthroplasty for children patients with hip tuberculosis, and they had been successful. This technique was described by Girdlestone in 1943 [8]. Smith-Petersen in Boston (1923) developed studies coating prosthetic glass, bakelite, and synthetic resin [9]. Philip Wiles (1938) [10] in London brought the concept of a femoral head attached to a rod. The first concept of an acetabular reaming was developed, so was born the concept of total hip arthroplasty (THA). Sir John Charnley [11] was the orthopedist who changed the concept of THA. His early experiments with Teflon have failed. But he developed the concepts of

Hip replacement is one of the most performed surgical procedures in orthopedic hip surgery. Through this surgery, the patient returns to most of his normal life and a life without pain. The primary indication for a hip arthroplasty remains osteoarthritis (OA). OA is a degenerative disease that affects synovial joints. A successful surgery is always preceded by good planning. The planning in turn takes into account the analysis of the patient and his physical examination and the radiological image. But also, the surgical planning must take into account another important factor, the choice of the surgical approach. In this chapter, the authors script a revision on the history of hip arthroplasty, total hip arthroplasty approaches, implant types, complications associated with hip arthroplasty, outcomes, and perspectives

## **Chapter 4** Hip Arthroplasty

*Carlos Roberto Galia, Tiango Aguiar Ribeiro, Cristiano Valter Diesel, Marcelo Reuwsaat Guimarães and Fernando Pagnussato*

## **Abstract**

Hip replacement is one of the most performed surgical procedures in orthopedic hip surgery. Through this surgery, the patient returns to most of his normal life and a life without pain. The primary indication for a hip arthroplasty remains osteoarthritis (OA). OA is a degenerative disease that affects synovial joints. A successful surgery is always preceded by good planning. The planning in turn takes into account the analysis of the patient and his physical examination and the radiological image. But also, the surgical planning must take into account another important factor, the choice of the surgical approach. In this chapter, the authors script a revision on the history of hip arthroplasty, total hip arthroplasty approaches, implant types, complications associated with hip arthroplasty, outcomes, and perspectives to the future. We wish you a good reading.

**Keywords:** bone biology, hip arthroplasty, total hip arthroplasty, orthopedic

## **1. Introduction and history of hip arthroplasty**

The hip arthroplasty is considered one of the greatest achievements of modern orthopedics [1, 2]. Through this surgery the patient returns to most of his normal life and a life without pain [3]. The primary indication for a hip arthroplasty remains osteoarthritis (OA). OA is a degenerative disease that affects synovial joints [4]. Because of the rapid recovery and return to most of the activities of daily living, hip arthroplasty was considered one of the few medical procedures with great benefit to the patient as a whole [5], and this surgery was considered the operation of the century by one of the most important medical journals in 2007 [3].

Hip arthroplasty began in Berlin in the late nineteenth century. Themistocles Gluck fashioned heads in ivory to replace the femoral head. This is the first concept of partial hip arthroplasty or hemiarthroplasty prosthesis. Gluck did these experiments in human patients with hip tuberculosis. These experiments demonstrated that the human body is tolerant to foreign bodies [6, 7]. Schmaltz (1817) and White (1821) underwent hip resection arthroplasty for children patients with hip tuberculosis, and they had been successful. This technique was described by Girdlestone in 1943 [8]. Smith-Petersen in Boston (1923) developed studies coating prosthetic glass, bakelite, and synthetic resin [9]. Philip Wiles (1938) [10] in London brought the concept of a femoral head attached to a rod. The first concept of an acetabular reaming was developed, so was born the concept of total hip arthroplasty (THA). Sir John Charnley [11] was the orthopedist who changed the concept of THA. His early experiments with Teflon have failed. But he developed the concepts of

low-friction arthroplasty [12] provided by decreasing the friction area due to the reduction in the diameter of the femoral head (22 mm). And, he used the highmolecular-weight polyethylene associated with methyl methacrylate (cement) [13] developed by Leon Wiltse in Los Angeles. These concepts of alliance were the concepts that changed the course of history of THA surgery. Notice that Haboush was the first orthopedic surgeon to use prosthesis with this cement. Muller was another important surgeon who introduced the prosthesis design with a 32-mm-diameter head [9]. But problems related to cementation generate concerns to improve the cementing techniques. But it was not just that, the search for a better cementation techniques grew. Miller [14] developed the low-viscosity cement, Harris [15, 16] describes techniques for improving cementing, and Robin Ling [17] emphasized the pressurization of the cement in the femoral canal. Despite the problems of cementing, orthopedic surgeons sought new fixation techniques. Pioneers in the area Pillar [18, 19] and Galante [20] introduced the concepts of cementless prosthetic components and the bone growth and pressurization (press fit). The hip arthroplasty surgery is still currently growing and developing. There are several new possibilities: articular surfaces of materials with less friction, more resistant materials, and minimally invasive techniques.

In this chapter, the major aspects of THA surgery will be addressed.

### **2. Total hip arthroplasty approaches**

A successful surgery is always preceded by good planning. The planning in turn takes into account the analysis of the patient and his physical examination and the radiological image. But also, the surgical planning must take into account another important factor, the choice of the surgical approach. The lateral, anterior, and posterior are the main approaches to perform hip arthroplasty. The Moore approach, also named posterior approach [21], is the most used surgical approach. The visibility of the surgical field is wide, and the anatomical approach when known by the surgeon becomes fast and easily accessible. Acetabular and femoral reaming becomes easy to perform due to extensive visibility. Even with an extensive visibility, some authors reported an increased incidence of luxation when this approach is compared to the lateral approach. However, other studies have shown that there is no such correlation [22, 23] and these authors attributed the excessive luxation to the incorrect position of the prosthetic components [22, 23]. Another great and important positive point of this surgical approach is that it does not harm the abductor tendons, so it does not cause limping for operated patients. The lower frequency of deep vein thrombosis (DVT) and bleeding is attributed to this surgical access [22–27]. The anterior surgical approach described by Smith-Petersen [28] and Hueter [29] is less used today, but it has gained new and notorious space among hip surgeons, due to its facilities and strengths for not detaching tendons and muscles. In the same way today, this approach is being used in less invasive and less aggressive surgeries, with the so-called mini-open approach. To the anterior approach, appropriate surgical instruments are needed, and the chance for lesion to occur in the femoral cutaneous nerve during surgery is elevated [30]. The last of the three most commonly used approaches is the direct lateral approach or Hardinge [31]. It has been the most used surgical technique. Hardinge approach is useful because it allows easy placement of the components and it is a familiar approach to a large number of surgeons. This feature makes Hardinge one of the most widely used approaches. Some authors attribute to this approach lower luxation rates than the posterior approach of Moore. But its drawback is that it is able to injure the abductor muscles and cause limping in the patient [22–24].

**63**

*Hip Arthroplasty*

**3. Implant types**

*DOI: http://dx.doi.org/10.5772/intechopen.84508*

implants to be observed carefully are:

are not well established in large series [43].

The choice of the implant type must also be regarded as extremely important to the success of the surgery. Basically, the implants used in hip arthroplasty can be divided into two groups: non-cemented (cementless implants) and cemented. This division is in regard to the different ways of fixation of the implant to the host patient bone. The main characteristic that distinguishes them is the presence or absence of bone cement (polymethyl methacrylate (PMMA)). Alternatively, a hybrid implant may be used, i.e., a component is fixed with PMMA and other not. The cemented implants wear the interposition of a polymer called PMMA as an interface between the patient's bone and the implant. This form of attachment was designed by Haboush and subsequently disseminated by Charnley in the 1960s [32]. PMMA has a modulus of elasticity very close to the human bone elasticity modulus (elasticity modulus cement +2GPa; elasticity modulus of trabecular bone +0.5– 1GPa). This polymer is very resistant to compressive forces but does not have good resistance to tension or shearing forces [33]. The long-term results to cemented implants depend on the quality of the cement mantle both in the acetabulum and in the femur. Initially, the placement of the cement manually, without the use of distal plug in the femoral canal, was used. The cement mixture was done manually, and pressurization into the canal was performed digitally. This technique was first called as the generation cementing technique. The retrograde filling of the femoral canal with the aid of cement pistols was later developed. They began to use femoral canal plug or plug restrictors, which aims to create a distal barrier to the stem that prevents the passage of cement and favors the pressurization and interdigitation of PMMA in the trabecular bone [34]. These advances represent the second generation of cementation. In the third generation, special techniques were introduced to the cement mixture (vacuum mixing or mixture in centrifuge). However, these special techniques for cement mixing are controversial and do not seem to improve the mechanical properties of PMMA [35]. One of the parameters often used to define an appropriate cementation is the presence of a uniform cement mantle, that is, with no bubbles or lines of radiolucency between the cement and the bone [36]. The thickness of the PMMA mantle is another parameter to define appropriate cementation. In this case, a thickness of 2 mm of the mantle between the femoral stem and the bone is considered adequate [36]. In the acetabulum, the mantle must have a thickness of 3 mm [37]. This trivial standard of cementation has the contrast of the controversial "French paradox," a way of cementation in which the femoral canal is filled with the largest possible stem by using the PMMA to fill the remaining spaces, sometimes getting fine and nonuniform mantels [38]. Other aspects in cemented

1.Design—Cemented femoral stems can be classified as simple wedge, double wedge, or triple wedge according to the geometry of the implant. Typical representatives of these subcategories are the stems of Charnley, Exeter, and C-stem, respectively [39]. Although the triple-wedge stems have lower stress in the cement mantle [40], a higher posterior rotation of this implant model is reported [41]. The clinical implications of these findings in the triple-wedge stem are not yet known, and yet this stem type has not demonstrated superiority over other

designs [42]. Currently, the stems in double wedge are most often used.

2.The covering of the implant—Traditionally, the best results are obtained with polished implants, i.e., smooth rods. There are femoral stems with rough surface, but these implants are not widely accepted, and its long-term results

## **3. Implant types**

*Hip Surgeries*

minimally invasive techniques.

**2. Total hip arthroplasty approaches**

muscles and cause limping in the patient [22–24].

low-friction arthroplasty [12] provided by decreasing the friction area due to the reduction in the diameter of the femoral head (22 mm). And, he used the highmolecular-weight polyethylene associated with methyl methacrylate (cement) [13] developed by Leon Wiltse in Los Angeles. These concepts of alliance were the concepts that changed the course of history of THA surgery. Notice that Haboush was the first orthopedic surgeon to use prosthesis with this cement. Muller was another important surgeon who introduced the prosthesis design with a 32-mm-diameter head [9]. But problems related to cementation generate concerns to improve the cementing techniques. But it was not just that, the search for a better cementation techniques grew. Miller [14] developed the low-viscosity cement, Harris [15, 16] describes techniques for improving cementing, and Robin Ling [17] emphasized the pressurization of the cement in the femoral canal. Despite the problems of cementing, orthopedic surgeons sought new fixation techniques. Pioneers in the area Pillar [18, 19] and Galante [20] introduced the concepts of cementless prosthetic components and the bone growth and pressurization (press fit). The hip arthroplasty surgery is still currently growing and developing. There are several new possibilities: articular surfaces of materials with less friction, more resistant materials, and

In this chapter, the major aspects of THA surgery will be addressed.

A successful surgery is always preceded by good planning. The planning in turn takes into account the analysis of the patient and his physical examination and the radiological image. But also, the surgical planning must take into account another important factor, the choice of the surgical approach. The lateral, anterior, and posterior are the main approaches to perform hip arthroplasty. The Moore approach, also named posterior approach [21], is the most used surgical approach. The visibility of the surgical field is wide, and the anatomical approach when known by the surgeon becomes fast and easily accessible. Acetabular and femoral reaming becomes easy to perform due to extensive visibility. Even with an extensive visibility, some authors reported an increased incidence of luxation when this approach is compared to the lateral approach. However, other studies have shown that there is no such correlation [22, 23] and these authors attributed the excessive luxation to the incorrect position of the prosthetic components [22, 23]. Another great and important positive point of this surgical approach is that it does not harm the abductor tendons, so it does not cause limping for operated patients. The lower frequency of deep vein thrombosis (DVT) and bleeding is attributed to this surgical access [22–27]. The anterior surgical approach described by Smith-Petersen [28] and Hueter [29] is less used today, but it has gained new and notorious space among hip surgeons, due to its facilities and strengths for not detaching tendons and muscles. In the same way today, this approach is being used in less invasive and less aggressive surgeries, with the so-called mini-open approach. To the anterior approach, appropriate surgical instruments are needed, and the chance for lesion to occur in the femoral cutaneous nerve during surgery is elevated [30]. The last of the three most commonly used approaches is the direct lateral approach or Hardinge [31]. It has been the most used surgical technique. Hardinge approach is useful because it allows easy placement of the components and it is a familiar approach to a large number of surgeons. This feature makes Hardinge one of the most widely used approaches. Some authors attribute to this approach lower luxation rates than the posterior approach of Moore. But its drawback is that it is able to injure the abductor

**62**

The choice of the implant type must also be regarded as extremely important to the success of the surgery. Basically, the implants used in hip arthroplasty can be divided into two groups: non-cemented (cementless implants) and cemented. This division is in regard to the different ways of fixation of the implant to the host patient bone. The main characteristic that distinguishes them is the presence or absence of bone cement (polymethyl methacrylate (PMMA)). Alternatively, a hybrid implant may be used, i.e., a component is fixed with PMMA and other not.

The cemented implants wear the interposition of a polymer called PMMA as an interface between the patient's bone and the implant. This form of attachment was designed by Haboush and subsequently disseminated by Charnley in the 1960s [32]. PMMA has a modulus of elasticity very close to the human bone elasticity modulus (elasticity modulus cement +2GPa; elasticity modulus of trabecular bone +0.5– 1GPa). This polymer is very resistant to compressive forces but does not have good resistance to tension or shearing forces [33]. The long-term results to cemented implants depend on the quality of the cement mantle both in the acetabulum and in the femur. Initially, the placement of the cement manually, without the use of distal plug in the femoral canal, was used. The cement mixture was done manually, and pressurization into the canal was performed digitally. This technique was first called as the generation cementing technique. The retrograde filling of the femoral canal with the aid of cement pistols was later developed. They began to use femoral canal plug or plug restrictors, which aims to create a distal barrier to the stem that prevents the passage of cement and favors the pressurization and interdigitation of PMMA in the trabecular bone [34]. These advances represent the second generation of cementation. In the third generation, special techniques were introduced to the cement mixture (vacuum mixing or mixture in centrifuge). However, these special techniques for cement mixing are controversial and do not seem to improve the mechanical properties of PMMA [35]. One of the parameters often used to define an appropriate cementation is the presence of a uniform cement mantle, that is, with no bubbles or lines of radiolucency between the cement and the bone [36]. The thickness of the PMMA mantle is another parameter to define appropriate cementation. In this case, a thickness of 2 mm of the mantle between the femoral stem and the bone is considered adequate [36]. In the acetabulum, the mantle must have a thickness of 3 mm [37]. This trivial standard of cementation has the contrast of the controversial "French paradox," a way of cementation in which the femoral canal is filled with the largest possible stem by using the PMMA to fill the remaining spaces, sometimes getting fine and nonuniform mantels [38]. Other aspects in cemented implants to be observed carefully are:


3.The implant material—Usually, the implants are made of chrome-cobalt alloys or stainless steel. Titanium implants were tested; however, the results were very short compared to the traditional metal alloy [44].

The cementless implant aims to obtain a biological fixation between the implant and the host bone. Summarized there is the expectation of bone growth to the porosity of the implant and thus its final attachment to the bone. Unlike cemented implants, the presence of porosity is an indispensable requisite for fixation. There is the use of PMMA in this technique of placing the uncemented prosthesis. The implants do not depend on the cemented macrolocking (primary fixation) and microlocking (secondary fixation). Macrolocking must occur upon insertion of the implant, being obtained by an intimate fit of the implant to the bone. Microlocking is due to the bone ingrowth, i.e., the formation of bony bridges between the host bone and the pores of the implant [45, 46]. Ultimately, this is the factor that determines the longevity and success of a cementless implant. Macrolocking or primary locking can be obtained by various techniques, dependent or not in changes in the design of the implant, such as screw fixing, flaps, or grooves. Currently, the most common technique in primary stabilization is the press fit. This type of stabilization requires the placement of the prosthesis in an undersized cavity. In cementless acetabular beyond the press fit, screws may also be used as an aid to the primary fixation; however, with a suitable press fit, screws can even be dispensed [46–48]. To bone ingrowth occur, macrolocking must produce sufficient stability in order to avoid micromotion. When micromotion occurs, even if slight, it can delay or prevent the formation of bone tissue onto the implant, thus favoring the formation of fibrous tissue [46–49]. For microlocking, porosities are indispensable in the implant surface. Thus, it becomes extremely important different characteristics of the pores, as its size, its geometry, and its interconnection. Studies show that the size of the pores should be between 100 and 400 μm. Pores smaller than 50 μm or greater than 500 μm facilitate the growth of fibrous tissue rather than bone tissue [49]. The pores may have different geometries. There are three traditional types of porosity: the plasma-sprayed coating, the sintered sphere coating, and the fiber mesh coating [49]. In recent years, derived surfaces of trabecular metal porous coating has proven promising in the coverage or in the production of cementless implant, but results with longer follow-up are still waited. It is estimated that the percentage porosity is greater for the fiber mesh coating—between 40 and 50%—and the porous trabecular metal coating—between 75 and 80% [50]. The interconnection between the pores also plays an essential role in bone coupling force to the implant. If it is higher, the interconnection between the pores is resulting in major coupling force between the bone bridges and the prosthesis. Theoretically, the form of the manufacturing fiber mesh coating and the trabecular metal coating allows for a better interconnection between the pores compared to the plasma-sprayed coating and the sphere coating [47].

Another type of arthroplasty are considered hybrid. In this type of prosthesis, one of the implants is cemented and the other does not. It was called hybrid arthroplasty prosthesis in the acetabulum, which is not a cemented and cementless femoral stem. The reverse, i.e., cemented and cementless acetabular rod, was called reverse hybrid arthroplasty.

With regard loading surfaces, tribology has also shown its importance in modern times and has contributed to the THA surgery that increased its longevity. The tribological pair most widely used and studied is the metal-polyethylene. Other tribological pairs are also used: ceramic-polyethylene, metal–metal, and ceramic– ceramic; these last two tribological pairs are also called hard on hard. Currently, there is a trend in replacing the ultrahigh-molecular-weight polyethylene

**65**

section [63].

*Hip Arthroplasty*

*DOI: http://dx.doi.org/10.5772/intechopen.84508*

(UHMWPE) by highly cross-linked polyethylene (XLPE). The XLPE result of a series of interventions during its production seeks to change the connections between the molecules, resulting in a harder and wear-resistant material [51]. It is estimated that 0.04 mm/year is the linear wear rate compared to the XLPE 0:22 mm/year UHMWPE [52, 53]. All new tribological pairs presented as benefit a less volumetric wear, a fact that in theory could be beneficial for the longevity of the arthroplasty. There are, however, some peculiarities in these pairs. The metal– metal surface has an extremely low volumetric wear; however, it is given to metal– metal surface to release chromium and cobalt ions, which can be adsorbed and present local and systemic complications [54]. Among the local complications, pseudotumor formation is the major problem [55]. Systemic effects include neurological and cardiac damage [56]. There are also carcinogenic potential of systemic release of chromium and cobalt, although the exact impact of this exposure is not well known [57]. These systemic effects led to a metal–metal contraindicated in patients with allergies to metals and, in particular, women of childbearing age [58]. The ceramic–ceramic tribological pair has greater resistance to volumetric wear than metal–metal surface. This combination is particularly suitable for very young patients with high activity level and has no contraindication for women of childbearing age. The disadvantages of ceramic–ceramic are fracture risk and the risk of producing noise (squeaking) during hip movement and the stripe wear. The risk of squeaking is multifactorial; the main factors are the malposition of the components, the implant design, and the type of material used in manufacturing, though not always the trigger is recognized [59, 60]. The risk of ceramic fracture is currently between 0.004 and 0.010% being associated with the wrong positioning of the components (acetabular or femoral head) [61]. The stripe wear can occur when there is decreased contact area between the femoral head and acetabular surface, which can arise during swing phase of gait occurs or when the impingement of the trunnion on the acetabular rim and ball leaves right from the socket. The stripe wear is of concern due to the large volumetric wear it can cause. Individuals with tissue hyperlaxity or excellent range of motion (ROM) and those who require placing the hip through the extreme ROM are prone to impingement and consequent stripe wear [62]. The cross-linked polyethylene-ceramic surface adds the benefits of not releasing metal ions, no risk of squeaking besides presenting a very low volumetric wear, however higher than that of the hard-on-hard surfaces. As the head of ceramic is used, there is a minimal risk of fracture of the component. Perhaps, it represents a suitable alternative for young patients and

factors that may complicate the use of other types of tribological pairs.

teristics and the surgeon's experience.

**4. Complications**

The proper choice of the type of implant, whether cemented or not, and the different tribological pairs should take into account the theoretical knowledge of the design features, materials, and long-term outcomes beyond the patient charac-

Complications associated with hip arthroplasty can vary among groups of patients—age, gender, bone quality, and comorbid. For classification purposes it can be divided by time: acute complications, as in intraoperative and early adverse events—generally within 30–90 days, and late postoperative complications that can be divided in short-term and long-term complications. The most common major complications include mortality, infection, dislocation, revision, and thromboembolic events and will be the center of discussion in this

#### *Hip Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.84508*

*Hip Surgeries*

3.The implant material—Usually, the implants are made of chrome-cobalt alloys or stainless steel. Titanium implants were tested; however, the results were

The cementless implant aims to obtain a biological fixation between the implant

and the host bone. Summarized there is the expectation of bone growth to the porosity of the implant and thus its final attachment to the bone. Unlike cemented implants, the presence of porosity is an indispensable requisite for fixation. There is the use of PMMA in this technique of placing the uncemented prosthesis. The implants do not depend on the cemented macrolocking (primary fixation) and microlocking (secondary fixation). Macrolocking must occur upon insertion of the implant, being obtained by an intimate fit of the implant to the bone. Microlocking is due to the bone ingrowth, i.e., the formation of bony bridges between the host bone and the pores of the implant [45, 46]. Ultimately, this is the factor that determines the longevity and success of a cementless implant. Macrolocking or primary locking can be obtained by various techniques, dependent or not in changes in the design of the implant, such as screw fixing, flaps, or grooves. Currently, the most common technique in primary stabilization is the press fit. This type of stabilization requires the placement of the prosthesis in an undersized cavity. In cementless acetabular beyond the press fit, screws may also be used as an aid to the primary fixation; however, with a suitable press fit, screws can even be dispensed [46–48]. To bone ingrowth occur, macrolocking must produce sufficient stability in order to avoid micromotion. When micromotion occurs, even if slight, it can delay or prevent the formation of bone tissue onto the implant, thus favoring the formation of fibrous tissue [46–49]. For microlocking, porosities are indispensable in the implant surface. Thus, it becomes extremely important different characteristics of the pores, as its size, its geometry, and its interconnection. Studies show that the size of the pores should be between 100 and 400 μm. Pores smaller than 50 μm or greater than 500 μm facilitate the growth of fibrous tissue rather than bone tissue [49]. The pores may have different geometries. There are three traditional types of porosity: the plasma-sprayed coating, the sintered sphere coating, and the fiber mesh coating [49]. In recent years, derived surfaces of trabecular metal porous coating has proven promising in the coverage or in the production of cementless implant, but results with longer follow-up are still waited. It is estimated that the percentage porosity is greater for the fiber mesh coating—between 40 and 50%—and the porous trabecular metal coating—between 75 and 80% [50]. The interconnection between the pores also plays an essential role in bone coupling force to the implant. If it is higher, the interconnection between the pores is resulting in major coupling force between the bone bridges and the prosthesis. Theoretically, the form of the manufacturing fiber mesh coating and the trabecular metal coating allows for a better interconnection between the pores compared to the plasma-sprayed coating and the sphere

Another type of arthroplasty are considered hybrid. In this type of prosthesis, one of the implants is cemented and the other does not. It was called hybrid arthroplasty prosthesis in the acetabulum, which is not a cemented and cementless femoral stem. The reverse, i.e., cemented and cementless acetabular rod, was called

With regard loading surfaces, tribology has also shown its importance in modern times and has contributed to the THA surgery that increased its longevity. The tribological pair most widely used and studied is the metal-polyethylene. Other tribological pairs are also used: ceramic-polyethylene, metal–metal, and ceramic– ceramic; these last two tribological pairs are also called hard on hard. Currently, there is a trend in replacing the ultrahigh-molecular-weight polyethylene

very short compared to the traditional metal alloy [44].

**64**

coating [47].

reverse hybrid arthroplasty.

(UHMWPE) by highly cross-linked polyethylene (XLPE). The XLPE result of a series of interventions during its production seeks to change the connections between the molecules, resulting in a harder and wear-resistant material [51]. It is estimated that 0.04 mm/year is the linear wear rate compared to the XLPE 0:22 mm/year UHMWPE [52, 53]. All new tribological pairs presented as benefit a less volumetric wear, a fact that in theory could be beneficial for the longevity of the arthroplasty. There are, however, some peculiarities in these pairs. The metal– metal surface has an extremely low volumetric wear; however, it is given to metal– metal surface to release chromium and cobalt ions, which can be adsorbed and present local and systemic complications [54]. Among the local complications, pseudotumor formation is the major problem [55]. Systemic effects include neurological and cardiac damage [56]. There are also carcinogenic potential of systemic release of chromium and cobalt, although the exact impact of this exposure is not well known [57]. These systemic effects led to a metal–metal contraindicated in patients with allergies to metals and, in particular, women of childbearing age [58]. The ceramic–ceramic tribological pair has greater resistance to volumetric wear than metal–metal surface. This combination is particularly suitable for very young patients with high activity level and has no contraindication for women of childbearing age. The disadvantages of ceramic–ceramic are fracture risk and the risk of producing noise (squeaking) during hip movement and the stripe wear. The risk of squeaking is multifactorial; the main factors are the malposition of the components, the implant design, and the type of material used in manufacturing, though not always the trigger is recognized [59, 60]. The risk of ceramic fracture is currently between 0.004 and 0.010% being associated with the wrong positioning of the components (acetabular or femoral head) [61]. The stripe wear can occur when there is decreased contact area between the femoral head and acetabular surface, which can arise during swing phase of gait occurs or when the impingement of the trunnion on the acetabular rim and ball leaves right from the socket. The stripe wear is of concern due to the large volumetric wear it can cause. Individuals with tissue hyperlaxity or excellent range of motion (ROM) and those who require placing the hip through the extreme ROM are prone to impingement and consequent stripe wear [62]. The cross-linked polyethylene-ceramic surface adds the benefits of not releasing metal ions, no risk of squeaking besides presenting a very low volumetric wear, however higher than that of the hard-on-hard surfaces. As the head of ceramic is used, there is a minimal risk of fracture of the component. Perhaps, it represents a suitable alternative for young patients and factors that may complicate the use of other types of tribological pairs.

The proper choice of the type of implant, whether cemented or not, and the different tribological pairs should take into account the theoretical knowledge of the design features, materials, and long-term outcomes beyond the patient characteristics and the surgeon's experience.

## **4. Complications**

Complications associated with hip arthroplasty can vary among groups of patients—age, gender, bone quality, and comorbid. For classification purposes it can be divided by time: acute complications, as in intraoperative and early adverse events—generally within 30–90 days, and late postoperative complications that can be divided in short-term and long-term complications. The most common major complications include mortality, infection, dislocation, revision, and thromboembolic events and will be the center of discussion in this section [63].

#### **4.1 Mortality**

The indications for arthroplasty have been expanded during recent years. More patients, both younger and old, are operated now, and, in that case, the older group runs a particularly greater natural risk of serious complications. That implicates that higher-risk patients undergo operation than anteriorly. In most recent registries, the short-term mortality rate (90-day mortality) in all patients who undergo hip arthroplasty has an average value of 6.9% [64]. In that period, the dominant causes seem to be cardiac, cerebrovascular, or thromboembolic illnesses. Mortality at 90 days postoperatively in the US Medicare population has been reported as 1% for primary total hip arthroplasty [63]. That shows that mortality can vary significantly, especially when specific groups are studied. In other registries when we divided the mortality rate of partial primary hip replacement—usually used in elderly patients with fractures, we find a rate of 21.53 per 100 person-years. Otherwise, the total primary hip replacement has a rate of 2.54 per 100 person-years [65].

#### **4.2 Thromboembolism**

Thromboembolism is a potentially catastrophic complication faced by all patients who undergo elective hip arthroplasty. During the 90 days following primary arthroplasty surgery, hospitalization due to symptomatic deep vein thrombosis occurs in 0.7%, while hospitalization due to pulmonary embolism occurs in 0.3% [66]. In early reports prior of routine prophylaxis, venous thrombosis occurred as high as 50% of times in patients after total hip replacement [67]. In 2001, the sixth conference held by the American College of Chest Physicians came to the conclusion that all patients undergoing total joint replacement needed to be placed in the highest-risk category for DVT [68]. Today, there are guidelines from different medical areas with the intent to patronize the use of drugs and to give information about the management of thromboembolic disease. Despite all the attempts to validate and embrace the use of these guidelines, the ideal method of thromboembolic events prophylaxis remains controversial.

The general concern for total joint replacement surgeons, about these publications considered as high-level recommendations (1A), was the promotion of aggressive treatment for all patients, regardless of their risk profile. In 2011 and 2012, reports from the FDA appointed that anticoagulants were the leading drug risk to patients and complications like bleeding, drainage, and wound complications were the critical counterpoint for routine aggressive prophylaxis [69].

Today, there is no current evidence whether factors other than a history of previous venous thromboembolism increase the risk of venous thromboembolism in patients undergoing elective hip arthroplasty [70]. There are many other factors that were appointed to increase risk, like, obesity, or advanced age, but there's no real evidence to support. There is a consensus that any other factor that can cause decrease of mobility can be a risk factor, the same way for hemostatic abnormalities that can cause hypercoagulable states. There are no image exams or laboratory markers that can indicate a greater risk for thromboembolism. Today, there is strong evidence against the routine use of ultrasound for the screening of patients after hip arthroplasty for DVT. Is important to bear in mind that, at least 50% of patients, diagnose is not clinically apparent.

The diagnosis of DVT is based in clinical findings, usually pain and tenderness in the calf or thigh, erythema, and swelling, most of the times unilateral. Venography still stands as the "gold standard" for confirmation of DVT, but the duplex ultrasound seems to be a low-cost, minimal morbidity, good sensitivity option, besides the risk of anaphylactic reaction to contrast and low chances of inducing DVT that

**67**

*Hip Arthroplasty*

pulmonary angiography.

the risk for formation of clots.

or external rotation of the limb.

**4.3 Dislocation**

*DOI: http://dx.doi.org/10.5772/intechopen.84508*

venography carries. Pulmonary embolism can curse with chest pain, breathlessness, and rapid pulse, and it's a cause of sudden death. The diagnosis can be confirmed by

has been a tendency to return the use of aspirin after hospital discharge [71].

It is a consensus, even when there's no evidence to support, that patients undergoing elective hip or knee arthroplasty, and who also have a known bleeding disorder (e.g., hemophilia) and/or active liver disease, use a less aggressive treatment with mechanical compressive devices for preventing venous thromboembolism. Early mobilization still is a low-cost, minimal risk to the patient and consistent method with the current practice. Mobilization as soon as possible following hip arthroplasty addresses the stasis limb of Virchow's triad (hypercoagulability, endothelial injury, and stasis) promoting the regional blood flow and diminishing

Dislocation is one of the most feared complications after THA. Probably, it is one of the most common indications for revision surgery. An incidence from 1 to 3% of dislocation after THA has been reported [72]. Risk factors include the type of surgical approach, previous surgery, obesity, fracture of proximal femur, malpositioning of components, impingement, insufficient abductor muscle, femoral component head sizes, and others. Many studies tried to isolated these causes, but there's not much medical evidence to support, and the most common conclusion is that retrospective randomized trials examining dislocation rates and other clinical parameters are needed [73]. Clinical finding include pain, shortening, and internal

Factors like age, height, or race are seen to be associated with bias with at least one technical-related factor when the disclosure is dislocation. However, in many

The most used surgical approaches for THA are the posterior and direct lateral approaches. The posterior approach is considered to be easy to perform; however, increased rates of dislocation have been reported. The direct lateral approach was related to an increased risk of limp. Studies indicate that soft tissue repair reduces the relative risk of dislocation using the posterior approach and that the dislocation rate for these approaches becomes similar. It has been advocated that bigger head

The vast majority of dislocations occur within 3 months of surgery. These early dislocation (<6 months) presents higher chance of success with nonoperative treatment. Late complications, after 5 years in general, are more challenging to treat because of the many factors that can be attributed to these cases [72]. The combination of muscular weakness and malposition implants is seen to be the worst scenario for hip stability. Besides all the discussion about head sizes and different approaches, the single, most effective way of preventing dislocation still is education of the patients and the people who assist them. They should be aware that which extreme movements

series, dislocation occurred in women more often than men.

sizes increase instability and have greater ROM [22, 74, 75].

The best method of prophylaxis still is not clear. There is evidence to suggest that pharmacological agents and/or mechanical compression devices reduce DVT rates in patients undergoing elective knee or hip arthroplasty. The results of analyses in recent studies did not consistently suggest that any one strategy is preferable to another. The most commonly used agents are low-molecular-weight heparin (LMWH), aspirin, direct factor Xa inhibitors ("xabans"), and warfarin. Devices of intermittent compression seem to be effective especially in distal emboli. There's no consensus either for the time that prophylaxis is maintained. It varies for at least 10 days as far as 35 days after surgery, depending on the patient and the drug. There

*Hip Surgeries*

**4.1 Mortality**

The indications for arthroplasty have been expanded during recent years. More patients, both younger and old, are operated now, and, in that case, the older group runs a particularly greater natural risk of serious complications. That implicates that higher-risk patients undergo operation than anteriorly. In most recent registries, the short-term mortality rate (90-day mortality) in all patients who undergo hip arthroplasty has an average value of 6.9% [64]. In that period, the dominant causes seem to be cardiac, cerebrovascular, or thromboembolic illnesses. Mortality at 90 days postoperatively in the US Medicare population has been reported as 1% for primary total hip arthroplasty [63]. That shows that mortality can vary significantly, especially when specific groups are studied. In other registries when we divided the mortality rate of partial primary hip replacement—usually used in elderly patients with fractures, we find a rate of 21.53 per 100 person-years. Otherwise, the total primary hip replace-

Thromboembolism is a potentially catastrophic complication faced by all patients who undergo elective hip arthroplasty. During the 90 days following primary arthroplasty surgery, hospitalization due to symptomatic deep vein thrombosis occurs in 0.7%, while hospitalization due to pulmonary embolism occurs in 0.3% [66]. In early reports prior of routine prophylaxis, venous thrombosis occurred as high as 50% of times in patients after total hip replacement [67]. In 2001, the sixth conference held by the American College of Chest Physicians came to the conclusion that all patients undergoing total joint replacement needed to be placed in the highest-risk category for DVT [68]. Today, there are guidelines from different medical areas with the intent to patronize the use of drugs and to give information about the management of thromboembolic disease. Despite all the attempts to validate and embrace the use of these guidelines, the ideal method of thromboembolic

The general concern for total joint replacement surgeons, about these publications considered as high-level recommendations (1A), was the promotion of aggressive treatment for all patients, regardless of their risk profile. In 2011 and 2012, reports from the FDA appointed that anticoagulants were the leading drug risk to patients and complications like bleeding, drainage, and wound complications were

Today, there is no current evidence whether factors other than a history of previous venous thromboembolism increase the risk of venous thromboembolism in patients undergoing elective hip arthroplasty [70]. There are many other factors that were appointed to increase risk, like, obesity, or advanced age, but there's no real evidence to support. There is a consensus that any other factor that can cause decrease of mobility can be a risk factor, the same way for hemostatic abnormalities that can cause hypercoagulable states. There are no image exams or laboratory markers that can indicate a greater risk for thromboembolism. Today, there is strong evidence against the routine use of ultrasound for the screening of patients after hip arthroplasty for DVT. Is important to bear in mind that, at least 50% of patients,

The diagnosis of DVT is based in clinical findings, usually pain and tenderness in the calf or thigh, erythema, and swelling, most of the times unilateral. Venography still stands as the "gold standard" for confirmation of DVT, but the duplex ultrasound seems to be a low-cost, minimal morbidity, good sensitivity option, besides the risk of anaphylactic reaction to contrast and low chances of inducing DVT that

the critical counterpoint for routine aggressive prophylaxis [69].

ment has a rate of 2.54 per 100 person-years [65].

events prophylaxis remains controversial.

diagnose is not clinically apparent.

**4.2 Thromboembolism**

**66**

venography carries. Pulmonary embolism can curse with chest pain, breathlessness, and rapid pulse, and it's a cause of sudden death. The diagnosis can be confirmed by pulmonary angiography.

The best method of prophylaxis still is not clear. There is evidence to suggest that pharmacological agents and/or mechanical compression devices reduce DVT rates in patients undergoing elective knee or hip arthroplasty. The results of analyses in recent studies did not consistently suggest that any one strategy is preferable to another. The most commonly used agents are low-molecular-weight heparin (LMWH), aspirin, direct factor Xa inhibitors ("xabans"), and warfarin. Devices of intermittent compression seem to be effective especially in distal emboli. There's no consensus either for the time that prophylaxis is maintained. It varies for at least 10 days as far as 35 days after surgery, depending on the patient and the drug. There has been a tendency to return the use of aspirin after hospital discharge [71].

It is a consensus, even when there's no evidence to support, that patients undergoing elective hip or knee arthroplasty, and who also have a known bleeding disorder (e.g., hemophilia) and/or active liver disease, use a less aggressive treatment with mechanical compressive devices for preventing venous thromboembolism.

Early mobilization still is a low-cost, minimal risk to the patient and consistent method with the current practice. Mobilization as soon as possible following hip arthroplasty addresses the stasis limb of Virchow's triad (hypercoagulability, endothelial injury, and stasis) promoting the regional blood flow and diminishing the risk for formation of clots.

#### **4.3 Dislocation**

Dislocation is one of the most feared complications after THA. Probably, it is one of the most common indications for revision surgery. An incidence from 1 to 3% of dislocation after THA has been reported [72]. Risk factors include the type of surgical approach, previous surgery, obesity, fracture of proximal femur, malpositioning of components, impingement, insufficient abductor muscle, femoral component head sizes, and others. Many studies tried to isolated these causes, but there's not much medical evidence to support, and the most common conclusion is that retrospective randomized trials examining dislocation rates and other clinical parameters are needed [73]. Clinical finding include pain, shortening, and internal or external rotation of the limb.

Factors like age, height, or race are seen to be associated with bias with at least one technical-related factor when the disclosure is dislocation. However, in many series, dislocation occurred in women more often than men.

The most used surgical approaches for THA are the posterior and direct lateral approaches. The posterior approach is considered to be easy to perform; however, increased rates of dislocation have been reported. The direct lateral approach was related to an increased risk of limp. Studies indicate that soft tissue repair reduces the relative risk of dislocation using the posterior approach and that the dislocation rate for these approaches becomes similar. It has been advocated that bigger head sizes increase instability and have greater ROM [22, 74, 75].

The vast majority of dislocations occur within 3 months of surgery. These early dislocation (<6 months) presents higher chance of success with nonoperative treatment. Late complications, after 5 years in general, are more challenging to treat because of the many factors that can be attributed to these cases [72]. The combination of muscular weakness and malposition implants is seen to be the worst scenario for hip stability.

Besides all the discussion about head sizes and different approaches, the single, most effective way of preventing dislocation still is education of the patients and the people who assist them. They should be aware that which extreme movements

and which specific position are most likely to cause dislocation, and the ways of avoid them without lose their independence. It's important that the patient is able to repeat and understand the instructions for precaution before hospital discharge and has reinforced these directions at follow-up routine.

The surgical options for treatment are as many as the causes for the dislocation can be. Change of components for longer and bigger heads, liner exchange, and elevated rim could be successful sometimes; otherwise, component revision, soft tissue reconstruction, or even constrained liner may be needed. Identifying the causes of instability after THA is essential for the correct approach and satisfactory outcome.

#### **4.4 Nerve and vascular injuries**

Nerve and vascular injuries are very uncommon complications in primary total hip replacement but can be the most distressing ones. With an incidence between 0.8 and 3.5% for nerve injuries, the most common nerve damage followed by femoral nerve has been the sciatic nerve palsy [76]. These numbers can be altered when you observe a specific kind of approach, as with the anterior direct approach, that can present with up to 15% of lateral femoral cutaneous nerve palsy in some reports [77].

Several risk factors were identified for nerve injuries, including previous surgery, revision procedures, type of approach, and excessive leg extension. However, no correlation between the amount of lengthening and nerve palsy in total arthroplasties performed for dysplasia of the hip has been reported [78]. Previous surgery or revisions were correlated with technically difficult in the surgical exposure, anatomical abnormalities, and injudicious retraction. In order to diagnose nerve palsy after orthopedic surgery, an electromyogram can be of use to assess the extent and prognosis. According to the literature, partial recovery can be expected in 70–80% of cases. Latest reports appoint only 50% of full recovery after common peroneal nerve palsy following total hip arthroplasty with the mean time of 12–18 mouths depending on the severity of lesion. Other studies showed improvement beyond the limit of 2 years and independent of the nerve affected. Obesity was appointed as a factor that adversely influenced the nerve recovery [79, 80].

Vascular injury in primary hip arthroplasty is rare and most frequently associated with the use of screws for fixation of structural grafts, acetabular components, and protrusio rings or cages. The individual risk is determined by multiple factors depending on the surgeon's skills, the number of previous surgeries, and the approach itself. The acetabular quadrant system as described by Wasielewski et al. is a useful tool to understand the neurovascular anatomy of the hip, to detect the safe zone, and subsequently prevents complications that can pose as a threat to the limb and the patient [81].

#### **4.5 Fractures**

The most common are those who affect the femur and are classified by the local of the fracture, the fixation of implant, and the bone stock of the femur. Can also be dived by time, as intraoperative and postoperative fractures, the most common being the intraoperative fractures of the femur with an uncemented steam.

There are moments during the procedure that the fracture is most likely to occur. One of the critical stages seems to be while attempting to dislocate the hip, especially in fragile bones of elderly patients and rheumatoid arthritis patients. During the stage of broaching or during the insertion of the implant, cortical defects and proximal deformities can elicit a fracture of the diaphysis. Acetabular fractures are much more uncommon also because often they are not recognized. The key moment is seen to be, with press-fit components, during the impaction of an underreamed acetabulum.

**69**

**Table 2.**

*Adapted from [84].*

*Hip Arthroplasty*

(**Table 1**).

results.

**Table 1.**

*Vancouver classification resume [82].*

fracture in active patient

compromised

Type AL Nonoperative treatment unless implant stability compromised

salvage procedures and elderly patients Type C Fixation with minimally invasive lateral locking plate

*Treatment of periprosthetic fractures of the femur after total hip arthroplasty.*

**4.6 Infection**

*DOI: http://dx.doi.org/10.5772/intechopen.84508*

The Vancouver classification of periprosthetic femoral fractures became known for postoperative fractures and was modified to include this intraoperative ones

Periprosthetic joint infection remains a challenge for the orthopedic surgeons. It represents a risk for disastrous and painful consequences for the patients, especially for those submitted to elective primary joint replacement. The incidence reports approximately 1% of infection after THA. Great effort is applied to identify risk factors, minimize, and prevent these complications in a systematic way. Currently, recommendations are based in large, multicenter studies, but still high-level evidence for these practices are few, and many are based on little to none scientific

Prosthetic fixation Stable Stable Stable Loose Loose Stable Bone quality Good Good Good Good Poor Good

Type AG Nonoperative treatment if nondisplaced; open reduction and internal fixation if displaced

Type B1 Fixation with minimally invasive lateral locking plate; addition of allograft strut if bone stock

Type B3 Revision with extensively coated tapered fluted stem (modular or nonmodular); if bone stock

grossly compromised, use allograft-prosthesis composite with megaprosthesis reserved for

Type B2 Revision with extensively coated tapered fluted stem (modular or nonmodular)

**Vancouver A Vancouver B Vancouver C**

**AG AL B1 B2 B3 C**

The treatment can be initiated by taking preventive actions: the anticipation of anatomical challenges in preoperative planning and templating; the choice of implants, by the use of moderate rotational force and with wider approaches; and the liberation of soft tissues that might be restraining to the adequate exposure. Patients with osteoporotic bone, neuromuscular disorders, and previous hip surgery should be of higher concern. The use of fluoroscopy is an important tool to identify these fractures when suspected. Each type of fracture needs a specific treatment. In a review by Misur et al. [83], they summarize recommendations for the treatment of periprosthetic fractures of the femur with grading of published evidence supporting each recommendation (**Table 2**). The need for adjunctive fixation should be assessed, extended approach for the correct assessment is often needed, and the result needs to present a stable construction. Clear orientation for the patient and family about weight-bearing and healing process of the fracture is essential for good

#### *Hip Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.84508*

The Vancouver classification of periprosthetic femoral fractures became known for postoperative fractures and was modified to include this intraoperative ones (**Table 1**).

The treatment can be initiated by taking preventive actions: the anticipation of anatomical challenges in preoperative planning and templating; the choice of implants, by the use of moderate rotational force and with wider approaches; and the liberation of soft tissues that might be restraining to the adequate exposure. Patients with osteoporotic bone, neuromuscular disorders, and previous hip surgery should be of higher concern. The use of fluoroscopy is an important tool to identify these fractures when suspected. Each type of fracture needs a specific treatment. In a review by Misur et al. [83], they summarize recommendations for the treatment of periprosthetic fractures of the femur with grading of published evidence supporting each recommendation (**Table 2**). The need for adjunctive fixation should be assessed, extended approach for the correct assessment is often needed, and the result needs to present a stable construction. Clear orientation for the patient and family about weight-bearing and healing process of the fracture is essential for good results.

## **4.6 Infection**

*Hip Surgeries*

and which specific position are most likely to cause dislocation, and the ways of avoid them without lose their independence. It's important that the patient is able to repeat and understand the instructions for precaution before hospital discharge and

The surgical options for treatment are as many as the causes for the dislocation can be. Change of components for longer and bigger heads, liner exchange, and elevated rim could be successful sometimes; otherwise, component revision, soft tissue reconstruction, or even constrained liner may be needed. Identifying the causes of instability after THA is essential for the correct approach and satisfactory outcome.

Nerve and vascular injuries are very uncommon complications in primary total hip replacement but can be the most distressing ones. With an incidence between 0.8 and 3.5% for nerve injuries, the most common nerve damage followed by femoral nerve has been the sciatic nerve palsy [76]. These numbers can be altered when you observe a specific kind of approach, as with the anterior direct approach, that can present with up to 15% of lateral femoral cutaneous nerve palsy in some reports [77]. Several risk factors were identified for nerve injuries, including previous surgery, revision procedures, type of approach, and excessive leg extension. However, no correlation between the amount of lengthening and nerve palsy in total arthroplasties performed for dysplasia of the hip has been reported [78]. Previous surgery or revisions were correlated with technically difficult in the surgical exposure, anatomical abnormalities, and injudicious retraction. In order to diagnose nerve palsy after orthopedic surgery, an electromyogram can be of use to assess the extent and prognosis. According to the literature, partial recovery can be expected in 70–80% of cases. Latest reports appoint only 50% of full recovery after common peroneal nerve palsy following total hip arthroplasty with the mean time of 12–18 mouths depending on the severity of lesion. Other studies showed improvement beyond the limit of 2 years and independent of the nerve affected. Obesity was appointed as a

Vascular injury in primary hip arthroplasty is rare and most frequently associated with the use of screws for fixation of structural grafts, acetabular components, and protrusio rings or cages. The individual risk is determined by multiple factors depending on the surgeon's skills, the number of previous surgeries, and the approach itself. The acetabular quadrant system as described by Wasielewski et al. is a useful tool to understand the neurovascular anatomy of the hip, to detect the safe zone, and subsequently prevents complications that can pose as a threat to the limb

The most common are those who affect the femur and are classified by the local of the fracture, the fixation of implant, and the bone stock of the femur. Can also be dived by time, as intraoperative and postoperative fractures, the most common

There are moments during the procedure that the fracture is most likely to occur. One of the critical stages seems to be while attempting to dislocate the hip, especially in fragile bones of elderly patients and rheumatoid arthritis patients. During the stage of broaching or during the insertion of the implant, cortical defects and proximal deformities can elicit a fracture of the diaphysis. Acetabular fractures are much more uncommon also because often they are not recognized. The key moment is seen to be, with press-fit components, during the impaction of an underreamed acetabulum.

being the intraoperative fractures of the femur with an uncemented steam.

has reinforced these directions at follow-up routine.

factor that adversely influenced the nerve recovery [79, 80].

**4.4 Nerve and vascular injuries**

**68**

and the patient [81].

**4.5 Fractures**

Periprosthetic joint infection remains a challenge for the orthopedic surgeons. It represents a risk for disastrous and painful consequences for the patients, especially for those submitted to elective primary joint replacement. The incidence reports approximately 1% of infection after THA. Great effort is applied to identify risk factors, minimize, and prevent these complications in a systematic way. Currently, recommendations are based in large, multicenter studies, but still high-level evidence for these practices are few, and many are based on little to none scientific


#### **Table 1.**

*Vancouver classification resume [82].*


#### **Table 2.**

*Treatment of periprosthetic fractures of the femur after total hip arthroplasty.*

foundation whatsoever. In 2014, the Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection in the attempt to unify the current knowledge and practice was published.

Risk factors were divided as significant and potential risks for development of surgical site infection (SSI) or periprosthetic joint infection (PJI) after elective total joint arthroplasty (TJA). In the first category, 99% of the delegates consensus that active infection of the arthritic joint (septic arthritis), presence of septicemia, and/or presence of active local cutaneous, subcutaneous, or deep tissue infection are all significant risk factors predisposing patients to and are contraindication to undertaking elective TJA. Ninety-four percent agree that history of the previous surgery, poorly controlled diabetes mellitus (glucose > 200 mg/L or HbA1C > 7%), malnutrition, morbid obesity (BMI > 40 Kg/m<sup>2</sup> ), active liver disease, chronic renal disease, excessive smoking (>1 pack per day), excessive alcohol consumption (>40 units per week), intravenous drug abuse, recent hospitalization, extended stay in a rehabilitation facility, male gender, diagnosis of posttraumatic arthritis, inflammatory arthropathy, prior surgical procedure in the affected joint, and severe immunodeficiency are potential risk factors for development of SSI or PJI [85].

Active infection in periodontal disease, methicillin-resistant *Staphylococcus aureus* (MRSA), and methicillin-sensitive *Staphylococcus aureus* (MSSA) colonization were appointed as factors that can contribute to development of the infection, as well as urinary tract infection (UTI); however, there's no medical evidence to support screening for these patients. Nevertheless, patients with a known history of recurrent urinary infection or for those with evidence of ongoing urinary symptoms suspicious for infection should receive special attention.

Antibiotic prophylaxis is, in general, the most important factor to reduce the chances of contaminating microorganisms to establish during the procedure exposure. For that it's important that, by the time of the incision, there is adequate tissue concentration of the drug. Most of the guidelines recommend that prophylactic antibiotics be completely infused within 1 hour before the surgical incision. A first- or second-generation cephalosporin is normally administered for routine perioperative surgical prophylaxis, mostly because of its broad spectrum of action, cost-effectiveness, and the need to preserve newer and more expensive therapies for drug-resistant microorganisms. Additionally, they have excellent distribution profiles in the bone, synovium, muscle, and hematomas. Patients who weigh more than 80 kg should receive double the amount of cefazolin usually used. The efficacy of 1 day of cefuroxime vs. 3 days of cefazolin on postoperative wound infections was tested and found to have no statistically significant difference between the two regimens [86]. An additional dose of antibiotic should be administered intraoperatively after two half-lives of the prophylactic agent or after important blood loss. The choice of antibiotics for patients with pre-existing prostheses such as heart valves is the same as that for routine elective arthroplasty.

If infection is suspected, it's important to understand in what moment of the disease the patient presents himself because time is a relevant factor in approaching these complications and might influence in the treatment options. There are many classifications; in general, they are divided as follows: (1) early postoperative infection that can vary between 3 and 6 weeks onset within the time of the surgery, depending on the author; (2) late chronic infection after these periods and with an insidious presentation of symptoms; and (3) acute hematogenous infection, defined by the onset after these 3 to 6 weeks in a previously well-functioning prosthesis, probably by a distant source of infection.

**71**

**Figure 1.**

*Hip Arthroplasty*

*DOI: http://dx.doi.org/10.5772/intechopen.84508*

cyte esterase test strip

• A single positive culture

present with a painful or failed arthroplasty.

• A sinus tract communicating with the joint

• Having three of the following minor criteria:

• Positive histological analysis of periprosthetic tissue

*The AAOS's algorithm for treatment to patients with a painful or failed arthroplasty [85].*

The diagnosis still is in debate; the consensus is defined as PJI as follows:

• Two positive periprosthetic cultures with phenotypically identical organisms

• Elevated serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)

• Elevated synovial fluid white blood cell (WBC) count OR ++change on leuko-

• Elevated synovial fluid polymorphonuclear neutrophil percentage (PMN%)

The AAOS's algorithm (**Figure 1**) was adapted to be applied to patients who

*Hip Surgeries*

edge and practice was published.

development of SSI or PJI [85].

routine elective arthroplasty.

prosthesis, probably by a distant source of infection.

attention.

foundation whatsoever. In 2014, the Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection in the attempt to unify the current knowl-

liver disease, chronic renal disease, excessive smoking (>1 pack per day), excessive alcohol consumption (>40 units per week), intravenous drug abuse, recent hospitalization, extended stay in a rehabilitation facility, male gender, diagnosis of posttraumatic arthritis, inflammatory arthropathy, prior surgical procedure in the affected joint, and severe immunodeficiency are potential risk factors for

Active infection in periodontal disease, methicillin-resistant *Staphylococcus aureus* (MRSA), and methicillin-sensitive *Staphylococcus aureus* (MSSA) colonization were appointed as factors that can contribute to development of the infection, as well as urinary tract infection (UTI); however, there's no medical evidence to support screening for these patients. Nevertheless, patients with a known history of recurrent urinary infection or for those with evidence of ongoing urinary symptoms suspicious for infection should receive special

Antibiotic prophylaxis is, in general, the most important factor to reduce the chances of contaminating microorganisms to establish during the procedure exposure. For that it's important that, by the time of the incision, there is adequate tissue concentration of the drug. Most of the guidelines recommend that prophylactic antibiotics be completely infused within 1 hour before the surgical incision. A first- or second-generation cephalosporin is normally administered for routine perioperative surgical prophylaxis, mostly because of its broad spectrum of action, cost-effectiveness, and the need to preserve newer and more expensive therapies for drug-resistant microorganisms. Additionally, they have excellent distribution profiles in the bone, synovium, muscle, and hematomas. Patients who weigh more than 80 kg should receive double the amount of cefazolin usually used. The efficacy of 1 day of cefuroxime vs. 3 days of cefazolin on postoperative wound infections was tested and found to have no statistically significant difference between the two regimens [86]. An additional dose of antibiotic should be administered intraoperatively after two half-lives of the prophylactic agent or after important blood loss. The choice of antibiotics for patients with pre-existing prostheses such as heart valves is the same as that for

If infection is suspected, it's important to understand in what moment of the disease the patient presents himself because time is a relevant factor in approaching these complications and might influence in the treatment options. There are many classifications; in general, they are divided as follows: (1) early postoperative infection that can vary between 3 and 6 weeks onset within the time of the surgery, depending on the author; (2) late chronic infection after these periods and with an insidious presentation of symptoms; and (3) acute hematogenous infection, defined by the onset after these 3 to 6 weeks in a previously well-functioning

HbA1C > 7%), malnutrition, morbid obesity (BMI > 40 Kg/m<sup>2</sup>

Risk factors were divided as significant and potential risks for development of surgical site infection (SSI) or periprosthetic joint infection (PJI) after elective total joint arthroplasty (TJA). In the first category, 99% of the delegates consensus that active infection of the arthritic joint (septic arthritis), presence of septicemia, and/or presence of active local cutaneous, subcutaneous, or deep tissue infection are all significant risk factors predisposing patients to and are contraindication to undertaking elective TJA. Ninety-four percent agree that history of the previous surgery, poorly controlled diabetes mellitus (glucose > 200 mg/L or

), active

**70**

The diagnosis still is in debate; the consensus is defined as PJI as follows:


The AAOS's algorithm (**Figure 1**) was adapted to be applied to patients who present with a painful or failed arthroplasty.

The major discussion nowadays among joint replacement hip surgeons is whether to perform a one-stage or two-stage revision in patients with diagnosis of infection. Patients with early postoperative infection apparently have strong chances of cure when an open debridement and change of mobile parts are realized as an early aggressive intervention [87].

Both procedures have the same intent: identification of the organisms; eradication of the foci; physical removal of any organism, tissue, or components that might have been exposed; appropriated treatment with antibiotics; and safe reconstruction of the joint in a healthy environment.

The bone cement loaded with antibiotics has been the main weapon in the one-stage enthusiasts, as the spacers have been for those who advocate four twostage revisions. The selection of patients has been seen to have an important role in that decision; the tendency has been the single-stage revision. With more studies published each year showing similar outcomes for both types of procedures, the social and economic advantages of one operation, like shorter hospitalization, early return to activities, and higher satisfaction rates, give the one-stage revision an increasing role in the treatment of joint infection.

#### **5. Outcomes**

The focus of THA registries traditionally has been on implant longevity and rates of revision surgery. The landmark of failure of the implant and the necessity of revision still are considered the best definition of clinical failure as well. Otherwise, the choice of parameters for the definition of failure, clinical or radiographic, could be troublesome. Short-term mortality rate (90 days postoperative) also has been used as an outcome. However, the latest publications signalize an important change in the outcome reports. Since pain, impaired joint function, and quality of life related to hip disease are the main indications for THA, thus to include this patient-related information in the results reported after primary hip replacement. The patient-reported outcome (PRO) includes pain relief, joint function, and other health-related quality-of-life improvements and represents an important aspect of hip arthroplasty results.

National joint registries are the most reliable and most quoted references when the subject is outcome. Through them it's been possible to have a greater view and more profound understanding of why arthroplasties fail. For example, in the Norwegian report of 2002, 9.2% of 17,323 primary Charnley hip prosthesis implants were revised after 10 years of follow-up, and 71% of the failures involved aseptic loosening of the femoral component. The use of a specific type of cements was appointed as an important and highly significant probable cause in this percentage [88]. Another example was the metal-on-metal surface and the early complications reported in many registries. For that manner, reports became an essential tool to orthopedic surgeons to understand the impact of all these variables—implant design, material, patient selection, surgical techniques, and others—and how they are influencing the outcomes in their clinical practice.

In general the most common causes for revision are the same in every other registry or study published. Sometimes, the percentages can vary depending on the population studied. In the 2012 Swedish reports, for example, aseptic loosening including osteolysis was the most common cause for revision (28%), followed by dislocation (26%), infection (22%), and periprosthetic fracture (13%) [89].

One of the major areas of discussion has been cemented versus cementless implants and how they can influence in the outcome. An increasing use of uncemented implants in the last 10 to 15 years has been reported. Over the same time

**73**

*Hip Arthroplasty*

*DOI: http://dx.doi.org/10.5772/intechopen.84508*

data of better outcome in patients older than 75 years [91].

prerequisite to reach adequate cementation [97].

period, there was a corresponding reduction in the use of cemented ones. The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man of 2014 reports that in 2003 cemented hip replacement was used in 60.5% in comparison to 33.2% in 2013. Otherwise, cementless increased from 16.8% in 2003 to 42.5% in 2013 [90]. The "new trend" defenses of uncemented implants are that it is faster surgically, avoids the third-body debris, and creates a biological interface of bone ingrown in the implant (and with that less rate of loosening) and less chances of embolic events that can occur during cementation. The cement users appoint that there are less fractures, intra- and postoperatively, less dislocation and leg length discrepancies, and less thigh pain report after surgery, and, mainly, there is registry

All these qualities or failures on both implants are, in fact, correct. Cemented hip arthroplasties have been reported to be better in many nation registries, especially in older patients [92, 93]. Otherwise, specific centers across the globe reported up to 99% of cementless steam survival after 12–26 years of follow-up [94, 95]. There are reports of the accuracy during cup position, and cemented cups seem to have better position than uncemented cups that have the tendency to deviate from their original place [96]. The incidence of periprosthetic femoral fractures is becoming more common, and that could be attributed to the larger use of uncemented implants. Thigh pain is most common with uncemented femoral steams, but in a great way, this can be attributed to the design of the implant that was used. The major issue in using cemented implants still is the technique and its reproducibility. Perfect cementing technique is essential to achieve all these excellent results. Pulsatile jetlavage to clean the cancellous bone and allow the cement to have good interdigitating as well as good pressurization and homogenous cement mantle is appointed as

Other important aspect of failure in hip arthroplasty has been between the implants that are used in partial arthroplasties. In the Australian report of 2014, in patients under the age of 75 years old after the neck of the femur fracture, the revision rate after 10 years for primary unipolar monoblock and unipolar modular hip replacement was the same (16.1%). To the same group of patients, the bipolar

In primary hip replacement for osteoartrite (OA), nation registry reports are similar, in an overall of 5–6% rate of revision in 10 years for all ages. When divided by the type, the British reports 3.2% for all cemented, 7.68% to all cementless implants, and a total of 3.95% for hybrids. The Australian reports 6, 5.4, and 4.8%, respectively. When divided by age and gender, younger females are in greater risk of revision in 10 years. Inversion occurs when the primary replacement is made around 65 years of age in men, showing a slightly higher incidence of revision than women after 10 years [90, 93].

A lot of attention is given to the type of bearing nowadays. The most recent surfaces

The material that steams are made also has an influence in the outcomes as well as femoral head sizes. Pure titanium seems to have lower revision rates than titanium

like ceramics, highly cross-linked polyethylene, and their combination with metal generate a lot of discussion in what would be the ideal, more durable surface, and for whom it should be use. Keeping aside the costs and a few laboratory assays, there is no real evidence in favor or against any of these, except for the metal-on-metal combination that has inferior outcomes in almost all the comparative published. In the 2014 Australian report, ceramic combined with ceramic and highly cross-linked polyethylene had similar 10-year rates, 4.7 and 4.5%, respectively. The lower revision rate was metal on highly cross-linked polyethylene with 4.3% in 1 years. Any of these combinations, when associated with an exchangeable femoral neck, showed two times higher rate of failure in that same period of time [93]. In the British reports, hybrid assembly with ceramic on polyethylene showed the outcome with 2.19% in 10 years [90].

presents a 9% rate of revision in the same period of 10 years [93].

#### *Hip Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.84508*

*Hip Surgeries*

**5. Outcomes**

hip arthroplasty results.

as an early aggressive intervention [87].

tion of the joint in a healthy environment.

increasing role in the treatment of joint infection.

The major discussion nowadays among joint replacement hip surgeons is whether to perform a one-stage or two-stage revision in patients with diagnosis of infection. Patients with early postoperative infection apparently have strong chances of cure when an open debridement and change of mobile parts are realized

Both procedures have the same intent: identification of the organisms; eradication of the foci; physical removal of any organism, tissue, or components that might have been exposed; appropriated treatment with antibiotics; and safe reconstruc-

The bone cement loaded with antibiotics has been the main weapon in the one-stage enthusiasts, as the spacers have been for those who advocate four twostage revisions. The selection of patients has been seen to have an important role in that decision; the tendency has been the single-stage revision. With more studies published each year showing similar outcomes for both types of procedures, the social and economic advantages of one operation, like shorter hospitalization, early return to activities, and higher satisfaction rates, give the one-stage revision an

The focus of THA registries traditionally has been on implant longevity and rates of revision surgery. The landmark of failure of the implant and the necessity of revision still are considered the best definition of clinical failure as well. Otherwise, the choice of parameters for the definition of failure, clinical or radiographic, could be troublesome. Short-term mortality rate (90 days postoperative) also has been used as an outcome. However, the latest publications signalize an important change in the outcome reports. Since pain, impaired joint function, and quality of life related to hip disease are the main indications for THA, thus to include this patient-related information in the results reported after primary hip replacement. The patient-reported outcome (PRO) includes pain relief, joint function, and other health-related quality-of-life improvements and represents an important aspect of

National joint registries are the most reliable and most quoted references when

the subject is outcome. Through them it's been possible to have a greater view and more profound understanding of why arthroplasties fail. For example, in the Norwegian report of 2002, 9.2% of 17,323 primary Charnley hip prosthesis implants were revised after 10 years of follow-up, and 71% of the failures involved aseptic loosening of the femoral component. The use of a specific type of cements was appointed as an important and highly significant probable cause in this percentage [88]. Another example was the metal-on-metal surface and the early complications reported in many registries. For that manner, reports became an essential tool to orthopedic surgeons to understand the impact of all these variables—implant design, material, patient selection, surgical techniques, and others—and how they

In general the most common causes for revision are the same in every other registry or study published. Sometimes, the percentages can vary depending on the population studied. In the 2012 Swedish reports, for example, aseptic loosening including osteolysis was the most common cause for revision (28%), followed by dislocation (26%), infection (22%), and periprosthetic fracture (13%) [89]. One of the major areas of discussion has been cemented versus cementless implants and how they can influence in the outcome. An increasing use of uncemented implants in the last 10 to 15 years has been reported. Over the same time

are influencing the outcomes in their clinical practice.

**72**

period, there was a corresponding reduction in the use of cemented ones. The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man of 2014 reports that in 2003 cemented hip replacement was used in 60.5% in comparison to 33.2% in 2013. Otherwise, cementless increased from 16.8% in 2003 to 42.5% in 2013 [90]. The "new trend" defenses of uncemented implants are that it is faster surgically, avoids the third-body debris, and creates a biological interface of bone ingrown in the implant (and with that less rate of loosening) and less chances of embolic events that can occur during cementation. The cement users appoint that there are less fractures, intra- and postoperatively, less dislocation and leg length discrepancies, and less thigh pain report after surgery, and, mainly, there is registry data of better outcome in patients older than 75 years [91].

All these qualities or failures on both implants are, in fact, correct. Cemented hip arthroplasties have been reported to be better in many nation registries, especially in older patients [92, 93]. Otherwise, specific centers across the globe reported up to 99% of cementless steam survival after 12–26 years of follow-up [94, 95]. There are reports of the accuracy during cup position, and cemented cups seem to have better position than uncemented cups that have the tendency to deviate from their original place [96]. The incidence of periprosthetic femoral fractures is becoming more common, and that could be attributed to the larger use of uncemented implants. Thigh pain is most common with uncemented femoral steams, but in a great way, this can be attributed to the design of the implant that was used. The major issue in using cemented implants still is the technique and its reproducibility. Perfect cementing technique is essential to achieve all these excellent results. Pulsatile jetlavage to clean the cancellous bone and allow the cement to have good interdigitating as well as good pressurization and homogenous cement mantle is appointed as prerequisite to reach adequate cementation [97].

Other important aspect of failure in hip arthroplasty has been between the implants that are used in partial arthroplasties. In the Australian report of 2014, in patients under the age of 75 years old after the neck of the femur fracture, the revision rate after 10 years for primary unipolar monoblock and unipolar modular hip replacement was the same (16.1%). To the same group of patients, the bipolar presents a 9% rate of revision in the same period of 10 years [93].

In primary hip replacement for osteoartrite (OA), nation registry reports are similar, in an overall of 5–6% rate of revision in 10 years for all ages. When divided by the type, the British reports 3.2% for all cemented, 7.68% to all cementless implants, and a total of 3.95% for hybrids. The Australian reports 6, 5.4, and 4.8%, respectively. When divided by age and gender, younger females are in greater risk of revision in 10 years. Inversion occurs when the primary replacement is made around 65 years of age in men, showing a slightly higher incidence of revision than women after 10 years [90, 93].

A lot of attention is given to the type of bearing nowadays. The most recent surfaces like ceramics, highly cross-linked polyethylene, and their combination with metal generate a lot of discussion in what would be the ideal, more durable surface, and for whom it should be use. Keeping aside the costs and a few laboratory assays, there is no real evidence in favor or against any of these, except for the metal-on-metal combination that has inferior outcomes in almost all the comparative published. In the 2014 Australian report, ceramic combined with ceramic and highly cross-linked polyethylene had similar 10-year rates, 4.7 and 4.5%, respectively. The lower revision rate was metal on highly cross-linked polyethylene with 4.3% in 1 years. Any of these combinations, when associated with an exchangeable femoral neck, showed two times higher rate of failure in that same period of time [93]. In the British reports, hybrid assembly with ceramic on polyethylene showed the outcome with 2.19% in 10 years [90].

The material that steams are made also has an influence in the outcomes as well as femoral head sizes. Pure titanium seems to have lower revision rates than titanium and cobalt-chrome in the steam/neck material. Head sizes of 32 mm have a lower rate of revision than head sizes of 28 mm or less. However, there is no difference when head size 32 mm is compared to larger head size. This can probably be attributed to the higher incidence of dislocation that 28 mm or less heads present [93].

It has been advocated that total hip arthroplasty is probably the most successful operative intervention performed by human beings. Still, a constant strive for innovation has a guide progress, especially in the technologic field. Every year more aspects are being reported, and a great volume of information has been gathered. More than never before, more patients, with a wider range of age and comorbidities, are having their hips replaced. The understanding of how this affects their lives and how to meet the changes in the demand and expectations for THA is an essential key to keep improving such celebrated medical procedure.

For this reason, patient-reported outcome measures (PROMs) are becoming increasingly important in the allocation of healthcare resources and the provision of guidelines for optimum care and management [89].The Swedish reports were pioneer in that area and are still improving the way to collect this information and how to process that in numbers. In 2012 reports, patient satisfaction 1 year of THA (2010–2011) varied from 82.8 to 93.4%. They analyzed other variables such as pain relief, healthrelated quality of life gained, 90-day mortality, coverage, reoperation within 2 years, 5-year implant survival, 10-year implant survival, and set and nationwide standard for comparison with the obtained by institutions. The conclusions highlight the great challenge that it's to organize the structure of information and engage the participants. Important influences were appointed related to anxiety and depression in the predictor of pain, pain relief, and patient satisfaction [98]. There's no doubt that this patientrelated information will have an increasing role in the advanced hip arthroplasty.

#### **6. Perspectives to the future**

Although hip arthroplasty celebrates over 50 years since its creation, how the procedure has been slow in recent years. The main lines of research thus far developed are concentrated in areas that seek alternatives to metal implants, the use of new biomaterials, as well as the use of computer tools for planning and development of surgery [99].

Several studies involving existing prostheses on the market seek to improve efficiency by reducing the rejection or failure and to find synergy between the contact areas. With this, new surfaces, such as porous, the use of mesh titanium, and the development of metal-polyethylene interaction, are being researched [100, 101].

The area of biomaterials points to major advances. Examples are the use of hydroxyapatite for surface coating, the use of alternative bone graft as humans or bovine lyophilized to assist in cases of bone loss, as well as the development of multidisciplinary techniques for bone regeneration, as in the case of VascuBone Project [102–104].

Among the computer tools for programming and development of surgery, the navigation techniques are the most researched. The main distinguishing feature of this feature is that it provides real-time measurements and precise alignments [105–109].

#### **7. Conclusions**

Regardless of the approach, the chosen implant, the THA surgery, is a major evolution of modern medicine and came as a great benefit to patients. Every technique employed should be well studied, and the patient must always be the most benefited from the surgery.

**75**

*Hip Arthroplasty*

**Acknowledgements**

**Conflict of interest**

ted version of the manuscript.

OA osteoarthritis

Gpa gigapascal

ROM range of motion

SSI surgical site infection

UTI urinary tract infection

THA total hip arthroplasty DVT deep vein thrombosis PMMA polymethyl methacrylate

**Nomenclature**

**Notes/thanks/other declarations**

Brazil, for the opportunity in developing this work.

UHMWPE ultrahigh-molecular-weight polyethylene

MRSA methicillin-resistant *Staphylococcus aureus* MSSA methicillin-sensitive *Staphylococcus aureus*

XLPE highly cross-linked polyethylene

LMWH low-molecular-weight heparin

PJI periprosthetic joint infection TJA total joint arthroplasty BMI body mass index

*DOI: http://dx.doi.org/10.5772/intechopen.84508*

The authors would like to thank the Federal University of Rio Grande do Sul (UFRGS), Department of Orthopedics, Tissue Bank Unit, at the Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul (RS), Brazil.

We hereby indicate that there is no financial or business interest concerning any author or their immediate family members of the manuscript entitled "Hip Arthroplasty." The submitted manuscript is a study on the history of hip arthroplasty, total hip arthroplasty approaches, implant types, complications associated

We also confirm that no conflict of interest for drugs, devices or prosthesis, or any other materials either biological or synthetic exists in this study if they are not

Moreover, no part of the investigation has been carried out or supported in grant by any related company or entity. None of the authors own stock, acted as a consultant, established contract work, served as an officer or member of the board, or received more than US\$ 2000 a year from any related company or entity within the past 2 years. Each author fulfills the requirements for authorship and publicly and legally responds for the content of the above manuscript, and all authors have read this final version of the paper and are aware of its content and agreed with the submit-

The authors would like to thank the Research Group in Hip, Biomaterials and Tissue Bank, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul,

with hip arthroplasty, outcomes, and perspectives to the future.

We assure that the information above is absolutely accurate.

being particularly assessed as part of the investigation.

## **Acknowledgements**

*Hip Surgeries*

and cobalt-chrome in the steam/neck material. Head sizes of 32 mm have a lower rate of revision than head sizes of 28 mm or less. However, there is no difference when head size 32 mm is compared to larger head size. This can probably be attributed to

It has been advocated that total hip arthroplasty is probably the most successful operative intervention performed by human beings. Still, a constant strive for innovation has a guide progress, especially in the technologic field. Every year more aspects are being reported, and a great volume of information has been gathered. More than never before, more patients, with a wider range of age and comorbidities, are having their hips replaced. The understanding of how this affects their lives and how to meet the changes in the demand and expectations for THA is an essen-

For this reason, patient-reported outcome measures (PROMs) are becoming increasingly important in the allocation of healthcare resources and the provision of guidelines for optimum care and management [89].The Swedish reports were pioneer in that area and are still improving the way to collect this information and how to process that in numbers. In 2012 reports, patient satisfaction 1 year of THA (2010–2011) varied from 82.8 to 93.4%. They analyzed other variables such as pain relief, healthrelated quality of life gained, 90-day mortality, coverage, reoperation within 2 years, 5-year implant survival, 10-year implant survival, and set and nationwide standard for comparison with the obtained by institutions. The conclusions highlight the great challenge that it's to organize the structure of information and engage the participants. Important influences were appointed related to anxiety and depression in the predictor of pain, pain relief, and patient satisfaction [98]. There's no doubt that this patientrelated information will have an increasing role in the advanced hip arthroplasty.

Although hip arthroplasty celebrates over 50 years since its creation, how the procedure has been slow in recent years. The main lines of research thus far developed are concentrated in areas that seek alternatives to metal implants, the use of new biomaterials, as well as the use of computer tools for planning and develop-

Several studies involving existing prostheses on the market seek to improve efficiency by reducing the rejection or failure and to find synergy between the contact areas. With this, new surfaces, such as porous, the use of mesh titanium, and the development of metal-polyethylene interaction, are being researched [100, 101]. The area of biomaterials points to major advances. Examples are the use of hydroxyapatite for surface coating, the use of alternative bone graft as humans or bovine lyophilized to assist in cases of bone loss, as well as the development of multidisciplinary techniques for bone regeneration, as in the case of VascuBone Project [102–104]. Among the computer tools for programming and development of surgery, the navigation techniques are the most researched. The main distinguishing feature of this feature is that it provides real-time measurements and precise alignments [105–109].

Regardless of the approach, the chosen implant, the THA surgery, is a major evolution of modern medicine and came as a great benefit to patients. Every technique employed should be well studied, and the patient must always be the most benefited

the higher incidence of dislocation that 28 mm or less heads present [93].

tial key to keep improving such celebrated medical procedure.

**6. Perspectives to the future**

ment of surgery [99].

**7. Conclusions**

from the surgery.

**74**

The authors would like to thank the Federal University of Rio Grande do Sul (UFRGS), Department of Orthopedics, Tissue Bank Unit, at the Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul (RS), Brazil.

## **Conflict of interest**

We hereby indicate that there is no financial or business interest concerning any author or their immediate family members of the manuscript entitled "Hip Arthroplasty." The submitted manuscript is a study on the history of hip arthroplasty, total hip arthroplasty approaches, implant types, complications associated with hip arthroplasty, outcomes, and perspectives to the future.

We also confirm that no conflict of interest for drugs, devices or prosthesis, or any other materials either biological or synthetic exists in this study if they are not being particularly assessed as part of the investigation.

Moreover, no part of the investigation has been carried out or supported in grant by any related company or entity. None of the authors own stock, acted as a consultant, established contract work, served as an officer or member of the board, or received more than US\$ 2000 a year from any related company or entity within the past 2 years.

Each author fulfills the requirements for authorship and publicly and legally responds for the content of the above manuscript, and all authors have read this final version of the paper and are aware of its content and agreed with the submitted version of the manuscript.

We assure that the information above is absolutely accurate.

## **Notes/thanks/other declarations**

The authors would like to thank the Research Group in Hip, Biomaterials and Tissue Bank, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil, for the opportunity in developing this work.

## **Nomenclature**



## **Author details**

Carlos Roberto Galia1,2,3,4\*, Tiango Aguiar Ribeiro5,6, Cristiano Valter Diesel2,3, Marcelo Reuwsaat Guimarães7 and Fernando Pagnussato2,4,8,9

1 Surgery Department, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul (RS), Brazil

2 Department of Orthopedics, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul (RS), Brazil

3 Medicine School of Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul (RS), Brazil

4 Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul (RS), Brazil

5 Surgery Department, Federal University of Santa Maria (UFSM), Santa Maria, Rio Grande do Sul (RS), Brazil

6 Department of Orthopedics (SOT), University Hospital of Santa Maria (UFSM), Santa Maria, Rio Grande do Sul (RS), Brazil

7 Orthopedic and Traumatologist Surgeon, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul (RS), Brazil

8 Federal University of Rio Grande do Sul. (UFRGS), Porto Alegre, Rio Grande do Sul (RS), Brazil

9 Tissue Bank, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul (RS), Brazil

\*Address all correspondence to: cgalia@hcpa.ufrgs.br

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**77**

*Hip Arthroplasty*

**References**

*DOI: http://dx.doi.org/10.5772/intechopen.84508*

[10] Wiles P. The Surgery of the

Surgery. 1958;**45**:488-497

1970;**72**:7-21

1982;**64**:619

pubmed/7166501

1975;**10**:126-131

Surgery. 1978;**92**(1):1-18

osteoarthritic hip. The British Journal of

[11] Waugh W. John Charnley: The Man and the Hip. London: Springer-Verlang; 1990

[12] Charnley J. Total hip replacement by low-friction arthroplasty. Clinical Orthopaedics and Related Research.

[13] Charnley J. Anchorage of the femoral head prosthesis to the shaft of the femur. The Journal of Bone and Joint

[14] Miller J. Pressure penetration of low viscosity acrylic cement for improved fixation of arthroplasty components. The Journal of Bone and Joint Surgery.

[15] Harris WH, McCarthy JC Jr, O�Neill DA. Femoral component loosening using contemporary techniques of femoral cement fixation. The Journal of Bone and Joint Surgery. 1982;**64**(7):1063-1067

[16] Harris WH, McCarthy JC Jr, O�Neill DA. Loosening of the femoral component of total hip replacement after plugging the femoral canal. The Hip. 1982:228-238. PMID: 7166501. https://www.ncbi.nlm.nih.gov/

[17] Lee AJ, Ling RS, Vangala SS. Some clinically relevant variables affecting the mechanical behaviour of bone cement. Archives of Orthopaedic and Trauma

[18] Bobyn JD et al. Porous surfaced layered prosthetic devices. Journal of Biomedical Engineering.

[19] Bobyn JD et al. The optimum pore size for the fixation of porous-surfaced metal implants by the ingrowth of bone.

Surgery. 1960;**42-B**:28-30

[1] Jones CA et al. Health related quality of life outcomes after total hip and knee arthroplasties in a community based population. The Journal of Rheumatology.

[2] Laupacis A et al. The effect of elective total hip replacement on health-related quality of life. The Journal of Bone and Joint Surgery.

[3] Learmonth DC et al. The operation of the century: Total hip replacement. The Lancet. 2007;**370**(9597):1508-1519

[4] Wood AM et al. A review on the management of hip and knee osteoarthritis. International Journal of

Chronic Diseases. 2013;**2013**:10

[5] Della Valle CJ, Rosenberg AG. Primary total hip arthroplasty: Indications and contraindications. In: Callaghan JJ, Rosenberg AG, Rubash HE, editors. The Adult Hip. Philadelphia, USA: Lippincott Williams

& Wilkins; 2007. pp. 851-858

Chirurgie. 1927;**54**:783-785

[8] Schwartsmann CR, Boschin LC. Quadril do adulto. In: Hebert S et al., editors. Ortopedia e Traumatologia: Princípios e Prática. Porto Alegre: Artmed

Editora S. A.; 2009. pp. 407-442

& Wilkins; 2007. pp. 3-31

[9] Peltier LF. A history of hip surgery. In: Callaghan JJ, Rosenberg AG, Rubash HE, editors. The Adult Hip. Philadelphia, USA: Lippincott Williams

732-736, 752-757

[6] Gluck T. Die invaginationsmethode der osteo-und arthroplastik. Berliner Klinische Wochenschrift. 1890;**28**:

[7] Haas J. Neue anwendungsgebiete der lorenz�schen bifurkation (gabelung des oberen femurendes). Zentralblatt für

2000;**27**(7):1745-1752

1993;**75**(11):1619-1626

### *Hip Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.84508*

## **References**

*Hip Surgeries*

**Author details**

Marcelo Reuwsaat Guimarães7

CRP C-reactive protein

WBC white blood cell

ESR erythrocyte sedimentation rate

PROs patient-reported outcome

PMN% polymorphonuclear neutrophil percentage AAOS American Academy of Orthopaedic Surgeons

PROMs patient-reported outcome measures

Rio Grande do Sul (RS), Brazil

Rio Grande do Sul (RS), Brazil

Rio Grande do Sul (RS), Brazil

Rio Grande do Sul (RS), Brazil

Porto Alegre, Rio Grande do Sul (RS), Brazil

Porto Alegre, Rio Grande do Sul (RS), Brazil

Porto Alegre, Rio Grande do Sul (RS), Brazil

Santa Maria, Rio Grande do Sul (RS), Brazil

(HCPA), Porto Alegre, Rio Grande do Sul (RS), Brazil

\*Address all correspondence to: cgalia@hcpa.ufrgs.br

8 Federal University of Rio Grande do Sul. (UFRGS), Porto Alegre,

9 Tissue Bank, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre,

**76**

provided the original work is properly cited.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Carlos Roberto Galia1,2,3,4\*, Tiango Aguiar Ribeiro5,6, Cristiano Valter Diesel2,3,

1 Surgery Department, Federal University of Rio Grande do Sul (UFRGS),

2 Department of Orthopedics, Hospital de Clínicas de Porto Alegre (HCPA),

5 Surgery Department, Federal University of Santa Maria (UFSM), Santa Maria,

6 Department of Orthopedics (SOT), University Hospital of Santa Maria (UFSM),

7 Orthopedic and Traumatologist Surgeon, Hospital de Clínicas de Porto Alegre

3 Medicine School of Federal University of Rio Grande do Sul (UFRGS),

4 Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre,

and Fernando Pagnussato2,4,8,9

[1] Jones CA et al. Health related quality of life outcomes after total hip and knee arthroplasties in a community based population. The Journal of Rheumatology. 2000;**27**(7):1745-1752

[2] Laupacis A et al. The effect of elective total hip replacement on health-related quality of life. The Journal of Bone and Joint Surgery. 1993;**75**(11):1619-1626

[3] Learmonth DC et al. The operation of the century: Total hip replacement. The Lancet. 2007;**370**(9597):1508-1519

[4] Wood AM et al. A review on the management of hip and knee osteoarthritis. International Journal of Chronic Diseases. 2013;**2013**:10

[5] Della Valle CJ, Rosenberg AG. Primary total hip arthroplasty: Indications and contraindications. In: Callaghan JJ, Rosenberg AG, Rubash HE, editors. The Adult Hip. Philadelphia, USA: Lippincott Williams & Wilkins; 2007. pp. 851-858

[6] Gluck T. Die invaginationsmethode der osteo-und arthroplastik. Berliner Klinische Wochenschrift. 1890;**28**: 732-736, 752-757

[7] Haas J. Neue anwendungsgebiete der lorenz�schen bifurkation (gabelung des oberen femurendes). Zentralblatt für Chirurgie. 1927;**54**:783-785

[8] Schwartsmann CR, Boschin LC. Quadril do adulto. In: Hebert S et al., editors. Ortopedia e Traumatologia: Princípios e Prática. Porto Alegre: Artmed Editora S. A.; 2009. pp. 407-442

[9] Peltier LF. A history of hip surgery. In: Callaghan JJ, Rosenberg AG, Rubash HE, editors. The Adult Hip. Philadelphia, USA: Lippincott Williams & Wilkins; 2007. pp. 3-31

[10] Wiles P. The Surgery of the osteoarthritic hip. The British Journal of Surgery. 1958;**45**:488-497

[11] Waugh W. John Charnley: The Man and the Hip. London: Springer-Verlang; 1990

[12] Charnley J. Total hip replacement by low-friction arthroplasty. Clinical Orthopaedics and Related Research. 1970;**72**:7-21

[13] Charnley J. Anchorage of the femoral head prosthesis to the shaft of the femur. The Journal of Bone and Joint Surgery. 1960;**42-B**:28-30

[14] Miller J. Pressure penetration of low viscosity acrylic cement for improved fixation of arthroplasty components. The Journal of Bone and Joint Surgery. 1982;**64**:619

[15] Harris WH, McCarthy JC Jr, O�Neill DA. Femoral component loosening using contemporary techniques of femoral cement fixation. The Journal of Bone and Joint Surgery. 1982;**64**(7):1063-1067

[16] Harris WH, McCarthy JC Jr, O�Neill DA. Loosening of the femoral component of total hip replacement after plugging the femoral canal. The Hip. 1982:228-238. PMID: 7166501. https://www.ncbi.nlm.nih.gov/ pubmed/7166501

[17] Lee AJ, Ling RS, Vangala SS. Some clinically relevant variables affecting the mechanical behaviour of bone cement. Archives of Orthopaedic and Trauma Surgery. 1978;**92**(1):1-18

[18] Bobyn JD et al. Porous surfaced layered prosthetic devices. Journal of Biomedical Engineering. 1975;**10**:126-131

[19] Bobyn JD et al. The optimum pore size for the fixation of porous-surfaced metal implants by the ingrowth of bone. Clinical Orthopaedics and Related Research. 1980;**150**(150):263-270

[20] Galante J. Total hip replacement. The Orthopedic Clinics of North America. 1971;**2**(1):139-155

[21] Moore AT. Metal hip joint; a new self-locking vitallium prosthesis. Southern Medical Journal. 1952;**45**(11):1015-1019

[22] Kwon MS et al. Does surgical approach affect total hip arthroplasty dislocation rates? Clinical Orthopaedics and Related Research. 2006;**447**:34-38

[23] Macedo CAS et al. Comparação das abordagens ântero-lateral e posterior em artroplastia total primária de quadril. Revista Brasileira de Ortopedia. 1997;**32**(10):777-780

[24] Alencar PGC, Abagge M. Artroplastia total do quadril por via de acesso póstero-lateral. Revista Brasileira de Ortopedia. 1995;**30**:509-513

[25] Gore DR et al. Anterolateral compared to posterior approach in total hip arthroplasty: Differences in component positioning, hip strength, and hip motion. Clinical Orthopaedics and Related Research. 1982;**165**:180-187

[26] Vicente JRN et al. A influência da via de acesso na luxação das artroplastias totais do quadril. Revista Brasileira de Ortopedia. 2009;**44**:507-507

[27] Sikorski JM, Hampson WG, Staddon GE. The natural history and aetiology of deep vein thrombosis after total hip replacement. The Journal of Bone and Joint Surgery. 1981;**63-B**(2):171-177

[28] Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clinical Orthopaedics and Related Research. 2005;**441**:115-124

[29] DeWal H, Su E, DiCesare PE. Instability following total hip arthroplasty. American Journal of Orthopedics. 2003;**32**(8):377-382

[30] Paillard P. Hip replacement by a minimal anterior approach. International Orthopaedics. 2007;**31**(Suppl. 1):S13-S15

[31] Hardinge K. The direct lateral approach to the hip. The Journal of Bone and Joint Surgery. 1982;**64**(1):17-19

[32] Charnley J. Arthroplasty of the hip. A new operation. Lancet. 1961;**1**(7187):1129-1132

[33] Webb JC, Spencer RF. The role of polymethylmethacrylate bone cement in modern orthopaedic surgery. The Journal of Bone and Joint Surgery. 2007;**89**:851-857

[34] Rice J et al. Femoral cementing techniques in total hip replacement. International Orthopaedics. 1998;**22**(5):308-311

[35] Geiger MH et al. The clinical significance of vacuum mixing bone cement. Clinical Orthopaedics and Related Research. 2001;**382**:258-266

[36] Chambers IR et al. Radiological features predictive of aseptic loosening in cemented Charnley femoral stems. The Journal of Bone and Joint Surgery. 2001;**83**(6):838-842

[37] Ritter MA et al. Radiological factors influencing femoral and acetabular failure in cemented Charnley total hip arthroplasties. The Journal of Bone and Joint Surgery. 1999;**81**(6):982-986

[38] Langlais F et al. The 'French paradox'. The Journal of Bone and Joint Surgery. 2003;**85**(1):17-20

[39] Jayasuriya RL et al. Effect of slidingtaper compared with composite-beam cemented femoral prosthesis loading regime on proximal femoral bone remodeling: A

**79**

*Hip Arthroplasty*

Suppl):s857-s862

2005;**20**(1):94-100

*DOI: http://dx.doi.org/10.5772/intechopen.84508*

The Adult Hip. Philadelphia: Lippincott Williams & Wilkins; 2007. pp. 195-206

[48] Hozack WJ et al. Primary cementless hip arthroplasty with a titanium plasma sprayed prosthesis. Clinical Orthopaedics and Related Research. 1996;**333**:217-225

[49] Jasty M et al. In vivo skeletal responses to porous-surfaced implants subjected to small induced motions. The Journal of Bone and Joint Surgery.

[50] Bobyn JD et al. Characteristics of bone ingrowth and interface mechanics of a new porous tantalum biomaterial. The Journal of Bone and Joint Surgery.

[51] McKellop H et al. Development of an extremely wear-resistant ultra high molecular weight polyethylene

[52] Engh CA Jr et al. A prospective, randomized study of cross-linked and non-cross-linked polyethylene for total hip arthroplasty at 10-year follow-up. The Journal of Arthroplasty. 2012;**27**

[53] Schwartsmann CR et al. Novas superfícies em artroplastia total do quadril. Revista Brasileira de Ortopedia.

[54] Clarke MT et al. Levels of metal ions after small- and large-diameter metal-on-metal hip arthroplasty. The Journal of Bone and Joint Surgery.

[55] Pandit H et al. Pseudotumours associated with metal-on-metal hip resurfacings. The Journal of Bone and Joint Surgery. 2008;**90**(7):847-851

[56] Tower SS. Arthroprosthetic cobaltism: Neurological and cardiac

for total hip replacements. Journal of Orthopaedic Research.

1997;**79**(5):707-714

1999;**81**(5):907-914

1999;**17**(2):157-167

(8 Suppl):2-7.e1

2012;**47**:154-159

2003;**85**(6):913-917

randomized clinical trial. The Journal of Bone and Joint Surgery. 2013;**95**(1):19-27

[40] New AM, Taylor M, Wroblewski BM. Effect of hip stem taper on cement stresses. Orthopedics. 2005;**28**(8

[41] Sundberg M et al. Movement patterns of the C-stem femoral

component: An RSA study of 33 primary total hip arthroplasties followed for two years. The Journal of Bone and Joint Surgery. 2005;**87**(10):1352-1356

[42] Ek ET, Choong PF. Comparison between triple-tapered and doubletapered cemented femoral stems in total hip arthroplasty: A prospective study comparing the C-stem versus the exeter universal early results after 5 years of clinical experience. The Journal of Arthroplasty.

[43] Verdonschot N, Tanck E, Huiskes R. Effects of prosthesis surface roughness on the failure process of cemented hip implants after stem-cement debonding.

Journal of Biomedical Materials Research. 1998;**42**(4):554-559

porous tantalum acetabular components: Early follow-up and failures in 613 primary total hip arthroplasties. The Journal of Arthroplasty. 2014;**29**(3):617-620

components. In: Callaghan JJ, Rosenberg AG, Rubash HE, editors. The Adult Hip. Philadelphia: Lippincott Williams & Wilkins; 2007. pp. 1036-1043

2005;**36**(1):105-111, vii

[47] Jasty M, Kienapfel H, Griss

[44] Noiseux NO et al. Uncemented

[45] Blaha JD, Borus TA. Press-fit femoral

[46] Sporer SM, Paprosky WG. Biologic fixation and bone ingrowth. The Orthopedic Clinics of North America.

P. Fixation by ingrowth. In: Callaghan JJ, Rosenberg AG, Rubash HE, editors.

#### *Hip Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.84508*

randomized clinical trial. The Journal of Bone and Joint Surgery. 2013;**95**(1):19-27

*Hip Surgeries*

Clinical Orthopaedics and Related Research. 1980;**150**(150):263-270

[29] DeWal H, Su E, DiCesare PE. Instability following total hip arthroplasty. American Journal of Orthopedics. 2003;**32**(8):377-382

[30] Paillard P. Hip replacement by a minimal anterior approach. International Orthopaedics. 2007;**31**(Suppl. 1):S13-S15

[31] Hardinge K. The direct lateral approach to the hip. The Journal of Bone and Joint Surgery. 1982;**64**(1):17-19

[32] Charnley J. Arthroplasty of the hip. A new operation. Lancet.

[33] Webb JC, Spencer RF. The role of polymethylmethacrylate bone cement in modern orthopaedic surgery. The Journal of Bone and Joint Surgery. 2007;**89**:851-857

[34] Rice J et al. Femoral cementing techniques in total hip replacement.

International Orthopaedics.

[35] Geiger MH et al. The clinical significance of vacuum mixing bone cement. Clinical Orthopaedics and Related Research. 2001;**382**:258-266

[36] Chambers IR et al. Radiological features predictive of aseptic loosening in cemented Charnley femoral stems. The Journal of Bone and Joint Surgery.

[37] Ritter MA et al. Radiological factors influencing femoral and acetabular failure in cemented Charnley total hip arthroplasties. The Journal of Bone and Joint Surgery. 1999;**81**(6):982-986

[38] Langlais F et al. The 'French paradox'. The Journal of Bone and Joint

[39] Jayasuriya RL et al. Effect of slidingtaper compared with composite-beam cemented femoral prosthesis loading regime on proximal femoral bone remodeling: A

Surgery. 2003;**85**(1):17-20

1998;**22**(5):308-311

2001;**83**(6):838-842

1961;**1**(7187):1129-1132

[20] Galante J. Total hip replacement. The Orthopedic Clinics of North America. 1971;**2**(1):139-155

prosthesis. Southern Medical Journal.

[22] Kwon MS et al. Does surgical approach affect total hip arthroplasty

Orthopaedics and Related Research.

[23] Macedo CAS et al. Comparação das abordagens ântero-lateral e posterior em artroplastia total primária de

quadril. Revista Brasileira de Ortopedia.

Artroplastia total do quadril por via de acesso póstero-lateral. Revista Brasileira

[21] Moore AT. Metal hip joint; a new self-locking vitallium

1952;**45**(11):1015-1019

2006;**447**:34-38

1997;**32**(10):777-780

1982;**165**:180-187

[24] Alencar PGC, Abagge M.

de Ortopedia. 1995;**30**:509-513

[25] Gore DR et al. Anterolateral compared to posterior approach in total hip arthroplasty: Differences in component positioning, hip strength, and hip motion. Clinical Orthopaedics and Related Research.

[26] Vicente JRN et al. A influência da via de acesso na luxação das artroplastias totais do quadril. Revista Brasileira de

[27] Sikorski JM, Hampson WG, Staddon GE. The natural history and aetiology of deep vein thrombosis after total hip replacement. The Journal of Bone and Joint Surgery. 1981;**63-B**(2):171-177

[28] Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clinical Orthopaedics and Related

Ortopedia. 2009;**44**:507-507

Research. 2005;**441**:115-124

dislocation rates? Clinical

**78**

[40] New AM, Taylor M, Wroblewski BM. Effect of hip stem taper on cement stresses. Orthopedics. 2005;**28**(8 Suppl):s857-s862

[41] Sundberg M et al. Movement patterns of the C-stem femoral component: An RSA study of 33 primary total hip arthroplasties followed for two years. The Journal of Bone and Joint Surgery. 2005;**87**(10):1352-1356

[42] Ek ET, Choong PF. Comparison between triple-tapered and doubletapered cemented femoral stems in total hip arthroplasty: A prospective study comparing the C-stem versus the exeter universal early results after 5 years of clinical experience. The Journal of Arthroplasty. 2005;**20**(1):94-100

[43] Verdonschot N, Tanck E, Huiskes R. Effects of prosthesis surface roughness on the failure process of cemented hip implants after stem-cement debonding. Journal of Biomedical Materials Research. 1998;**42**(4):554-559

[44] Noiseux NO et al. Uncemented porous tantalum acetabular components: Early follow-up and failures in 613 primary total hip arthroplasties. The Journal of Arthroplasty. 2014;**29**(3):617-620

[45] Blaha JD, Borus TA. Press-fit femoral components. In: Callaghan JJ, Rosenberg AG, Rubash HE, editors. The Adult Hip. Philadelphia: Lippincott Williams & Wilkins; 2007. pp. 1036-1043

[46] Sporer SM, Paprosky WG. Biologic fixation and bone ingrowth. The Orthopedic Clinics of North America. 2005;**36**(1):105-111, vii

[47] Jasty M, Kienapfel H, Griss P. Fixation by ingrowth. In: Callaghan JJ, Rosenberg AG, Rubash HE, editors.

The Adult Hip. Philadelphia: Lippincott Williams & Wilkins; 2007. pp. 195-206

[48] Hozack WJ et al. Primary cementless hip arthroplasty with a titanium plasma sprayed prosthesis. Clinical Orthopaedics and Related Research. 1996;**333**:217-225

[49] Jasty M et al. In vivo skeletal responses to porous-surfaced implants subjected to small induced motions. The Journal of Bone and Joint Surgery. 1997;**79**(5):707-714

[50] Bobyn JD et al. Characteristics of bone ingrowth and interface mechanics of a new porous tantalum biomaterial. The Journal of Bone and Joint Surgery. 1999;**81**(5):907-914

[51] McKellop H et al. Development of an extremely wear-resistant ultra high molecular weight polyethylene for total hip replacements. Journal of Orthopaedic Research. 1999;**17**(2):157-167

[52] Engh CA Jr et al. A prospective, randomized study of cross-linked and non-cross-linked polyethylene for total hip arthroplasty at 10-year follow-up. The Journal of Arthroplasty. 2012;**27** (8 Suppl):2-7.e1

[53] Schwartsmann CR et al. Novas superfícies em artroplastia total do quadril. Revista Brasileira de Ortopedia. 2012;**47**:154-159

[54] Clarke MT et al. Levels of metal ions after small- and large-diameter metal-on-metal hip arthroplasty. The Journal of Bone and Joint Surgery. 2003;**85**(6):913-917

[55] Pandit H et al. Pseudotumours associated with metal-on-metal hip resurfacings. The Journal of Bone and Joint Surgery. 2008;**90**(7):847-851

[56] Tower SS. Arthroprosthetic cobaltism: Neurological and cardiac manifestations in two patients with metal-on-metal arthroplasty: A case report. The Journal of Bone and Joint Surgery. 2010;**92**(17):2847-2851

[57] Ladon D et al. Changes in metal levels and chromosome aberrations in the peripheral blood of patients after metalon-metal hip arthroplasty. The Journal of Arthroplasty. 2004;**19**(8 Suppl 3):78-83

[58] Ziaee H et al. Transplacental transfer of cobalt and chromium in patients with metal-on-metal hip arthroplasty: A controlled study. The Journal of Bone and Joint Surgery. 2007;**89**(3):301-305

[59] Jarrett CA et al. The squeaking hip: A phenomenon of ceramic-onceramic total hip arthroplasty. The Journal of Bone and Joint Surgery. 2009;**91**(6):1344-1349

[60] Restrepo C et al. The noisy ceramic hip: Is component malpositioning the cause? The Journal of Arthroplasty. 2008;**23**(5):643-649

[61] Min BW et al. Delayed fracture of a ceramic insert with modern ceramic total hip replacement. The Journal of Arthroplasty. 2007;**22**(1):136-139

[62] Walter WL et al. Edge loading in third generation alumina ceramicon-ceramic bearings: Stripe wear. Journal of Arthroplasty. 2004;**19**(4):402-413

[63] Canale ST, Beaty JH. Arthroplasty of the hip. In: Campbell's Operative Orthopaedics. 12th ed. 2012. Vol. I. pp. 158-310

[64] Garellick G, Rogmark C, Kärrholm J, Rolfson O. Swedish Hip Arthroplasty Register Annual Report. 2012; 113-116

[65] Australian Orthopaedic Association National Joint Replacement Registry. Annual Report. 2014—Mortality following Primary Hip and Knee Replacement. Available from: https://

aoanjrr.dmac.adelaide.edu.au/ documents/10180/172288/Mortality%20 following%20Primary%20Hip%20 and%20Knee%20Replacement

[66] American Academy of Orthopaedic Surgeons. AAOS Clinical Practice Guidelines (CPG): Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty. Available from: http:// www.aaos.org/Research/guidelines/ VTE/VTE\_guideline.asp

[67] Johnson R, Carmichael JH, Almond HG, Loynes RP. Deep venous thrombosis following Charnley arthroplasty. Clinical Orthopaedics and Related Research. 1978;**132**:24-30

[68] American College of Chest Physicians. Antithrombotic Therapy and the Prevention of Thrombosis: American College of Chest Physicians Evidence-based Guidelines. Resources related to these guidelines can be found on the ACCP Antithrombotic Guidelines 9th Ed. 2012

[69] ISMP—Institute for Safe Medication Practices. Monitoring FDA MedWatch Reports Anticoagulants the Leading Reported Drug Risk in 2011. Available from: http://www.ismp.org/ quarterwatch/pdfs/2011Q4.pdf

[70] American Academy of Orthopaedic Surgeons. AAOS Clinical Practice Guidelines (CPG): Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty. Second edition. 2011

[71] Jevsevar D, Shea K, Cummins D, Murray J, Sanders J. Recent changes in the AAOS evidence-based clinical practice guidelines process. The Journal of Bone and Joint Surgery. 2014;**96**(20):1740- 1741. DOI: 10.2106/JBJS.N.00658

[72] Brooks PJ. Dislocation following total hip replacement: Causes and cures. The Bone & Joint Journal.

**81**

*Hip Arthroplasty*

*DOI: http://dx.doi.org/10.5772/intechopen.84508*

prognosis of nerve palsy after total hip arthroplasty: Results of two-yearfollow-ups and long-term results after a mean time of 8 years. Archives of Orthopaedic and Trauma Surgery. 2014;**134**(10):1477-1482. DOI: 10.1007/

[80] JH1 P, Hozack B, Kim P, Norton R, Mandel S, Restrepo C, et al. Common peroneal nerve palsy following total hip arthroplasty: Prognostic factors for recovery. The Journal of Bone and Joint Surgery. 2013;**95**(9):e551-e555. DOI:

[81] Wasielewski RC, Cooperstein LA, Kruger MP, Rubash HE. Acetabular anatomy and the transacetabular fixation of screws in total hip

arthroplasty. The Journal of Bone and Joint Surgery. 1990;**72**(4):501-508

[82] Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation and treatment. Clinical Orthopaedics and Related Research. 2004;**420**:80-95. DOI: 10.1097/00003086-200403000-00012

[83] NV1 G, Mitchell PA, Masri BA, Garbuz DS, Duncan CP. Principles of management and results of treating the fractured femur during and after total hip arthroplasty. Instructional Course

[84] Misur PN, Duncan CP, Masri BA. The treatment of periprosthetic femoral fractures after total hip arthroplasty.

[85] Parvizi J, Gehrke T. Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection.

Available from: http://www.msis-na.org/ wp-content/themes/msis-temp/pdf/ismperiprosthetic-joint-information.pdf

[86] Mauerhan DR, Nelson CL, Smith DL, Fitzgerald RH Jr, Slama TG, Petty RW, et al. Prophylaxis against infection in total joint arthroplasty. One day of

Lectures. 2003;**52**:309-322

JBJS Reviews. 2014;**2**(8):1-9

s00402-014-2038-0

10.2106/JBJS.L.00160

[73] Lindgren V, Garellick G, Kärrholm J, Wretenberg P. The type of surgical approach influences the risk of revision in total hip arthroplasty: A study from the Swedish Hip Arthroplasty Register of 90,662 total hipreplacements with 3 different cemented prostheses. Acta Orthopaedica. 2012;**83**(6):559-565. DOI:

2013;**95-B**(11 Suppl A):67-69. DOI: 10.1302/0301-620X.95B11.32645

10.3109/17453674.2012.742394

2003;**74**(5):514-524

[75] Prietzel T, Hammer N,

DOI: 10.1055/s-0034-1368209

2014;**22**(9):595-603

1999;**81**(5):843-845

[76] Barrack RL. Neurovascular injury: Avoiding catastrophe. The Journal of Arthroplasty. 2004;**19**(4 Suppl 1):104-107

[77] Post ZD, Orozco F, Diaz-Ledezma C, Hozack WJ, Ong A. Direct anterior approach for total hip arthroplasty: Indications, technique, and results. The Journal of the American Academy of Orthopaedic Surgeons.

[78] Eggli S, Hankemayer S, Müller ME. Nerve palsy after leg lengthening in total replacement arthroplasty for developmental dysplasia of the hip. The Journal of Bone and Joint Surgery.

[79] Zappe B, Glauser PM, Majewski M, Stöckli HR, Ochsner PE. Long-term

[74] Byström S, Espehaug B, Furnes O, Havelin LI, Norwegian Arthroplasty Register. Femoral head size is a risk factor for total hip luxation: A study of 42,987 primary hip arthroplasties from the Norwegian Arthroplasty Register. Acta Orthopaedica Scandinavica.

Schleifenbaum S, Adler D, Pretzsch M, Köhler L, et al. The impact of capsular repair on the dislocation rate after primary total hip arthroplasty: A retrospective analysis of 1972 cases. Zeitschrift für Orthopädie und Unfallchirurgie. 2014;**152**(2):130-143.

2013;**95-B**(11 Suppl A):67-69. DOI: 10.1302/0301-620X.95B11.32645

*Hip Surgeries*

manifestations in two patients with metal-on-metal arthroplasty: A case report. The Journal of Bone and Joint Surgery. 2010;**92**(17):2847-2851

aoanjrr.dmac.adelaide.edu.au/

VTE/VTE\_guideline.asp

[67] Johnson R, Carmichael JH, Almond HG, Loynes RP. Deep venous thrombosis following Charnley

[68] American College of Chest Physicians. Antithrombotic Therapy and the Prevention of Thrombosis: American College of Chest Physicians Evidence-based Guidelines. Resources related to these guidelines can be found on the ACCP Antithrombotic Guidelines

[69] ISMP—Institute for Safe

Medication Practices. Monitoring FDA MedWatch Reports Anticoagulants the Leading Reported Drug Risk in 2011. Available from: http://www.ismp.org/ quarterwatch/pdfs/2011Q4.pdf

[70] American Academy of Orthopaedic Surgeons. AAOS Clinical Practice Guidelines (CPG): Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty. Second edition. 2011

[71] Jevsevar D, Shea K, Cummins D, Murray J, Sanders J. Recent changes in the AAOS evidence-based clinical practice guidelines process. The Journal of Bone and Joint Surgery. 2014;**96**(20):1740- 1741. DOI: 10.2106/JBJS.N.00658

[72] Brooks PJ. Dislocation following total hip replacement: Causes and cures. The Bone & Joint Journal.

9th Ed. 2012

arthroplasty. Clinical Orthopaedics and Related Research. 1978;**132**:24-30

documents/10180/172288/Mortality%20 following%20Primary%20Hip%20 and%20Knee%20Replacement

[66] American Academy of Orthopaedic Surgeons. AAOS Clinical Practice Guidelines (CPG): Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty. Available from: http:// www.aaos.org/Research/guidelines/

[57] Ladon D et al. Changes in metal levels and chromosome aberrations in the peripheral blood of patients after metalon-metal hip arthroplasty. The Journal of Arthroplasty. 2004;**19**(8 Suppl 3):78-83

[58] Ziaee H et al. Transplacental transfer of cobalt and chromium in patients with metal-on-metal hip arthroplasty: A controlled study. The Journal of Bone and Joint Surgery.

[59] Jarrett CA et al. The squeaking hip: A phenomenon of ceramic-onceramic total hip arthroplasty. The Journal of Bone and Joint Surgery.

[60] Restrepo C et al. The noisy ceramic hip: Is component malpositioning the cause? The Journal of Arthroplasty.

[61] Min BW et al. Delayed fracture of a ceramic insert with modern ceramic total hip replacement. The Journal of Arthroplasty. 2007;**22**(1):136-139

[62] Walter WL et al. Edge loading in third generation alumina ceramicon-ceramic bearings: Stripe wear. Journal of Arthroplasty. 2004;**19**(4):402-413

[63] Canale ST, Beaty JH. Arthroplasty of the hip. In: Campbell's Operative Orthopaedics. 12th ed. 2012. Vol. I.

[64] Garellick G, Rogmark C, Kärrholm J, Rolfson O. Swedish Hip Arthroplasty Register Annual Report. 2012; 113-116

[65] Australian Orthopaedic Association National Joint Replacement Registry. Annual Report. 2014—Mortality following Primary Hip and Knee Replacement. Available from: https://

2007;**89**(3):301-305

2009;**91**(6):1344-1349

2008;**23**(5):643-649

**80**

pp. 158-310

[73] Lindgren V, Garellick G, Kärrholm J, Wretenberg P. The type of surgical approach influences the risk of revision in total hip arthroplasty: A study from the Swedish Hip Arthroplasty Register of 90,662 total hipreplacements with 3 different cemented prostheses. Acta Orthopaedica. 2012;**83**(6):559-565. DOI: 10.3109/17453674.2012.742394

[74] Byström S, Espehaug B, Furnes O, Havelin LI, Norwegian Arthroplasty Register. Femoral head size is a risk factor for total hip luxation: A study of 42,987 primary hip arthroplasties from the Norwegian Arthroplasty Register. Acta Orthopaedica Scandinavica. 2003;**74**(5):514-524

[75] Prietzel T, Hammer N, Schleifenbaum S, Adler D, Pretzsch M, Köhler L, et al. The impact of capsular repair on the dislocation rate after primary total hip arthroplasty: A retrospective analysis of 1972 cases. Zeitschrift für Orthopädie und Unfallchirurgie. 2014;**152**(2):130-143. DOI: 10.1055/s-0034-1368209

[76] Barrack RL. Neurovascular injury: Avoiding catastrophe. The Journal of Arthroplasty. 2004;**19**(4 Suppl 1):104-107

[77] Post ZD, Orozco F, Diaz-Ledezma C, Hozack WJ, Ong A. Direct anterior approach for total hip arthroplasty: Indications, technique, and results. The Journal of the American Academy of Orthopaedic Surgeons. 2014;**22**(9):595-603

[78] Eggli S, Hankemayer S, Müller ME. Nerve palsy after leg lengthening in total replacement arthroplasty for developmental dysplasia of the hip. The Journal of Bone and Joint Surgery. 1999;**81**(5):843-845

[79] Zappe B, Glauser PM, Majewski M, Stöckli HR, Ochsner PE. Long-term

prognosis of nerve palsy after total hip arthroplasty: Results of two-yearfollow-ups and long-term results after a mean time of 8 years. Archives of Orthopaedic and Trauma Surgery. 2014;**134**(10):1477-1482. DOI: 10.1007/ s00402-014-2038-0

[80] JH1 P, Hozack B, Kim P, Norton R, Mandel S, Restrepo C, et al. Common peroneal nerve palsy following total hip arthroplasty: Prognostic factors for recovery. The Journal of Bone and Joint Surgery. 2013;**95**(9):e551-e555. DOI: 10.2106/JBJS.L.00160

[81] Wasielewski RC, Cooperstein LA, Kruger MP, Rubash HE. Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. The Journal of Bone and Joint Surgery. 1990;**72**(4):501-508

[82] Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation and treatment. Clinical Orthopaedics and Related Research. 2004;**420**:80-95. DOI: 10.1097/00003086-200403000-00012

[83] NV1 G, Mitchell PA, Masri BA, Garbuz DS, Duncan CP. Principles of management and results of treating the fractured femur during and after total hip arthroplasty. Instructional Course Lectures. 2003;**52**:309-322

[84] Misur PN, Duncan CP, Masri BA. The treatment of periprosthetic femoral fractures after total hip arthroplasty. JBJS Reviews. 2014;**2**(8):1-9

[85] Parvizi J, Gehrke T. Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection. Available from: http://www.msis-na.org/ wp-content/themes/msis-temp/pdf/ismperiprosthetic-joint-information.pdf

[86] Mauerhan DR, Nelson CL, Smith DL, Fitzgerald RH Jr, Slama TG, Petty RW, et al. Prophylaxis against infection in total joint arthroplasty. One day of

cefuroxime compared with three days of cefazolin. The Journal of Bone and Joint Surgery. 1994;**76**(1):39-45

[87] Klouche S, Lhotellier L, Mamoudy P. Infected total hip arthroplasty treated by an irrigation-debridement/ component retention protocol. A prospective study in a 12-case series with minimum 2 years� follow-up. Orthopaedics & Traumatology, Surgery & Research. 2011;**97**(2):134-138

[88] Espehaug B, Furnes O, Havelin LI, Engesaeter LB, Vollset SEJ. The type of cement and failure of total hip replacements. The Journal of Bone and Joint Surgery. 2002;**84**(6):832-838

[89] Garellick G, Rogmark C, Kärrholm J, Rolfson O. Swedish Hip Arthroplasty Register Annual Report. 2012

[90] National Joint Registry for England and Wales. 11th Annual Report. 2014. Available from: http://www-new. njrcentre.org.uk/njrcentre/Portals/0/ Documents/England/Reports/ 11th\_annual\_report /NJR%2011th%20 Annual%20Report%202014.pdf [Accessed: Jan 26, 2015]

[91] Troelsen A, Malchau E, Sillesen N, Malchau H. A review of current fixation use and registry outcomes in total hip arthroplasty: The uncemented paradox. Clinical Orthopaedics and Related Research. 2013;**471**(7):2052-2059. DOI: 10.1007/s11999-013-2941-7

[92] Wyatt M, Hooper G, Frampton C, Rothwell A. Survival outcomes of cemented compared to uncemented stems in primary total hip replacement. World Journal of Orthopedics. 2014;**5**(5): 591-596. DOI: 10.5312/wjo.v5.i5.591

[93] Australian Orthopaedic Association National Joint Replacement Registry. Annual Report. 2014. Available from: https://aoanjrr.dmac.adelaide.edu.au/ documents/10180/172288/Mortality%20 following%20Primary%20Hip%20

and%20Knee%20Replacement [Accessed: Jan 26, 2015]

[94] McLaughlin JR, Lee KR. Uncemented total hip arthroplasty with a tapered femoral component: A 22- to 26-year follow-up study. Orthopedics. 2010;**33**(9):639. DOI: 10.3928/01477447-20100722-40

[95] Evola FR, Evola G, Graceffa A, Sessa A, Pavone V, Costarella L, et al. Performance of the CLS Spotorno uncemented stem in the third decade after implantation. The Bone & Joint Journal. 2014;**96-B**(4):455-461. DOI: 10.1302/0301-620X.96B4.32607

[96] Chawda M, Hucker P, Whitehouse SL, Crawford RW, English H, Donnelly WJ. Comparison of cemented vs uncemented acetabular component positioning using an imageless navigation system. The Journal of Arthroplasty. 2009;**24**(8):1170-1173. DOI: 10.1016/j.arth.2008.09.018

[97] Breusch SJ, Norman TL, Schneider U, Reitzel T, Blaha JD, Lukoschek M. Lavage technique in total hip arthroplasty: Jet lavage produces better cement penetration than syringe lavage in the proximal femur. The Journal of Arthroplasty. 2000;**15**(7):921-927

[98] Rolfson O. Patient-reported Outcome Measures and Health-economic Aspects of Total Hip Arthroplasty—A study of the Swedish Hip Arthroplasty Register. Institute of Clinical Sciences at Sahlgrenska Academy University of Gothenburg, Sweden. 2010

[99] Affatato S. Perspectives in Total Hip Arthroplasty: Advances in Biomaterials and their Tribological Interactions. Netherlands: Amsterdam: Elsevier: Woodhead Publishing; 2014. p. 164

[100] Pulido L, Rachala SR, Cabanela ME. Cementless acetabular revision: Past, present, and future. Revision total hip arthroplasty: The acetabular

**83**

*Hip Arthroplasty*

2011;**35**(2):289-298

2006;**17**(2):88-92

2009;**36**:157-160

10-11-2014]

*DOI: http://dx.doi.org/10.5772/intechopen.84508*

[109] Tarwala R, Dorr LD. Robotic assisted total hip arthroplasty using the MAKO platform. Current Reviews in Musculoskeletal Medicine.

2011;**4**(3):151-156

side using cementless implants. International Orthopaedics.

[101] Mont MA et al. The Future of high performance total hip

arthroplasty. Seminars in Arthroplasty.

[102] Galia CR et al. Caracterização físico-química de ossos liofilizados de origem bovina e humana. Revista do Colégio Brasileiro de Cirurgiões.

[103] Goosen JH et al. Porous-coated femoral components with or without hydroxyapatite in primary uncemented total hip arthroplasty: A systematic review of randomized controlled trials. Archives of Orthopaedic and Trauma Surgery. 2009;**129**(9):1165-1169

[104] Walles H, Andrees-Ostovan I. VascuBone. 2013. Available from: http:// www.vascubone.fraunhofer.eu/ [cited

[105] National Joint Registry for England and Wales. 11th Annual Report. 2014. Available from: http:// www-new.njrcentre.org.uk/njrcentre/ Portals/0/Documents/England/ Reports/11th\_annual\_report/NJR%20 11th%20Annual%20Report%202014.

pdf [Accessed: Jan 26, 2015]

assisted total hip arthroplasty: The present and the future. Future Rheumatology. 2006;**1**(1):121-131

[106] Hafez MA, Digioia AM. Computer-

[107] Kunz M et al. Computer-assisted hip resurfacing using individualized drill templates. The Journal of Arthroplasty. 2010;**25**(4):600-606

[108] Sugano N et al. Comparison of mini-incision total hip arthroplasty through an anterior approach and a posterior approach using navigation. The Orthopedic Clinics of North America. 2009;**40**(3):365-370

#### *Hip Arthroplasty DOI: http://dx.doi.org/10.5772/intechopen.84508*

side using cementless implants. International Orthopaedics. 2011;**35**(2):289-298

*Hip Surgeries*

cefuroxime compared with three days of cefazolin. The Journal of Bone and Joint

and%20Knee%20Replacement

[94] McLaughlin JR, Lee KR. Uncemented total hip arthroplasty with a tapered femoral component: A 22- to 26-year follow-up study. Orthopedics. 2010;**33**(9):639. DOI: 10.3928/01477447-20100722-40

[95] Evola FR, Evola G, Graceffa A, Sessa A, Pavone V, Costarella L, et al. Performance of the CLS Spotorno uncemented stem in the third decade after implantation. The Bone & Joint Journal. 2014;**96-B**(4):455-461. DOI: 10.1302/0301-620X.96B4.32607

[96] Chawda M, Hucker P, Whitehouse SL, Crawford RW, English H, Donnelly WJ.

[97] Breusch SJ, Norman TL, Schneider U, Reitzel T, Blaha JD, Lukoschek M. Lavage technique in total hip

arthroplasty: Jet lavage produces better cement penetration than syringe lavage in the proximal femur. The Journal of Arthroplasty. 2000;**15**(7):921-927

Outcome Measures and Health-economic Aspects of Total Hip Arthroplasty—A study of the Swedish Hip Arthroplasty Register. Institute of Clinical Sciences at Sahlgrenska Academy University of

[99] Affatato S. Perspectives in Total Hip Arthroplasty: Advances in Biomaterials and their Tribological Interactions. Netherlands: Amsterdam: Elsevier: Woodhead Publishing; 2014. p. 164

[100] Pulido L, Rachala SR, Cabanela ME. Cementless acetabular revision: Past, present, and future. Revision total hip arthroplasty: The acetabular

[98] Rolfson O. Patient-reported

Gothenburg, Sweden. 2010

Comparison of cemented vs uncemented acetabular component positioning using an imageless navigation system. The Journal of Arthroplasty. 2009;**24**(8):1170-1173. DOI: 10.1016/j.arth.2008.09.018

[Accessed: Jan 26, 2015]

[87] Klouche S, Lhotellier L, Mamoudy P. Infected total hip arthroplasty treated

Surgery. 1994;**76**(1):39-45

by an irrigation-debridement/ component retention protocol. A prospective study in a 12-case series with minimum 2 years� follow-up. Orthopaedics & Traumatology, Surgery

& Research. 2011;**97**(2):134-138

[88] Espehaug B, Furnes O, Havelin LI, Engesaeter LB, Vollset SEJ. The type of cement and failure of total hip replacements. The Journal of Bone and Joint Surgery. 2002;**84**(6):832-838

[89] Garellick G, Rogmark C, Kärrholm J, Rolfson O. Swedish Hip Arthroplasty

[90] National Joint Registry for England and Wales. 11th Annual Report. 2014. Available from: http://www-new. njrcentre.org.uk/njrcentre/Portals/0/ Documents/England/Reports/ 11th\_annual\_report /NJR%2011th%20 Annual%20Report%202014.pdf

[91] Troelsen A, Malchau E, Sillesen N, Malchau H. A review of current fixation use and registry outcomes in total hip arthroplasty: The uncemented paradox. Clinical Orthopaedics and Related Research. 2013;**471**(7):2052-2059. DOI:

[92] Wyatt M, Hooper G, Frampton C, Rothwell A. Survival outcomes of

cemented compared to uncemented stems in primary total hip replacement. World Journal of Orthopedics. 2014;**5**(5): 591-596. DOI: 10.5312/wjo.v5.i5.591

[93] Australian Orthopaedic Association National Joint Replacement Registry. Annual Report. 2014. Available from: https://aoanjrr.dmac.adelaide.edu.au/ documents/10180/172288/Mortality%20 following%20Primary%20Hip%20

Register Annual Report. 2012

[Accessed: Jan 26, 2015]

10.1007/s11999-013-2941-7

**82**

[101] Mont MA et al. The Future of high performance total hip arthroplasty. Seminars in Arthroplasty. 2006;**17**(2):88-92

[102] Galia CR et al. Caracterização físico-química de ossos liofilizados de origem bovina e humana. Revista do Colégio Brasileiro de Cirurgiões. 2009;**36**:157-160

[103] Goosen JH et al. Porous-coated femoral components with or without hydroxyapatite in primary uncemented total hip arthroplasty: A systematic review of randomized controlled trials. Archives of Orthopaedic and Trauma Surgery. 2009;**129**(9):1165-1169

[104] Walles H, Andrees-Ostovan I. VascuBone. 2013. Available from: http:// www.vascubone.fraunhofer.eu/ [cited 10-11-2014]

[105] National Joint Registry for England and Wales. 11th Annual Report. 2014. Available from: http:// www-new.njrcentre.org.uk/njrcentre/ Portals/0/Documents/England/ Reports/11th\_annual\_report/NJR%20 11th%20Annual%20Report%202014. pdf [Accessed: Jan 26, 2015]

[106] Hafez MA, Digioia AM. Computerassisted total hip arthroplasty: The present and the future. Future Rheumatology. 2006;**1**(1):121-131

[107] Kunz M et al. Computer-assisted hip resurfacing using individualized drill templates. The Journal of Arthroplasty. 2010;**25**(4):600-606

[108] Sugano N et al. Comparison of mini-incision total hip arthroplasty through an anterior approach and a posterior approach using navigation. The Orthopedic Clinics of North America. 2009;**40**(3):365-370

[109] Tarwala R, Dorr LD. Robotic assisted total hip arthroplasty using the MAKO platform. Current Reviews in Musculoskeletal Medicine. 2011;**4**(3):151-156

**85**

**Chapter 5**

**Abstract**

Arthroplasty as a Choice of

The hip joint bears the most load in the human body. For this reason, it carries the potential risk of degenerative arthritis in individuals with a functionally active lifestyle. The main goal in the treatment of degenerative arthritis is to achieve pain relief and create a hip joint range of motion close to normal. Even today, it is not possible to transform the hip joint, which has been degenerated due to several reasons and worn out due to the physiological properties of the cartilage structure, back to its natural state. Osteotomies, resection arthroplasties and hip arthrodeses, which are designed to compensate the load distribution affecting the hip and relieve the pain, are still employed methods. Total hip arthroplasty, on the other hand, is an alternative solution for the problem. Cemented, cementless and hybrid methods are widely used for this purpose in total hip arthroplasties. The purpose of hip prosthesis surgery is to shape the bone tips and to fill the fragments with various materials and keep these two structures as separate surfaces. Total hip arthroplasty consists of a femoral component placed in the medullas of the femur and an acetabular component placed in the acetabulum. In this article we will review the aims, causes, types

**Keywords:** acetabulum, arthritis, femur, rehabilitation, total hip arthroplasty

The hip joint bears the most load in the human body. Therefore, a functional lifestyle naturally carries a potential risk of degenerative arthritis. In a hip with degenerative arthritis, the main purpose of the treatment is to relieve the pain and create a hip joint range of motion close to normal. Even today, it is not possible to transform the hip joint, which has been degenerated due to several reasons and worn out due to the physiological properties of the cartilage structure, back to its

Osteotomies, resection arthroplasties and hip arthrodeses, which are designed to compensate the load distribution affecting the hip and relieve the pain, are still employed methods. Total hip arthroplasty (THA), on the other hand, is an alternative solution for the problem. Cemented, cementless and hybrid methods are widely

Three different methods, including unipolar hemiarthroplasty, bipolar hemiarthroplasty and THA can be applied in femoral neck fractures, taking the patient's age, functional status before fracture and other accompanying diseases into consideration.

Treatment in Hip Surgery

*Mehmet Umit Cetin, Yaşar Mahsut Dincel* 

*and Yavuz Selim Kabukcuoglu*

and techniques of total hip arthroplasty.

**1. Introduction**

natural state.

used for this purpose in THAs.

## **Chapter 5**
