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HIP JOINT The hip joint is a spheroidal type of synovial joint formed between the head of femur and the acetabulum of the hip bone. It is a typical ball-and-socket joint. Articular surfaces The head of the femur is globular and forms two-thirds of a sphere. It is covered by an articular cartilage which is thickest superiorly in the line of weight bearing. The cartilage thins out inferiorly. The cartilage is also missing at the pit or fovea where the ligament of the head of femur attaches. The articular (lunate) surface of the acetabulum is horse-shoe-shaped. Its cartilage is thick superiorly, but thins out inferiorly. The articular surface forms an arch around the non-articular acetabular fossa. The latter contains a mass of fat covered by the synovial membrane. Inferiorly, the rim of the acetabulum bears the acetabular notch. The latter is bridged-over by the transverse acetabular ligament. The acetabulum is thickened by a fibrocartilage known as the acetabular labrum. The latter is attached to the bony rim of the acetabulum and to the transverse acetabular ligament. The free thin edge of the labrum cups around the head of femur and holds it firmly. This helps to prevent dislocation. Articular capsule This is particularly strong and thick. It consists of both a synovial and a fibrous component. Proximally, the fibrous capsule is attached to the edge of the acetabulum and to the transverse acetabular ligament. Distally, the capsule is attached anteriorly to the intertrochanteric line. Posteriorly, it covers only twothirds of the neck of the femur. Most of the fibres of the capsule are longitudinal, running from the pelvis to the femur. However, some deeper fibres run circularly around the neck of the femur. These fibres form the orbicular zone which helps to hold the head of the femur in the acetabulum. [Some of the longitudinal fibres at the femoral attachment are reflected back along the femoral neck towards the head of the femur. These are called retinacula and they carry small arteries to the head of femur]. The articular capsule is further strengthened by the presence of the 3 intrinsic ligaments. The latter are thickened parts of the fibrous capsule and are named after the part of the hip bone they attach to. The ligaments are: the iliofemoral, pubofemoral and ischiofemoral ligaments. Another ligament runs within the

joint cavity and is called the ligament of the head of femur (ligamentum capitis femoris). (A) Intrinsic ligaments (i) The iliofemoral ligament lies on the anterior surface of the capsule. It has an inverted Y shape, the stem being attached to the anterior inferior iliac spine. The diverging fibres attach to the entire length of the intertrochanteric line. The iliofemoral ligament becomes tense in full extension of the hip joint and hence helps to maintain the erect posture. The ligament contributes to the screw-home effect. As the thigh becomes fully extended, the capsule is twisted and shortened. This results in the head of the femur being guided like a screw into its socket (i.e., the acetabulum). [The iliofemoral ligament is important in the mechanism called locking of the hip joint. In this mechanism, the individual is able to stand upright with little expenditure of energy in form of muscle contraction. This is because in full extension of the hip joint, the head of femur and acetabulum now almost fit tightly together. The iliofemoral ligament becomes taut (tense), thus preventing hyperextension. The weight of the body is now supported by the iliofemoral ligament]. (ii) The pubofemoral ligament is applied to the medial and inferior parts of the capsule. It becomes tight during extension of the hip joint. It also limits abduction. (iii) The ischiofemoral ligament lies on the posterior aspect of the joint capsule. It arises from the ischial portion of the acetabulum. It then spirals laterally and superiorly across the posterior part of the femoral neck. It prevents hyper-extension of the hip joint. (B) Ligament of the head of femur (ligamentum capitis femoris) This is also known as the round ligament of the head of femur (ligamentun teres femoris). It is intracapsular, being surrounded by a synovial membrane. It arises from the margins of the acetabular notch and transverse acetabular ligament. It ends in the fovea of the head of femur. It is about 3.5 cm long, and it appears to be of little importance in preventing dislocation of the hip joint. However, it becomes stretched when the femur is abducted. The synovial membrane

This lines the fibrous capsule, and lines the ligament of the head of femur. It also surrounds the fat pad of the acetabular fossa and covers the acetabular labrum. [At the femoral attachment of the capsule, it is reflected back along the femoral neck]. There is a prolongation of the synovial capsule beyond the free inferior margin of the fibrous capsule posteriorly. Here it serves as the bursa for the tendon of the obturator externus muscle. Movements of the hip joint The hip joint is capable of a wide range of movements. These include (i) extension and flexion (ii) abduction and adduction (iii) medial and lateral rotation and (iv) circumduction. Blood supply of the hip joint Arteries of the hip joint are branches of the medial and lateral circumflex femoral arteries, the inferior gluteal artery and the deep division of the superior gluteal artery. The proximal part of the head of femur remains separated from its distal part and neck by an epiphyseal plate. This is the situation up to the age of 18 20 years when fusion of the two parts finally occurs. Before fusion, the proximal part receives its blood supply from a small branch of the obturator artery which travels within the ligament of the head of femur. The neck and adjacent part of the head of femur receive their blood supply from the lateral and medial circumflex femoral arteries via retinacula. These two arteries are branches of the deep femoral artery. After fusion of the two parts, the circumflex femoral artery supply becomes more important, and the supply via the ligament of the head of femur becomes minor. Consequently, fractures of the neck of femur in the adult may interrupt blood supply to parts of the head of femur, resulting in slow healing of the fracture or avascular necrosis of head of femur. Nerve supply to the hip joint The joint has four sources of nerve supply (a) femoral nerve (b) sciatic nerve (c) the anterior division of the obturator nerve (d) superior gluteal nerve. Some clinical aspects of the hip joint

(i) Dislocation of the hip joint The nature of the articular surfaces of the hip joint and surrounding ligaments confer a high degree of stability to this joint. Therefore, dislocation is rare, except when extreme forces are involved. Such forces are encountered in car accidents. In these situations, the individual is in a sitting position, so that the hip joint is flexed and the femur medially rotated. In a car collision, there may be a forceful impact of the knee with the dashboard. The force is transmitted through the femur into the hip joint, thus causing dislocation. When this happens, the femoral head is dislodged from the acetabulum and is displaced superiorly along the lateral surface of the ilium. The affected limb is shortened and medially rotated. (ii) Traumatic fracture of the neck of femur The neck of the femur is prone to fracture in individuals who are over sixty years of age. This is mainly due to a condition called osteoporosis(rarefaction, bone becoming more porous) which weakens the femoral neck with advancing age. The condition is more common in women in which osteoporosis is relatively more severe than in men. This is due to hormonal imbalance that follows menopause in women. Under these circumstances, usually a small force [e.g., falling after slipping or tripping on an object] is enough to cause the fracture of the femoral neck. [Such cases are now treated by replacing the upper end and head of femur with a metal or plastic prosthesis]. Fracture of the neck of femur also interferes with blood supply to the femoral head. The latter undergoes ischemic necrosis, also known as avascular necrosis of the head of femur. (iii) Osteoarthritis (degenerative arthritis) This is a painful condition of the hip in which the articular cartilage gets destroyed progressively. This results in bits of the articular cartilage disappearing, so that the articular surfaces are no longer smooth. The resultant direct contact between parts of the articulating bones leads to extreme pain.