Hip.

The hip is a ball-and-socket joint between the head of the femur and the pelvis. Smooth cartilage covers both surfaces; arthritis describes the loss of that cartilage and the rough bone-on-bone wear that follows.

Types of arthritis

• Osteoarthritis — age- and load-related cartilage wear; the most common form.
• Inflammatory arthritis — rheumatoid and related conditions.
• Post-traumatic arthritis — accelerated wear following previous injury or fracture.
• Secondary to other hip conditions — dysplasia, FAI, AVN.

Symptoms

• Groin pain, often referred to the front of the thigh or the buttock.
• Morning stiffness; loss of rotation and difficulty putting on shoes.
• Grinding or catching with activity, limping with longer walks.

Diagnosis

Standing X-rays of the pelvis and hip remain the cornerstone of diagnosis. MRI is reserved for early disease where X-rays are normal but symptoms warrant further investigation.

Non-surgical treatment

• Physiotherapy — gait, range of motion, gluteal strengthening.
• Weight management — every kilogram off reduces joint load.
• Anti-inflammatories (NSAIDs) where medically appropriate.
• Activity modification and walking aids for severe symptoms.

Surgical treatment

When non-surgical measures no longer give adequate quality of life, total hip replacement is the definitive surgical treatment. Mr Gormack offers both anterior and posterior approaches — see Total Hip Replacement and Anterior Approach.

Femoro-acetabular impingement (FAI) describes excess bone at the ball, the socket, or both, which causes the two bony surfaces to impinge against each other through the hip's normal range of motion. The labrum — a cartilage rim around the socket — is often damaged as a consequence.

Types of impingement

• CAM — excess bone at the femoral head/neck junction.
• Pincer — excess bone on the rim of the socket (acetabulum).
• Mixed CAM and pincer — most common pattern.

The labrum

The labrum is the cartilage seal around the socket. Repeated impingement causes the labrum to fray, tear, or detach from the bone — generating groin pain and a sensation of catching in the hip.

Symptoms

• Groin pain worsened by sports, twisting, or prolonged sitting.
• Pain rotating the hip inward; "C-sign" — patient cups the hip with the fingers.
• Mechanical symptoms — clicking, catching, occasional giving way.

Diagnosis

X-rays identify the bony impingement; MRI (often MR arthrogram) confirms the labral tear and assesses cartilage. CT is sometimes added for surgical planning.

Treatment

Approximately 60% of patients respond to non-surgical management — physiotherapy, activity modification, anti-inflammatories, and a cortisone injection where appropriate. Persistent symptoms despite this are typically treated with hip arthroscopy to debride the impinging bone and repair or stabilise the labrum.

Avascular necrosis (AVN) describes the loss of blood supply to the femoral head. Without circulation the bone dies, weakens, and eventually collapses. AVN most commonly presents between the ages of 30 and 50.

Risk factors

• Trauma — hip dislocation or femoral neck fracture.
• Steroid use — particularly long-term, high-dose courses.
• Alcohol — heavy and chronic consumption.
• Diving — decompression illness.
• Sickle cell disease and chemotherapy.
• Idiopathic — no identifiable cause.

Symptoms

Groin or buttock pain that progresses over weeks to months, often unrelated to a specific injury. Pain is worse on weight-bearing and at night.

Diagnosis

• Early disease — X-rays may be normal; MRI is required.
• Established disease — X-ray shows the classic crescent sign or femoral head collapse.

Treatment

Early AVN may respond to core decompression — drilling small channels to relieve pressure and stimulate revascularisation. Success preventing collapse is reported at 50–80% when intervention occurs before bony collapse. Once the femoral head has collapsed, total hip replacement is the definitive treatment.

A hip replacement that becomes painful after a period of well-functioning service warrants systematic investigation. There are six common mechanisms of failure — each diagnosed and treated differently.

Mechanisms of failure

• Loosening — the implant losing its bond to bone over time.
• Wear — polyethylene liner wear, triggering bone loss (osteolysis).
• Infection — early post-operative or late haematogenous.
• Dislocation — particularly with certain bearing surfaces.
• Periprosthetic fracture — broken bone around the implant.
• Adverse metal reaction — particularly metal-on-metal pairings.

Investigation

• Serial X-rays comparing the current implant position with the original post-op films.
• CT scan for component orientation and bone stock.
• MRI (metal artefact reduction) for soft-tissue and metal reaction.
• Nuclear bone scan and SPECT-CT for loosening or infection.
• Blood tests — inflammatory markers, joint aspiration where infection is suspected.

Treatment

Conservative monitoring is appropriate for patients with low-grade symptoms and no progressive findings. Otherwise treatment proceeds to revision hip surgery.

Total hip replacement removes the damaged hip joint and replaces it with a prosthetic implant. The procedure typically takes 90 minutes under spinal or general anaesthesia, with a hospital stay of two to three nights.

Conditions treated

• Severe hip arthritis (osteoarthritis, inflammatory, post-traumatic).
• Advanced avascular necrosis with femoral head collapse.
• Selected fractures of the femoral neck.

The implant

• Femoral stem — titanium, set inside the femur.
• Femoral head — a precision ball that mounts on the stem.
• Acetabular cup — a titanium shell fixed into the socket of the pelvis.
• Liner — highly cross-linked polyethylene, ceramic, or metal.

Surgical approaches

Mr Gormack performs both posterior, direct superior, and anterior approaches; the choice depends on patient anatomy, body habitus, and prior surgery. The anterior approach is discussed separately.

Preparation

• Stop smoking ahead of surgery if you can — improves wound healing and reduces complications.
• Optimise diabetes control; ensure dental health is up to date to reduce infection risk.
• Weight optimisation reduces post-operative risk.

Recovery timeline

• Standing and walking with assistance the day of surgery.
• Crutches typically required for 2–4 weeks.
• Most patients off all aids by 6 weeks.
• Full recovery to all activities by 6 months.
• Driving from 6 weeks; return to most work within 6–12 weeks depending on demands.

Implant longevity

• Greater than 90% of modern hip implants last 10 years or more.
• Greater than 70% last 20 years or more.
• Airport metal detectors will sometimes be triggered — a card or letter is available on request.

Surgical risks

Infection (low single-digit percentages), dislocation, leg length difference, blood clot (DVT/PE), nerve injury, periprosthetic fracture, and the standard general anaesthetic risks. Mr Gormack will discuss these in detail prior to consent.

The direct anterior approach uses an incision on the front of the thigh and works between muscles without cutting tendons. The same prosthetic components are inserted as in a conventional hip replacement — but the technique aims for faster mobilisation and a lower dislocation rate.

Benefits

• Shorter hospital stay — typically 1–2 nights vs 2–3.
• Faster recovery of balance and ability to walk independently.
• Many patients are aid-free by 2 weeks.
• Lower dislocation rate — 0.2–0.5% versus approximately 1% with posterior approaches.
• No hip precautions required post-operatively.

Specific risks

• Numbness in the outer thigh from injury to the lateral femoral cutaneous nerve — usually settles over months.
• Slightly increased risk of femoral fracture (under 0.5%).
• Wound healing issues in patients with abdominal pannus.

Suitability

The anterior approach is not suitable for every patient. Mr Gormack assesses body habitus, hip anatomy, and prior surgery to decide whether anterior, posterior, or direct superior is the best approach in your case.

Revision hip surgery covers any operation that re-does parts of a previous hip replacement — from a straightforward liner exchange through to a complete two-stage reconstruction for infection.

Reasons for revision

• Loosening of one or both components.
• Wear of the bearing surface.
• Infection, early or late.
• Recurrent dislocation.
• Periprosthetic fracture.
• Adverse local tissue reaction (particularly metal-on-metal).

The procedure

Performed under spinal anaesthesia in most cases, the operation takes approximately four hours. Hospital stay is two to seven nights depending on complexity. Specialised revision components — modular stems, augmented cups, bone grafts — are used where required.

Outcomes

Approximately 90% of revision procedures successfully resolve the underlying problem — pain, dislocation, infection.

Recovery

• Crutches typically for six weeks.
• Full recovery measured in several months rather than weeks.
• Risk profile is higher than primary replacement: infection, bleeding, nerve injury, DVT/PE, dislocation, fracture, leg-length difference, cardiac events.

Hip arthroscopy is keyhole surgery — performed through two or three small incisions using a camera and specialised instruments. The patient lies on a traction table to gently open the joint space. The operation is under general anaesthesia.

Conditions treated

• FAI — CAM and pincer debridement.
• Labral repair with suture anchors, or selective debridement.
• Loose body removal.
• Os acetabuli.
• PSOAS tendon release.
• Microfracture for focal cartilage damage.

Hip arthroscopy is not a treatment for hip arthritis.

Hospital stay

Typically one night. Crutches are required for partial weight bearing during the initial healing window.

Rehabilitation

• Total rehabilitation timeline: 12–18 months.
• Return to contact sport: 4–6 months minimum.
• Driving — typically 2–3 weeks if operated side is the left; longer for the right.
• Return to office-based work — 1–2 weeks. Manual work — 6–12 weeks.

Risks

Specific risks include transient numbness from traction, instrument breakage (rare), heterotopic ossification, and a low rate of revision arthroscopy.

A proximal hamstring tear involves all three hamstring tendons detaching from their attachment at the pelvis. The injury causes severe buttock pain, bruising tracking down the back of the thigh, and significant difficulty walking.

Diagnosis

MRI is the imaging of choice — confirming the tear, the degree of tendon retraction, and the time-window for repair.

Outcomes: surgical vs non-surgical

• Non-surgical management — approximately 50% recovery of hamstring strength.
• Surgical repair — approximately 90% recovery of hamstring strength.

The operation

• Patient prone, 10–15cm incision over the gluteal crease.
• Tendon retrieved, suture anchors placed into the ischial tuberosity.
• Operative time 90 minutes to 4 hours depending on retraction.

Recovery

• Crutches with touch weight-bearing for the first 2 weeks.
• Gradual increase in load and gentle physiotherapy thereafter.
• Return to full activities: 6–12 months.

Complications include re-tear, wound issues, and transient sciatic nerve irritation.