Failed Hip Fractures Leading to Arthritis and Revision Surgery

It depends on the pathology and on the activity — for example, Andy Murray, the tennis player, had a hip replacement and could carry on with most of his activities, though one cannot guarantee 100%. If someone has had a total hip replacement, high-impact sports of that kind are generally not advisable — but they can change to a different sport. If the condition is femoroacetabular impingement (FAI) rather than arthritis, we do hip arthroscopy to remove the impingement, clean the cartilage, and inject stem cell therapy; the hip regenerates over about 6 months and results on repeat MRI are often excellent. Most sport-related damage is to ligaments or cartilage, not true hip arthritis — hip arthritis itself means the cartilage is gone and the anatomy is deformed, which is a different issue, and after that kind of hip replacement patients feel great satisfaction just resuming daily activities.

We look at the X-ray to see whether the hip joint space is maintained. If pain has started but mobility is still there and the joint space and cartilage are maintained, we don't straight away advise hip replacement — we have other options, such as the arthroscopic method, where we clean up osteochondral extra bone formation or damaged cartilage and repair it with stem cell therapy. That is a good option instead of hip replacement. Once the cartilage is completely damaged on CT or MRI, with no blood flow to the femoral head, then the only answer is hip replacement.

For sickle cell disease in children, bone marrow transplant is the standard treatment, with the best results when done early while the patient is still a child — my colleague Dr. Dharma Choudhary's centre specialises in this. As for hip arthroplasty itself, it is not recommended below 17–18 years of age because the hip does not develop enough. Below that age we instead use arthroscopy to clean up damage, or osteotomies — we change the weight-bearing surface of the hip with procedures like valgus or varus osteotomy — based on where the MRI shows the main damage, which relieves pain much better.

After hip replacement, certain things are not recommended: sitting on the floor, sitting cross-legged, and squatting, as these positions can damage the implant and cause loosening. High-energy sport activity should also be avoided. Following these recommendations, a well-fitted hip can last 30–35 years, and since most hip replacement candidates are of an older age profile, most patients will not need it again in their lifetime.

Stem cells are osteoprogenitor or osteopotent cells that can convert into osteoblasts, osteoclasts, or chondroblasts. For hip cartilage damage, we clean the damaged islands of cartilage with hip arthroscopy and inject stem cells; over time, review MRIs show the cartilage growing back, like grass growing, with less damage and fewer symptoms after about 6 months — though it does take time. In orthopaedics we harvest stem cells from the iliac crest, using a Jamshidi needle, taking around 120 ml of blood from the marrow (posterior or anterior, near the spine). This is then put into a centrifuge machine for about 45 minutes to 1 hour to concentrate the stem cells before injection.

A hip fracture that fails to heal correctly, whether it does not unite, develops avascular necrosis, or leaves the neck shortened and deformed, often progresses to secondary traumatic arthritis that needs complex hip arthroplasty to correct.

Neck of femur fractures, especially subcapital fractures, have a guarded blood supply and a high incidence of avascular necrosis, even in cases where the fracture itself goes on to unite. In other cases, a fracture can unite but leave the neck foreshortened, producing a collapse of the neck and a varus deformity that leads to secondary traumatic arthritis.

One of the hardest parts of these revisions is reaming the femoral canal, because the bone is frequently osteoporotic after multiple prior surgeries or from a complex underlying anatomy, creating a real risk of puncturing the femoral cortex and displacing the implant.

A guide wire technique similar to that used in femur nailing, checked repeatedly under C-arm imaging, is used to avoid puncturing the femoral cortex, along with close monitoring of blood loss throughout the procedure.