FAQ Category: Hip

Surgeons classify hip fractures from A1-A3 for reference of the direction and extent of a break. An A1 is a stable fracture that was a “clean break,” or one that there are no other fragments and the two bones are still aligned. An A3 break is one in which there are multiple fragments and the break is oblique and the bones are not aligned.  An A2 break is between the two of these and there is often question of whether to use a rod to fix this or external screws.  A recent article suggests that in 70 per cent of A2 breaks it is most cost effective to use an external screw versus a rod. That being said, this decision is left up to the surgeon and their decision is base on numerous factors so ultimately this is a question for them.

An intramedullary nail is a rod that is placed in the bone shaft itself and screwed in place.  It is used in cases where the bone is not easily screwed together with plates on the outside of the bone, or a “extramedullary sliding hip screw.” Depending on the type and extent of your hip fracture, an intramedullary nail might be necessary. This is something that you should discuss with your surgeon.

According to a recent study presented by Post et al. there are a few possible complications with a direct anterior approach for total hip replacement As with all hip replacement, dislocation is a risk and is reported between one and one and a half percent. Another complication is damage to the lateral femoral cutaneous nerve which is reported to range from less than one percent to as high at sixty seven percent. Fortunately most parathesias from damage to this nerve often resolve and do not commonly present with a functional limitation. Fractures of the greater trochanter have been described as a complication. Fractures of the ankle have been associated with use of a fracture table during surgery with the direct anterior approach for hip replacement. Local wound complications are also a possibility due to the moist nature of the groin area. All of these complications have been reported to decrease in frequency with increased surgeon experience.

In a report out recently by Post et al., the direct anterior approach for total hip replacement has been described and reported on. These authors describe a technique which has the advantage of decreased muscle injury and the possibility of faster and less painful recovery. One issue they discuss is the steep learning curve and the need for surgical expertise for the most optimal outcomes. This is due to the complicated anatomy and the challenge in determining the appropriate location for dissection. The positioning and use of the tools to perform the replacement is also improved with experience. This report describes improvements in outcomes with experienced surgeons and reports that studies have found that complications decrease when the surgeon experience is greater than one hundred cases.

Although the underlying pathology is not quite understood there are multiple factors that must occur to develop femoral osteonecrosis.  The primary risk factors are excessive corticosteroid or alcohol use, trauma, or a blood clotting disorder.  The blood clotting disorder can be hereditary, but does not necessarily mean that you will develop the disease process as your mom did.  Do keep in mind, however that the earlier femoral osteonecrosis is detected, the better the prognosis.

An MRI is the gold standard for femoral osteonecrosis detection.  Surgeons determine the stage of the disease progression by location, size, and amount of swelling present.

Depending on the underlying cause of your hip pain, surgery may or may not be an option.  The most current evidence is not that strong regarding hip pain being alleviated by surgery, however this depends on the underlying cause of the pain.  Sometimes the pain itself can be managed through stretching, correcting movement patterns and underlying muscle imbalances.  

The two major predictors for eventual need of a hip replacement are increased age and a chondral injury. The good news is that there are good to excellent outcomes with pain relief. Total hip replacements are continuously evolving with technique and material choices which is further extending the life of the replacement.   People can be limited in their activity choices.  Surgeons caution against partaking in high-impact activities like jogging and contact sports.  Activities that are allowed include: golf, biking, doubles tennis, weight lifting, swimming, bowling, Pilates, ice skating, cross-country or downhill skiing, low-impact aerobics.   

Slipped capital femoral epiphysis (SCFE) is a condition that affects the hip in teenagers most often between the ages of 12 and 16. In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone).

If untreated this can lead to serious problems in the hip joint later in life. Fortunately, the condition can be treated and the complications avoided or reduced if recognized early. The primary goal of the treatment of SCFE is to stop any further slippage of the capital femoral epiphysis. The less slip, the lower the risk of problems in the hip during the child’s life and later as an adult. Surgery (such as you had with pinning) is usually necessary to stabilize the hip and prevent the situation from getting worse.

Even with treatment, there can be some important factors to consider when planning a total hip replacement. For example, a past history of slipped capital femoral epiphysis (SCFE) can lead to a position of the femoral head in the hip socket that is offset (off-center). The end-result can be a limb-length difference and early degenerative arthritis of the hip.

If there is a leg-length difference, the surgeon can’t just take the old hip joint out and put the new implant in. Careful planning and adjusting of the component parts of the implant are important in preventing continuation or even worsening of the leg length discrepancy.

When a total hip replacement is needed later in life because of slipped capital femoral epiphysis present at an earlier age, the surgeon must evaluate any and all contributing factors, including functional and structural causes of leg length differences. Special X-rays (teleoroentgenography, scanography) and more advanced imaging studies (CT scans) are taken preoperatively.

Careful review of these images provides the surgeon with an appreciation of significant issues (e.g., femoral neck shortening or lengthening, a large femoral offset, excessive coxa vara or twist in the femur). Beware that replacing the hip joint will not change problems lower down in the knee or ankle or higher up in the spine. In the case of limb-length differences, surgical correction can’t be predicted or guaranteed — even with surgical release of tight soft tissues around the hip.

Preoperative assessment and surgical techniques today make it possible to remove those pins and replace the hip to give you pain relief and improved joint motion and function. Be sure and talk with your surgeon about what to expect. Ask for specifics about what the hip replacement can and cannot do for you.

The hip joint is made up of two basic parts: the femur (thigh bone) and the acetabulum (hip socket). At the top of the femur is a round ball of bone called the femoral head. This ball fits into the socket and rotates in all directions to give us hip motion.

Between the long shaft of the femur and the femoral head is the femoral neck. The neck is like a short bridge between these two parts. The “twist” the physician mentioned refers to the angle of this “neck” between the shaft of the long bone and the round head at the top.

The femoral neck angle is usually about 150 degrees at birth. With time, growth and development, and weight-bearing, this angle decreases. By adulthood, it is more in the range of 125 to 135 degrees. Some experts suggest coxa vara occurs when the angle between the ball and the shaft of the femur is less than 120 degree (in adults). The condition may or may not be painful but usually results in a limp because one leg is shorter than the other.

When one leg is shorter (or longer) than the other leg, the condition is referred to as a leg-length discrepancy. Placement of a hip implant in conditions like your grandpa’s requires some special planning on the part of the surgeon. A shorter neck length can place the femoral head up higher in the hip socket (rather than in the center). The two anatomical changes (short neck with a twist) will be addressed during the hip replacement procedure.

The surgeon will use imaging studies before the surgery to study the hip shape and alignment. Sometimes, the actual surgical techniques to correct problems aren’t decided until during the procedure when the surgeon can see all of the structures in three-dimensions. The ultimate goal is to provide restoration of the proper limb length and center the implant correctly.

There are many different signs and symptoms of various hip conditions. Your description of the limited motion (called internal rotation) on one side is a potential sign of a condition known as femoroacetabular impingement or FAI.

Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. Femoroacetabular tells us the impingement is occurring where the femur (thigh bone) meets the acetabulum (hip socket). There are several different types of impingement. They differ slightly depending on what gets pinched and where the impingement occurs.

But FAI does not have one symptom or one clinical test that tells the physician, “Yes, this person has femoroacetabular impingement FAI)”. Instead, the diagnosis is one of exclusion based on patient history, clinical symptoms, physical examination, and the results of imaging studies (X-rays, MRIs).

We say the diagnosis is one of exclusion because there are other hip problems with similar presentation. The examining physician formulates the diagnosis by excluding other potential causes in order to make the final determination just what is the condition responsible for your patient symptoms.

If this is an ongoing problem that has not resolved in a few weeks, then you should seek a medical evaluation. They physician usually begins with your history (as it relates to this problem) and conducts a step-by-step physical examination. X-rays or other imaging studies may be needed. Only with the combination of these three factors can the final diagnosis be made with certainty.

With some hip problems, there isn’t one test, one symptom, or one clinical finding that confirms the diagnosis. A thorough evaluation is required. Sometimes it becomes very clear what the problem is. In other cases, with patience and persistence, the physician can sort through important points in the patient history. Combining that information with findings from the physical examination and imaging studies will be necessary to make the final diagnosis. The differential diagnosis is often one of exclusion through a process or “ruling out” other hip conditions, one at a time.

Stem cells are useful because they can divide and develop into any type of cell in the body (including bone or cartilage). Stem cells from the person’s own bone marrow have two major advantages: the patient does not experience cell rejection and this source of stem cells avoids the controversy over the use of embryonic stem cells.

Surgeons can remove or aspirate stem cells from the sternum (breast bone), vertebrae (spinal bones), and iliac crest (top of the pelvic bones). These are places where the bone is close to the skin. A collecting needle punctures through the skin and can be inserted down into the bone to withdraw bone marrow cells. The needle can be withdrawn and other areas nearby can be punctured for a second or third collection of cells.

The cells are then taken to a lab and processed. The cells are prepared in such a way to allow them to replicate (grow and multiply) over a period of days to weeks. For example, to create more bone cells (osteoblasts), the stem cells are placed in a culture that contains bone material. in this way, the stem cells are induced (persuaded or influenced) to differentiate into osteoblasts (bone building bone cells).

Likewise, to encourage stem cells to become cartilage, fat cells (adipose), or connective tissue, specific culture mediums are used that aid the stem cells in expanding. More research is focused now on tissue regeneration for soft tissue and bone repair in humans. One type called connective-tissue progenitor cells are especially useful for repair of connective tissue.

Connective-tissue progenitor cells are somewhat limited in bone marrow tissue. And usually the number of stem cells used in tissue repair is in the millions. So finding the site with the best yield will be helpful. Studies are underway to compare yield from the different harvest sites. And, there are many, many different factors that can affect the total yield of these cells. Site of harvest in only one. The age and sex of the patient may make a difference. These are additional points of interest being investigated.

You may be experiencing symptoms of osteoarthritis (OA) but it’s also possible that you have a hip condition such as femoroacetabular impingement (FAI). Femoroacetabular impingement (FAI) refers to some portion of the soft tissue around the hip socket getting pinched or compressed. Femoroacetabular tells us the impingement is occurring where the femur (thigh bone) meets the acetabulum (hip socket).

There are several different types of impingement. They differ slightly depending on what gets pinched and where the impingement occurs. Anatomic abnormalities of the femur and/or the acetabulum predispose the person to damage of the soft tissue structures inside the joint. Vigorous, repetitive hip motion creates abnormal contact and collision that result in hip pain.

The pain comes on slowly at first. Symptoms remain centered around the hip but can travel down the leg (rarely going into the buttocks or past the knee). Rest usually does relieve symptoms of osteoarthritis but when femoroacetabular impingement is present, symptoms are made worse by prolonged hip flexion (sitting). If this is the problem, you may lose hip motion (especially hip flexion and internal rotation). An X-ray will show the changes in the hip typically associated with femoroacetabular impingement (FAI).

For an accurate diagnosis, you will need to see your primary care physician or an orthopedic surgeon. The physician who examines you will assess three areas: 1) symptoms of FAI, 2) positive hip impingement test pain with hip flexion and internal rotation), and 3) imaging findings seen with FAI (e.g., increased alpha angle, bone cysts from impingement, increased lateral center-edge angle).

As you probably know by now, femoroacetabular impingement (FAI) refers to some portion of the soft tissue around the hip socket getting pinched or compressed. Femoroacetabular tells us the impingement is occurring where the femur (thigh bone) meets the acetabulum (hip socket).

There are several different types of impingement. They differ slightly depending on what gets pinched and where the impingement occurs. Anatomic abnormalities of the femur and/or the acetabulum predispose the person to damage of the soft tissue structures inside the joint. Vigorous, repetitive hip motion creates abnormal contact and collision that result in hip pain.

It looks like one particular impingement type (called cam-type impingement) is more likely to lead to tears of the labrum (fibrous rim of cartilage around the hip socket). The cam-type of impingement occurs when the round head of the femur isn’t as round as it should be. It’s more of a pistol grip shape. It’s even referred to as a pistol grip deformity. The femoral head isn’t round enough on one side (and it’s too round on the other side) to move properly inside the socket.

There is some new evidence that the cam-type impingement is the result of participation in high-impact sports. Adolescents (teens) develop this condition as the bones mature. In other words, they aren’t born this way. It appears as though the repetitive motion of the sports activity reshapes the hip resulting in a femoroacetabular impingement (FAI).

Several studies have shown that cam-type deformities are linked with osteoarthritis. But people with cam-type deformities and osteoarthritis are not more likely to end up with a total hip replacement than people without this type of femoroacetabular impingement.

Future studies will focus on finding out who is at risk for developing femoroacetabular impingement that will lead to osteoarthritis and hip replacement. Finding ways to prevent femoroacetabular impingement (and osteoarthritis) would be a natural outcome of these findings. It is possible that risk factors for those who develop osteoarthritis early in life are different than risk factors for adults who develop osteoarthritis in mid- to late-life. This must be investigated as well.

Osteoarthritis is a potentially disabling condition typically affecting the large joints (e.g., hips, knees, ankles). Areas of the protective cartilage wear down to the bone and then destructive changes in the bone occur. The soft tissues around the joint (called the capsule) get thicker and stiffer. The result can be pain, stiffness, loss of motion, loss of function, and disability.

The surprising thing about osteoarthritis is that there can be evidence of severe disease (as seen on X-rays or other imaging studies) without any symptoms. And other people with mild disease can have severe symptoms. Reasons for the differences remain unknown. Likewise, all the reasons why someone develops osteoarthritis while someone else of the same age, size, and demographics does not have not been fully discovered.

We do know there are some risk factors for osteoarthritis. Obesity is the number one risk factor for osteoarthritis of the hip and knee. A full one-third of the baby boomers are considered obese. The number of people who are obese has increased (more than doubled) in the last 25 years. Predictions are that this won’t change any time soon. In fact the trend is going in the opposite direction (i.e., getting worse).

High-impact and high-intensity physical activities (related to recreation, sports, or occupation) is another risk factor for the development of osteoarthritis of the hips and knees. And a third known risk factor involves structural (anatomic) abnormalities. The most common of these is a condition known as femoroacetabular impingement (FAI).

With FAI, the shape of the hip (from birth) puts the person at increased risk for degenerative disease later in life. Studies are underway to identify other risk factors and to predict who will develop arthritis. The next step in research is to determine how to prevent osteoarthritis from happening. With proper weight management and appropriate exercise this upward trend of osteoarthritis (with or without the impingement problem) may be slowed or possibly even halted.

Consider these statistics: 202,500 total hip replacements were done in 2003. In that same year, 36,000 total hip replacements were operated on again to revise, remove, or replace the first implant. The number of between the ages of 30 and 65 who will develop osteoarthritis is expected to increase two to 10 times the current rate.

With the rising problem of obesity in the United States and the aging population, it is predicted that these figures will increase. For example, it is estimated that by the year 2030, the number of primary (first) hip replacements will increase by 174 per cent. And the number of revision procedures will double in number.

We have always known that hip osteoarthritis is a common problem and one that can be very disabling. But the pace at which the need for hip replacement is rising has taken the orthopedic community by surprise. This may be what you are seeing in your community as well. All previous estimates of future numbers of primary and revision total hip replacements have been way under par.

How do we know the number of cases of total hip replacement has exceeded the projected estimates? Hospitals keep data that is logged into a national data base. Hospital administrators use this information to plan ahead for future needs (e.g., personnel, supplies, facilities) based on current trends.

Not only are more adults being affected by osteoarthritis resulting in hip degeneration, but the age at which the need (the demand!) has occurred has declined. In other words, more and more younger adults (younger than 55 years old) are getting total hip replacements. And that trend is expected to continue into the future as well.

In your mother’s case, there may be other reasons why the surgeons are so backed up but it may very well be explained by the trends reported here. If your mother is in dire pain, it may be possible to put her on the surgery cancellation list. If someone who was scheduled for a similar operation has passed away, moved away, changed his or her mind, or have some other reason to cancel, another patient could get that spot. With a little persistence, that could be your mother. Call and check with the surgeon’s staff and found out what her options might be.

Studies in this area agree that about half the time, it is unclear what the true cause of the problem may be. Clearly, the nerve gets pinched, pressed, cut, deprived of oxygen, or exposed to high heat and sometimes the cause is a combination of those factors. The result can be muscle weakness, loss of normal motor function (movement), and altered sensation.

When the lower leg is affected, it is usually because the peroneal nerve (a branch of the much larger sciatic nerve) has been damaged. The large sciatic nerve splits just above the knee to form the tibial nerve and the common peroneal nerve. These two nerves travel to the lower leg and foot, supplying sensation and muscle control. The tibial nerve continues down the back of the leg while the common peroneal nerve travels around the outside of the knee and down the front of the leg to the foot. Both of these nerves can be damaged by injuries around the knee.

This is a rare complication. According to a recent study from Thomas Jefferson University Hospital in Philadelphia, Pennsylvania one-third of one percent (0.32%) of their patients (that’s 31 out of 9,570) had a confirmed case of peroneal nerve palsy following a total hip replacement.

By taking a look at all the patient characteristics of the 31 patients and comparing them to the rest of the (much larger) group, the authors were able to see one risk factor predicting peroneal nerve palsy. Younger age (less than 56 years old) increased the risk of nerve palsy and poor or slow recovery.

They also saw one prognostic factor (i.e., able to predict when peroneal nerve palsy is more likely to happen). Being significantly overweight (obese) influences recovery in a negative way. In other words, a larger body-mass index (BMI) is a red flag for potential nerve problems associated with total hip replacement.

Even with CT scans and MRIs, the exact cause of the peroneal palsy was not known in half of the 31 cases. Some of the reasons why patients did develop this type of nerve palsy included compression from a hematoma (pocket of blood), lipoma (benign fat tumor), and screw used in the hip replacement (pressing against the nerve).

There were quite a few cases from traction (pulling) on the nerve either directly or indirectly from the use of a surgical tool known as a retractor. In a smaller number of patients, hip dislocation or limb lengthening contributed to nerve damage leading to nerve palsy. And one patient developed nerve palsy from being in a position that put pressure on the lower leg bone (fibula), which in turn, pressed against the nerve.

Your surgeon has given you the most up-to-date information available today based on the most recent histories. For example, in a recent study from Thomas Jefferson University Hospital in Philadelphia, Pennsylvania one-third of one percent (0.32%) of their 9570 total hip patients developed a peroneal nerve palsy.

The peroneal nerve is a branch of the much larger sciatic nerve). It was pinched, pressed, cut, deprived of oxygen, or exposed to high heat. The result was muscle weakness, loss of normal motor function (movement), and altered sensation.

The large sciatic nerve splits just above the knee to form the tibial nerve and the common peroneal nerve. These two nerves travel to the lower leg and foot, supplying sensation and muscle control. The tibial nerve continues down the back of the leg while the common peroneal nerve travels around the outside of the knee and down the front of the leg to the foot. Either one of these nerves can be damaged by injuries around the knee.

In the end, only slightly more than half (57 per cent) of the patients with a peroneal nerve palsy recovered fully after their total hip replacement. These results are the same as reported by others. In general, it seems to take about a year for patients to regain as much of the lost sensory and/or motor function as possible. In some cases, this time period was extended to 18 months (one and a half years).

By taking a look at all the patient characteristics of the 31 patients and comparing them to the rest of the (much larger) group, the authors were able to see one prognostic factor (i.e., able to predict when peroneal nerve palsy is more likely to happen). Being significantly overweight (obese) influences recovery in a negative way. In other words, a larger body-mass index (BMI) is a red flag for potential nerve problems associated with total hip replacement.

Time to recovery ranged from one month up to 50 months (four years, two months). Time in the operating room and amount of blood loss did not seem to be significant factors in recovery time. Body size/weight was the main determining factor in whether or not there was full recovery (not whether it was complete or incomplete at the time of the injury).

This study was unable to identify a single body mass index (BMI) threshold (the number at which a nerve palsy is likely to develop). There was a trend observed: the higher the BMI, the greater the chance for incomplete recovery. The lower the BMI, the more likely the patient was to experience full sensory and motor recovery.

You can search our website for the latest information and evidence-based research on any topic by typing in the specific diagnosis or disorder you are interested in. You may also find a recent in-depth review of arthroscopic hip surgery published by orthopedic surgeons from Northwestern University in Chicago, Illinois. They offer their insights, opinions, and recent research evidence for treatment decisions regarding a variety of hip problems. Here’s a quick review of what you will find in that article.

Anyone with hip pain that doesn’t go away with a little stretching, movement, or change in position will need a thorough, systematic patient history and physical examination. Posture, walking pattern, hip range-of-motion, and strength will be evaluated. Special tests to look for specific problems (e.g., labral tears, femoroacetabular or psoas impingement, muscle tightness, instability, bursitis).

Imaging studies such as X-rays will be used to rule out bone fractures and/or detect joint changes due to arthritic degenerative disease. For each of these potential problems, the authors provide a detailed discussion of who is at greatest risk, what the clinical presentation might be, and the choices for surgical management when conservative (nonoperative) care is not successful.

Tables outlining views taken on X-rays and MRIs provide the surgeon with an idea of what to evaluate, what is considered normal versus abnormal, and signs of bony abnormality. Important factors to assess when viewing X-rays when evaluating patients with femoroacetabular impingement (FAI) are also presented in a special table. X-ray examples are included to give a visual understanding of this condition.

Once an accurate diagnosis has been made, then the decision-making process begins in planning the most appropriate and effective treatment. The authors confine their discussion to problems that require arthroscopic hip surgery.

This can include painful labral tears, femoroacetabular impingement (FAI), loose bodies in the joint (e.g., fragment of bone or cartilage), ruptured ligaments, psoas impingement, and snapping hip syndrome. Every effort is made to look for (and find!) secondary or associated injuries that might be present along with the primary condition. This could affect tendon, ligaments, bone, or joint capsule.

Details of patient position during surgery, location of portals (area where arthroscope is inserted into the skin and through the soft tissue to the joint), and surgical technique are provided for each of the conditions mentioned. Once again, the authors provide drawings and patient photos taken during surgery to show exactly what they are describing.

Postoperative rehabilitation, possible complications, and outcomes from long-term studies and systematic reviews make up the final one-third of the article. Now that minimally invasive arthroscopic techniques and tools are available, more and more hip reconstructive surgeries can be done this way. When patients are carefully selected (taking age and severity of the problem into consideration), results are good to excellent with very low complication rates.

The orthopedic surgeon you are working with may also have some suggestions and recommendations for recent publications that may be of interest. Do take a little time to browse our website and see if what you are looking for might not be readily available here.

You may find our Patient Guide to Labral Tears of the Hip helpful as you begin to explore this diagnosis and potential treatment options. Basically, the acetabular labrum is a fibrous rim of cartilage around the hip socket that is important in normal function of the hip. It helps keep the head of the femur (thigh bone) inside the acetabulum (hip socket). It provides stability to the joint.

Labral tears occur most often with major trauma to the hip. Sometimes minor trauma such as twisting or slipping and/or repeated hip motions can lead to labral tears. When caught early while the tear is small enough, conservative (nonoperative) care can be successful in managing the symptoms and preventing further damage.

But when painful symptoms are not relieved and basic activities such as sitting, standing, and walking become so painful — then surgery may be needed. Sometimes a simple debridement procedure is done. The surgeon carefully shaves away the jagged, torn portion of the labrum and reattaches any part that can be saved.

If labral repair is unsuccessful or not advised, labral reconstruction is possible. In fact, this surgery has become more popular as surgical techniques and tools have improved. This may be the type of surgery you mentioned. Restoring the labral seal in order to reinstate physiologic function of the hip joint is now possible.

Patients who have severe labral damage that can’t be fixed may benefit from the use of graft tissue to replace the original labrum. Graft tissue can come from the patient’s own body such as from the gracilis tendon, ligamentum teres capitus, or iliotibial band. The harvested tissue is used to span the gap caused by labral deficiency.

Studies of long-term outcomes following this type of surgery are not available yet. But early studies with limited short-term results show that the procedure is safe and results are satisfactory.