FAQ Category: Hip

The risk of falls increases in anyone with Parkinson’s disease as the disease progresses (or when the symptoms are poorly controlled by medication). Balance disturbances and a sudden drop in blood pressure when standing up (called postural hypotension) are symptoms that increase the risk of falls.

Parkinson patients also suffer from a tendency to fall backwards or to the side. With a rigid body and an inability to move the arms quickly to catch themselves, falls can be a major problem. On top of that, most Parkinson patients are older adults who are also at risk for osteoporosis (brittle bones). They have twice the risk of hip fracture compared with adults their same age who don’t have Parkinson’s disease.

There are several steps that can be taken. First, consult with his primary care physician. Ask about getting a baseline bone density test done. This will give the doctor, patient, and family an idea of how serious the problem is at this time. If bone density levels are low, medications called bisphosphonates can be prescribed. Taking a calcium supplement with vitamin D is also recommended.

Taking calcium with vitamin D has been proven effective in lowering the risk of bone fracture. And in patients with Parkinson’s disease, vitamin D deficiency is common, making supplementation all the more important.

Exercise is also important. Strength training, balance training, improving proprioception (joint sense of position), and kinesthesia (sense of boy movement through space) are all key factors in maintaining balance. Parkinson’s patients tend to be rigid and unable to move the arms and legs quickly in order to regain balance once the equilibrium has been challenged.

A physical therapist can help you with this part of the program. The therapist can also offer many suggestions for ways to modify the home to prevent falls. This is one time where Ben Franklin’s admonition: an ounce of prevention is worth a pound of cure is especially appropriate. Hip fractures can be disabling enough in a healthy adult. But in someone with a neurologic problem like Parkinson’s disease, a hip fracture can be devastating. Prevention is extremely important.

Greater trochanteric pain syndrome (GTPS), also known as hip bursitis is a common cause of hip pain. But the pain pattern it creates is very similar to many other musculoskeletal conditions. It can take some time (up to several years for some patients) for an accurate diagnosis to be made.

The greater trochanter is the large bump on the outside of the upper end of the femur (thigh bone). This bump is the point where the large buttock muscles that move the hip connect to the femur. The gluteus maximus is the largest of these muscles. It attaches lower down on the femur.

If you lie on a hard surface for very long, you will feel the effects on your greater trochanter. Where friction occurs between muscles, tendons, and bones, there is usually a structure called a bursa. A bursa is a thin sac of tissue that contains fluid to lubricate the area and reduce friction. The bursa is a normal structure. The body will even produce a bursa in response to friction.

Sometimes a bursa can become inflamed (swollen and irritated) because of too much friction or because of an injury to the bursa. An inflamed bursa can cause pain because movement makes the structures around the bursa rub against it.

Inflammation in the bursa between the tendon and the greater trochanter leads to greater trochanteric pain syndrome. This problem is common in older individuals. It may also occur in younger patients who are extremely active in exercises such as walking, running, or biking.

Sometimes it isn’t until the patient has gone through a long process of trial and error in treating the problem that the true source of the symptoms becomes apparent. In the case of hip bursitis, one treatment doesn’t work for everyone. Some people get better with a single steroid injection into the bursa. Others require two or three injections.

Some patients respond to physical therapy with stretching, strengthening, and core training. Others don’t improve until issues of postural alignment are addressed with proper shoes, shoe inserts, or for some athletes, correcting training errors.

There are even some patients who have surgery to remove any pieces of loose cartilage, frayed edges of the bursa, or torn tendons before the pain is relieved. And in some cases, the surgeon has to remove some of the bone that’s pinching the bursa against the tendon.

All-in-all, your experience is more typical than you might have guessed. With recent advances in the evaluation of patients and better understanding of the underlying anatomical cause(s) of bursitis, we hope future patients will be spared the long and drawn-out diagnostic process you experienced.

Injecting a numbing agent and an antiinflammatory drug into the bursa can have significant results in just one or two treatments. Most physicians will try as many as three injections but only if the patient is continuing to get pain relief.

Correct placement of the injection is the key to success with this treatment. If the needle misses the bursa and injects the drug into the tendon, it can cause tendon rupture. Successful steroid injection may end the problem. If it does not, then other options exist.

Patients with hip bursitis can get relief with physical therapy treatment. Besides treating the local area of inflammation, the therapist can address the underlying cause(s) of the problem. Often, this is an issue of postural or body alignment.

Friction can build in the bursa during walking if the long tendon on the side of the thigh is tight. It is unclear what causes this tightening of the tendon. The gluteus maximus attaches to this long tendon. As you walk, the gluteus maximus pulls this tendon over the greater trochanter with each step. When the tendon is tight, it rubs against the bursa.

Stretching the overlying soft tissue structures makes sense. Relieving tension in the structures around the greater trochanter reduces friction leading to the pain syndrome. The therapist has several other tools to help realign structures for pain relief.

A proper relationship between the joint surfaces and muscle to joint interface is important. Good alignment means good joint integrity and normal range-of-motion. Leg alignment and symmetry is a big part of posture and alignment needed for normal biomechanics.

The foot is a good place to start when lining up the legs, hips, pelvis, and spine. Proper shoes that distribute the weight evenly over the foot and up into the legs is important. Athletes in training (and even older adults who walk or run long distances over time) should especially pay attention to how many miles they put on a shoe and replace them often. New shoes should be purchased when the person has met the shoe manufacturer’s limits on the lifespan of each pair of shoes.

Once the foot is in a stable, supported position of alignment, the entire kinetic chain (connection and force spread from foot to ankle to knee to thigh to hip) is supported. This is a large part of the prevention program. Core training is the next step. Strengthening the muscles of the spine, abdomen, and hips can also help prevent hip pain.

Hip pain with limitations on full hip motion in an active adult requires special attention — especially if you are in your 20s or 30s. Early diagnosis and treatment is imperative to avoid degenerative changes in the hip joint later in life. There are many possible causes of this type of hip pain. Given your description, one of the most likely would be femoroacetabular impingement (FAI).

Femoroacetabular impingement (FAI) describes a condition where the top of the femur (thigh bone) pinches the rim of the hip socket. The area that gets compressed is referred to as the acetabular rim. This type of impingement occurs most often when the hip is flexed and internally rotated.

For a long time, it was believed that FAI only occurred in people with some kind of abnormal anatomy of the hip. There was either a backward tilted angle of the hip socket called retroversion, a larger socket than the ball (head of the femur) inside the socket, or flattening of the femoral head. One type of abnormal shape of the hip was labeled a pistol grip because of the resemblance to the grip of a handgun.

More recent studies have shown it’s possible to develop FAI even when the hip structure and anatomy are essentially normal. But, in general, more people with acetabular retroversion end up with hip pain and problems leading to degenerative hip osteoarthritis than any others.

To get to the bottom of the cause of hip pain, a thorough history and examination are required. An orthopedic surgeon or sports medicine physician is the best one to see. The physician will look at your foot position, leg angles, leg length differences from one side to the other, hip motion, and muscle strength. Gait (walking) patterns will be evaluated.

Special tests such as the impingement test are done to identify the presence of an underlying FAI as the cause of the painful symptoms and restricted motion. X-rays, CT scans and/or MRIs may be used to confirm the diagnosis. The results of all of these tests are important pieces of information when deciding on the best treatment approach.

With early diagnosis and treatment of young, active patients with FAI the problem can be managed by conservative measures. Surgery may be needed to restore as normal hip anatomy as possible. But before jumping to any conclusions, make an appointment and see a specialist to find out for sure what might be causing the problem. If you’ve had this for a while and it hasn’t gone away (even with your yoga practice), don’t wait any longer.

It sounds like you might have a condition called femoroacetabular impingement (FAI). With FAI, the top of the femur (thigh bone) pinches the rim of the hip socket. The area that gets compressed is referred to as the acetabular rim. This type of impingement occurs most often when the hip is flexed and internally rotated.

Surgery is often recommended as the most successful treatment for this problem. There are three surgical choices: 1) surgical hip dislocation, 2) periacetabular osteotomy, and 3) hip arthroscopy. Surgical hip dislocation is considered the current gold standard, though some experts expect improved arthroscopic techniques will change that in the future.

Surgical dislocation refers to taking the femoral head out of the socket and making adjustments and
repairs as necessary, and then putting the head back in place. The operation can be done without cutting through the muscles and with the least amount of trauma possible. Any damage to the labrum (rim of cartilage around the hip socket) can be repaired. Any problems with mismatch of the femoral head and neck with the acetabulum (hip socket) can be taken care of. This type of surgery allows for preservation of the joint, which is important in young, active adults.

Periacetabular osteotomy corrects the retroversion (tipped or tilted position of the acetabulum). The capsule surrounding the hip joint is cut open. The femoral head and neck are reshaped by shaving or cutting off portions of the bone. The goal is to correct the placement of the femoral head in the hip socket.

The third surgical option (hip arthroscopy) to treat FAI allows the surgeon to gain access to the inside of the joint without cutting it open. This avoids pulling the femoral head away from the socket. Arthroscopic surgery also makes it possible to reattach (rather than remove) a torn labrum.

Studies show that the best way to approach this problem is by restoring as normal hip anatomy as possible. Surgical hip dislocation is used with good success for patients with mild to moderate (but not severe) degeneration of the joint cartilage, surface, and surrounding capsule.

It sounds like your surgeon is right on track with current evidence for best practice. You can always seek a second opinion to help you understand your condition and the various treatment options available.

While it’s not possible without seeing your mother and mother-in-law and their charts, it sounds like your mother had a traumatic hip fracture and it could be that your mother-in-law had a fatigue or stress fracture. In your mother’s case, the break was sudden and harsh, and depending on where the location around the hip, may have caused a good deal of damage.

If your mother-in-laws hip fracture is really a stress fracture, then it’s not unusual at all that she didn’t have a lot of pain nor could the doctor see it right away on an x-ray. This type of fracture has to be repaired just as much as the type your mother had because if it’s not, the bones could move and cause damage. As well, the pain would likely increase, causing your mother-in-law to slow down.

Total joint replacements (especially hip and knee replacements) are fairly common in adults over the age of 65. They are rare (but not unheard of) in patients older than 100 years old. In those patients, it’s often a matter of what’s referred to as nonelective surgery. In other words, they probably broke their hip and have to have the surgery.

Whenever possible, surgeons will pin a broken hip in someone so old. Replacing the entire joint isn’t always needed. This is especially true for the person who is bed or wheelchair bound and no longer walking.

But for some of today’s senior seniors (90 years old and older), otherwise good health and mobility suggest the need for a joint replacement in order to maintain this status. Losing function and losing independence may not be an acceptable option for these folks.

And in the long run, joint replacement is actually cost-effective. Being upright and moving reduces the risk of many other health care problems that can be quite costly to treat (e.g., bed sores, blood clots).

It’s not uncommon for women to lag behind men when it comes to having elective surgery such as a total hip or total knee replacement. Women tend to worry more about taking care of their families after surgery. The unknown factors of how long it will take to get back up on their feet and independent can hold them back.

In many cultures, men are more used to being taken care of and provided for in the home. Becoming more dependent in these areas after surgery is not such a stumbling block for them. Women may have a more difficult time asking for and accepting help from others.

The first step may be just to have her evaluated by your surgeon of choice. He or she may be able to answer any questions you or your mother may have. Asking questions about healing time, length of hospitalization, expected time for recovery may help your mother decide what’s best for her.

Most patients are seen right away in the hospital by a physical therapist. The therapist helps them get up and get moving again. Joint motion and muscle strengthening are part of the rehab program. The therapist will advise patients about what’s needed at home. If your father had this surgery a year ago, it’s likely they already have everything they need (e.g., raised toilet seat, walker or cane, grab bars in the bathroom).

These are just a few suggestions for getting to the bottom of your mother’s hesitation. If you think she could (and would) tell you, perhaps asking her straight out might help solve the issue. It is a big step for many people but most patients agree that the benefits are well worth the effort.

A broken hip can be devastating for anyone, particularly a senior. When someone breaks any bone, there are the issues of pain, and so on. But when a hip is broken, mobility also becomes a big problem. And, as people age, their bones may not heal as well as when they were younger, and the seniors may have other health issues as well, which can make recovery more difficult.

After having surgery for a broken hip, there is a lot of pain that can make it difficult to move around. Or, they may have had some difficulty from the anesthetic as this is a shock to their system. As people don’t move around, they don’t have much of an appetite. If they don’t eat well, they become malnourished and this can affect their healing. If they aren’t moving around or eating, they may not move their bowels and constipation can become a big problem. If someone can’t move on their own and depend on others to help them to the bathroom, they may not get to the bathroom on time and they may start soiling themselves. This can lead to skin breakdown and it can lead to shame and withdrawal from other people. As people don’t move, their muscles get weaker and their body gets weaker – and the cycle has begun.

While this all sounds very depressing, it doesn’t always happen. Many elderly people break a hip and do quite well afterwards. But it’s very important to be sure that they get good medical and follow up care to help increase their chances of recovery.

That’s an interesting idea but not all that practical. First of all, not all seniors do break their hip, so it would become difficult to have to decide who would get a replacement and who wouldn’t. But, setting that all aside, this type of question shows that there is a misconception about the risks of surgery.

Any type of surgery has its risks. Not everyone is healthy enough to have a major surgery like a hip replacement. Illnesses such as heart disease, asthma, and diabetes, can cause problems post-surgery. Hip replacement surgery requires that a patient go under a general anesthetic (risky on its own) and be subject to many of the potential surgical complications, such as infections, blood loss, and malfunction of the implant, to name a few. Then after the surgery, the patient has to be confined to bed and chair for a while and then undergo physiotherapy to regain the strength in the leg and hip. For some people, this is easy, for others, this is much more difficult.

So, while the idea is certainly an interesting one, it’s not a practical one.

Revision tells us that your sister had a primary or index (first) hip replacement procedure already. Revision suggests the need to remove and/or replace one or all of the implant parts.

The most common reason for implant revision is loosening of the stem on the femoral (thigh bone) or acetabular (cup or socket) side. This can occur with or without infection. The surgeon removes the old implant and replaces it with a new one.

In the case of implants with a polyethylene (plastic) liner, excessive wear can cause tiny flecks of the liner to slough off and enter into the joint. Sometimes the bone around the liner starts to disintegrate.

If the whole implant is removed and exchanged or replaced, it’s like having the surgery all over again. Your sister will have to go through a shortened version of the original rehab program. Having had the surgery already one time, she will be more prepared for the postoperative recovery than she was the first time.

She will be able to tell you if she needs extra help for a day or two. There’s always the chance that complications will occur, which could mean a longer recovery time and the need for more help.

You are right to be concerned about the risk of falls and fractures in someone who has already had one fracture. The risk of another fracture does go up after the first one. And fractures are known to reduce function, increase disability, and even result in death.

Now for the good news. Medications like Fosamax (a bisphosphonates) have been shown to reduce fractures, especially hip fractures. Bisphosphonates help slow down how fast the bone is resorbed (destroyed). Everyday new bone cells are formed and old bone cells are resorbed or destroyed. During childhood, new bone cells are formed faster than old ones are destroyed. In the aging adult, resorption exceeds formation.

The problem of drug adherence is a major challenge in the treatment of osteoporosis. Adherence includes both treatment persistence (taking medications over a long period of time) and treatment compliance (taking the drug correctly).

Treatment persistence and compliance are important because the risk of a second hip fracture after the first is very high. Taking bisphosphonates reduces that risk. The mortality (death) rate after a hip fracture is also high (up to 50 per cent). And for those people who survive the fracture, half will never walk unassisted again and 25 per cent end up in a nursing home.

The first step may be to identify the reason(s) why your father isn’t taking the medication as prescribed. Is he purchasing the medication but not taking it? Or just not filling the prescription? Is there a lack of money (or perceived lack of money)? Some patients can afford the medication but see the price tag and balk at spending that much.

Or they may purchase the medication and then discontinue it later due to side effects. Some patients stop taking their bisphosphonates because they don’t understand why it’s important to take these medications as prescribed over a lifetime. Since there aren’t very many (if any) obvious symptoms of osteoporosis, it’s easy to think, I don’t really need this drug.

The new and improved dosing (one pill each month instead of daily pills) may help improve adherence and reduce the rate of hip fractures. You may want to check with the pharmacist and see what kind of dosing schedule there is with the current medication. It may be easier to gain his cooperation and monitor his drug taking if it’s on a once a week or once a month basis rather than daily dosage.

And finally, ask your father’s prescribing physician to help monitor his compliance. Sometimes a brief explanation from the doctor is all that the patient needs to get on the program and stay there.

There is a mistaken belief that by the time a fracture has occurred, it’s too late to do anything about the underlying osteoporosis. Nothing could be further from the truth. Study after study has confirmed the benefit of a three-arm approach to the prevention and treatment of osteoporosis (which includes preventing a second fracture).

The first is calcium supplementation with Vitamin D. The second is exercise. Weight-bearing exercises on land (not a swimming or aquatic program) helps bone formation. When the muscles contract and their tendons pull on the bone, it has the effect of stimulating bone formation. And third is the use of anti-osteoporotic medications called bisphosphonates.

Bisphosphonates such as alendronate (Fosamax), ibandronate (Boniva), or risedronate (Actonel) help slow down how fast the bone is resorbed (destroyed). Everyday new bone cells are formed and old bone cells are resorbed or destroyed. During childhood, new bone cells are formed faster than old ones are destroyed. In the aging adult, resorption exceeds formation.

Despite the number of older adults with osteoporosis and even a history of hip fracture, not very many people are taking these medications. And for those patients who do have a prescription, taking it on a regular basis is not consistent.

But they have been proven effective in reducing hip fractures and the death rate associated with hip fractures in patients with osteoporosis. And since your risk of a second fracture goes up dramatically after the first one, your doctor is right in strongly urging you to take this medication. It’s important to take it as prescribed over a long period of time.

Follow your doctor and pharmacist’s directions when taking this (or any) medication. Report any side effects. The drug dosage or specific drug can be changed or altered. The goal is to give you the maximum benefit with the least amount of adverse effects.

Golf is a low-impact activity that can be resumed after rehab for total hip replacement. If you let your physical therapist know of your interest in getting back on the golf course, your rehab program can be advanced to include specific sports-training for golf. This is a good idea in order to prevent further injuries and to spare your implant excess torque or load.

Studies show that of all the sports patients are involved in before joint replacement, golf is the one more people return to. There’s some evidence that your handicap may increase as well as the your drive length. The average change in handicap is an increase of 1.1 strokes. The average drive length increases by 3.3 yards.

Even though golfing can involve a fair amount of walking (which is good exercise), you may want to consider using a golf cart — especially at first until you see how well you do. Sometimes golfers with total joint replacements report mild pain or aching after playing golf. Using a golf cart can help reduce this by decreasing joint load and wear on the joint surface. Some golfers use the cart until they build up their strength and stamina. Try this yourself. Then you can reevaluate the benefit of continuing (or not).

In a recently published review of athletic activity after joint replacement, experts in the field tried to give patients and surgeons an idea what is safe and appropriate athletic activity after total joint replacement. They base their comments on information taken from several studies published on athletic activity after hip and knee replacements. They also used surveys of surgeons collected by the Hip and Knee Society.

In general, it looks like there is agreement that patients with total joint replacements CAN participate in demanding sports. Some of the high-demand sports patients were involved in included tennis, jogging, downhill skiing, racquetball or squash, and basketball. But it’s not clear whether or not it is wise to do so. Most surgeons advise avoiding these activities because of the high-impact loading and twisting motions required.

Other activities such as bowling, horseback riding, cross-country skiing (even downhill skiing), or weight lifting are allowed but with certain precautions. Patients must have some prior experience with these activities. They should be aware of the risks associated with each activity. Training is a must.

At least six to eight weeks of back, hip, and knee rehab along with core strength training is advised. This can protect the joint, prevent injury, and reduce your risk of implant failure from wear or loosening.

If you choose your sport carefully, understand the risks, train to protect, then there’s no reason why you can’t engage in those activities and have fun!

More long-term studies are available now comparing implants used in hip replacements than ever before. Studies comparing results based on age, activity level, and different types of implants are ongoing.

Most surgeons still use give patients 10 to 15 years as the expected survival rate of the average implant. Your age at the time of the surgery and your activity level since are both key factors in how well the implants hold up.

In younger adults (less than 75 years old), the type of implant does make a difference. Cementless stem implants seem to have better survival rates and lower revision rates when compared with the loaded-taper cemented stems. Patients who are older than 75 show no difference in outcomes based on stem type. These statements are based on the results of a large study done in Finland.

In this same study, they compared the survival of various acetabular cups (socket side of the hip). There was no overall difference between cemented and cementless cups after 10 years. Based on age, adults less than 75 years old did better with the cementless cups. There were fewer cases of revision because of loosening of the cup. In the older group, cementless, hydroxyapatite-coated press-fit cups were less likely to loosen or need revision.

When problems did occur with the cups, there was one main difference between cemented and cementless cups. Cups with a polyethylene (synthetic or plastic) liner showed excessive wear in the cementless group under age 75. The large number of wear-related revisions of cementless cups points to the need for an improved (wear resistant) design.

When reviewing the overall results of the total hip replacement (both stem and cup components), the cementless implants had the better outcomes. The 10-year survival rate was 90 per cent or better for all total hip groups. When broken down by age, there was no major difference in the risk of revision among the groups.

Ceramic component parts of total hip replacements (THRs) have been around long enough to find long-term reports of 20 years or more. In fact, there are reports of excellent results over the last 40 years.

At first, there were problems with fractures. But over time, these have been reduced considerably. The implant manufacturers have designed a better implant and improved ways of making them.

However, one new problem seems to be popping up. That’s a rise in the number of ceramic hip implants that squeak. It’s most noticeable when bending, walking, using the stairs, and during sexual activity. Surgeons are studying the problem and trying to identify the cause.

So far, they’ve noticed that the wear pattern on the implant often shows signs of impingement (pinching) of the femoral neck where it meets the rim of the acetabulum (socket). Further testing with an electron microscope showed metal debris along the area of wear.

Rim impingement is probably the number one cause of hip squeaking. But there isn’t just one cause of impingement. Besides socket malposition, there could be a loss of fluid film lubricating the joint. Some patients have lax (loose) ligaments that can lead to impingement.

There’s been some suggestion that an incomplete seal around the socket liner could cause squeaking. Some studies have shown that thicker sockets don’t squeak but thin ones do. It’s possible that the thinner sockets deform when they are put in place. Incomplete positioning of the liner may be the problem there.

Knowing all this, what can be done to stop the problem of squeaking in total hip replacements? First of all, the authors suggest a plan of prevention. Placement of the implant in the correct position and correct orientation is number one.

Patients with loose ligaments need some extra care and consideration during the procedure. The authors suggest using a polyethylene (plastic) liner for these patients. And for all patients, matching up the sockets with the right stem is a helpful strategy.

You are not alone with this problem. In a recent survey of 149 patients with a THR, about one in 10 reported a squeaking hip. In that group, the sound was most noticeable when the patients were bending, walking, using the stairs, and during sexual activity.

There are many theories about what can cause this to happen. The best way to find out for sure is to remove the implant and take a look at what’s going on. But this isn’t always possible. The most common effect is seen as a broad stripe of wear on the femoral head.

The wear pattern on implants removed and examined also show signs of impingement (pinching) of the femoral neck. The pinching occurs where the femoral neck meets the rim of the acetabulum (socket). Further testing with an electron microscope showed metal debris along the area of wear.

Rim impingement is probably the number one cause of hip squeaking. But there isn’t just one cause of impingement. Besides socket malposition, there could be a loss of fluid film lubricating the joint. Some patients have lax (loose) ligaments that can lead to impingement.

There’s been some suggestion that an incomplete seal around the socket liner could cause squeaking. Some studies have shown that thicker sockets don’t squeak but thin ones do. It’s possible that the thinner sockets deform when they are put in place. Incomplete positioning of the liner may be the problem there.

Whatever the cause, there does not seem to be a way to stop it without removing the implant and revising the hip replacement. This may mean replacing part or all of the components. It’s important to match the socket with the right stem.

The difference in resonance between the two parts can be enough to cause friction that creates vibration and then squeaking. Adding this variable to a patient with malpositioned components increases the risk of squeaking. Position and placement of the socket is important in preventing these wear patterns.

Ceramic-on-ceramic bearings have always shown good wear with low incidence of debris. Debris refers to tiny flakes of material chipped off the implant. The debris falls back into the joint causing an inflammatory reaction.

In general, ceramic implants wear well with few problems. Early on, there were cases of ceramic fracture. But over time, these have been reduced considerably. In the past 20 to 30 years, the implant manufacturers have designed a better implant and improved ways of making them.

Even so, in the last few years, there have been increasing reports of problems with squeaking or grinding with the ceramic implants. Efforts to get to the bottom of this complication have led surgeons to believe it may be linked with the type of components used.

The fact that the squeaking started at a specific time period points to the time when surgeons started combining the ceramic-on-ceramic bearings with any of the femoral components available (conventional titanium stem, beta titanium stem, thinner stem). So for example, hip implants could include a ceramic liner but a titanium stem. And the titanium could be a pure (conventional) or mixed (beta) alloy.

The results of a recently published study suggest that impingement caused by a beta titanium femoral component (compared to conventional titanium alloy) bumping up against the titanium rim of the hip socket shell creates problems with the alumina ceramic bearings.

Flush-mounted liners with conventional titanium femoral stems did not cause squeaking. Flush-mounted means that the edges of the shell and the liner are even with each other. The problem wasn’t with the ceramic bearings as much as it was the materials around the bearings. A recessed liner with a beta titanium alloy combined together seemed to cause the most problems. With the recessed liner, the edge is not even with the shell. Instead, the edge of the liner is slightly below the rim of the shell.

What we don’t know is the type of debris (e.g., molybdenum, zirconium, iron) put out by beta titanium. Maybe some types of wear debris cause more problems than others. Future studies are needed to improve the materials and the design of hip implants, especially the ceramic ones that can cause squeaking when used with titanium alloy stems.

Talk to your surgeon about what option is best for you. Age, general health, activity level, and type of implants available are all considerations when planning this type of surgery.

Most surgeons perform a screening exam to look for high-risk patients. Patients who are considered high-risk don’t just have problems with alcohol use and abuse. They may have other significant health problems. Dementia, Alzheimer’s, diabetes, and heart disease are common in older adults who need a hip replacement.

The presence of a drinking problem doesn’t mean the patient can’t be treated. First of all, even older adults can get help for an addiction problem with alcohol or other drugs. A psychologist or social worker in the community who specializes in this type of problem can be very helpful.

Second, precautions can be taken to prevent falls and hip trauma. A physical therapist is the best one to assess both the patient and his or her home for ways to reduce the risk of falls and fractures or dislocations.

Third, if revision surgery is needed, the surgeon may want to put the patient in a brace or cast to slow him or her down and give the soft tissues a chance to heal. Sometimes, for the older adult (and especially someone with weak muscles or lax (loose) soft tissues), a specific type of implant is used that is less likely to dislocate. The surgeon may choose an implant with a larger femoral head and then cement the socket portion in place. Both of these steps help stabilize the joint.

So, it’s never too late to offer information that can help direct and guide treatment as well as prevent further complications. It may be best if the patient (in this case, your mother) disclose this type of information to the physician. Encourage your mother to confide in her surgeon. Having them work together to solve the problem is usually more helpful than family members stepping in without the patient’s permission.