FAQ Category: Hip

Noises from a hip implant such as squeaking or grinding have been reported and studied carefully. It doesn’t happen very often (less than one per cent of the time), but it’s annoying and can be painful.

There are many theories as to the possible cause of the problem. Some experts have suggested it’s a problem with mismatched ceramic bearing diameters, malpositioning of the implant, or loss of the protective fluid film. Others have investigated the possibility that the use of short necks in the femoral component or wear debris from metal pinching against other metal could cause this problem.

In a recent study, researchers show that metallosis caused by impingement (pinching) of the femoral neck against the rim of the acetabulum (hip socket) is the most common cause of squeaking. Metallosis refers to wear debris from the metal parts of the implant. It can cause a painful inflammatory reaction in the soft tissues and bone around the implant.

Be sure and mention this to your surgeon. It may require a revision surgery to correct but it may be better to address the problem sooner than later to avoid further complications.

Quality of life is an important issue at any age and in any circumstance. The presence of Alzheimer’s, dementia, or other neurologic problem must be considered but isn’t a reason to withhold treatment.

In the case of hip replacements, an assessment of need should be done. An orthopedic surgeon is the best one to consult for this. There may be other less invasive treatments that can make a difference. Physical therapy to help restore motion and strength can help. If they haven’t been tried yet, cortisone injections and/or antiinflammatory medications may provide some effective relief.

And if it turns out that surgery really is the best option, the surgeon will modify treatment to take the cognitive condition of the patient into account. For example, there are minimally invasive surgical techniques that can be used to take the old joint out and put the new implant in. The postoperative protocol allows for early weight-bearing. There are fewer restrictions on movements and positions.

The type of implant used can be chosen based on the patient’s specific needs. A larger femoral head component helps reduce the risk of dislocation. Cementing the prosthesis in place also makes for a more stable joint. Preventing complications is a key factor in cases like this. Having a team approach with family, patient, and health care providers will go a long way to provide a good result.

There are two basic types of femoral neck fractures: nondisplaced and displaced. Nondisplaced means the bone is broken but the fracture line has not separated. Displaced refers to the fact that the two sides of the broken bone have moved apart and no longer line up. Since you describe yourself as having a badly broken leg, we are assuming you have a displaced femoral neck fracture.

Of the choices you mentioned, internal fixation (compared to hemiarthroplasty) has a faster surgical time, less blood loss and lower infection rate. However, a second (revision) surgery is more common after internal fixation (40 per cent compared to only five percent with hemiarthroplasty). And the incidence of nonunion and osteonecrosis (death of bone) is higher with internal fixation.

The mortality (death) rate is usually something doctors pay close attention to. But this is more important for adults aged 65 and older. Studies show that the complication rates are lower and hip function is higher among patients with a total hip replacement (compared to internal fixation).

For younger patients, if a complete hip replacement isn’t needed, then hemiarthroplasty is the next best option. At that point, there are other decisions to be made as well. What type of hemiarthroplasty hould the surgeon use? The two main types are unipolar and bipolar. Each has its pros and cons. And whould they be put in with or without fixation (cemented versus cementless).

These and other considerations can complicate the care of femoral neck fractures. Your surgeon is the best one to advise you in this matter. His or her experience, familiarity, and comfort level with each of these procedures is important. But so are various factors centered around you and your health. Your age, general health, mental status, and function before the fracture are taken into consideration. Type, severity, and location of the fracture must also be reviewed.

Many studies have been done comparing these two approaches when putting in a partial hip replacement. This type of implant is called a hemiarthroplasty. Although there are pros and cons to both, the results are more favorable for cemented fixation. The studies were focused on the femoral head, neck, and stem portion of the implant.

Patients receiving a cemented hemiarthroplasty had less thigh pain, faster recovery, and better overall function. Patients with cementless stems required the use of a walking aid (walker, cane, crutches) more often when compared with cemented implants.

The final outcome was higher patient satisfaction among the cemented group. There have been reports of fracture around the implant when cementless components were used. Patients who received the cementless type were older, so age may be a factor.

Surgeon preference and experience are also important. Results are likely to be better when the surgeon works with what is familiar and comfortable. Take your cues from him or her. Unless there are medical reasons to go with a cementless implant, follow the recommendation made by your surgeon.

Calcific bursitis occurs as a result of tiny calcium deposits in the collagen tissue around the hip. The cause is chronic inflammation of the bursae. The bursa is a normal structure. It is a thin sac of tissue that contains fluid to lubricate areas and reduce friction between muscles, tendons, and bones.

The patient reports pain and/or tenderness along the side of the hip. This is the area of the greater trochanter. The greater trochanter is a large bump of bone that juts outward from the top of the femur (thigh bone). Large and important muscles connect to the greater trochanter. Sometimes these muscles are referred to as the rotator cuff of the hip. Chronic tendinitis of the hip rotator cuff can also contribute to this problem.

The calcium deposits are called calcification. They can occur as long as there is inflammation of the bursae (or tendons). The deposits don’t always go away after the inflammation has been taken care of, but the symptoms improve.

Treatment can help to prevent further calcification as well as relieve pain and stiffness. Antiinflammatory drugs, cortisone injections into the bursa, and physical therapy have been shown effective. In rare cases, the inflamed bursa is surgically removed.

There are many, many possible causes of hip pain. An accurate diagnosis is needed to direct treatment. But this can be elusive and take a long time to make. The physician’s examination takes into account the possible etiology or cause of the problem. Was there some trauma? The mechanism of acute hip pain caused by injury is often a twisting motion. Overuse, repetitive motion, and diseases or degenerative conditions are other potential causes of hip pain.

Pain patterns associated with hip problems start with a deep aching and stiffness in the hip. True hip pain is experienced in the front of the body down into the groin area. Hip pain along the pelvic rim, down the side of the leg, or down the back of the leg is usually a sign that the cause of the pain is extraarticular (outside the hip joint). This could be coming from pinching of the soft tissues, nerve entrapment, or other extraarticular lesions. Loss of motion and/or function can help point to the specific soft tissue structures affected.

It sounds like your physician has been very thorough. Evaluation of hip pain may require imaging studies such as X-rays or MRIs. But unnecessary X-rays and other imaging studies should be avoided. Results are viewed cautiously as many changes in and around the hip may be observed but may not be the cause of the painful symptoms. The most obvious pathologies that must be treated include tumors, fractures, hematoma from bleeding after a fall, and infections.

Often in the face of an unknown cause of joint pain, a short course of physical therapy can be a diagnostic aid for the physician and helpful to the patient. As experts in human movement dysfunction, the therapist can evaluate and treat the soft tissues and postural issues that could be the underlying cause of the problem.

Arthritis is a very common problem for adults 55 and older. In fact, it’s estimated that up to one in four (25 per cent) of older adults will be diagnosed with this condition. Early and accurate diagnosis is the number one key to stay as functional and independent as possible for as long as possible.

For women who are postmenopausal, declining estrogen levels are linked with changes in soft tissue. Decreased blood circulation of estrogen contributes to reduced elasticity of ligaments and joint capsules. In the hip, ligaments surround the joint forming a capsule to support and stabilize the joint. With less estrogen available, these structures tighten up and become less supple or flexible and inflexible.

The change in your flexibility could also be caused by a sedentary (inactive) lifestyle. But before you assign blame or cause to your problem, it might be a good idea to see your primary care physician for an accurate diagnosis.

If it turns out that you do have osteoarthritis, in order to prevent disability pay attention to good nutrition, getting enough fluids, and exercise. These four step in self-care are all equally important. With or without early signs of arthritis, if you are overweight, weight loss is always advised. See a physical therapist for help with an exercise program designed to help you maintain flexibility, joint motion, strength, and endurance.

X-rays are still the number one tool physicians rely on to make an accurate diagnosis of osteoarthritis (OA). The radiograph shows changes that can’t be seen with a clinical exam. For example, narrowing of the joint space and bone spurs associated with OA are easily seen on X-rays.

Other changes common with OA that can be observed with X-rays include changes at the joint margins and subchondral bone. Subchondral bone refers to the first layer of bone underneath cartilage. Once the joint cartilage is destroyed by the OA process, the subchondral bone can be affected, too.

Without X-rays, there are some clinical tests that can be helpful in diagnosing hip OA. Hip range-of-motion (quantity and quality) is a key factor. A quick and easy screening test for the hip is to try assuming a squat position. If this position aggravates the symptoms (or you cannot do it because of hip pain), the hip is involved in some way.

The examiner looks for a specific pattern of motion typical with OA. Loss of hip internal rotation is a positive sign of OA. The examiner also relies on how the joint feels during testing motions. There should be a smooth, easy give through the full arc of motion. The examiner feels for a slight spring at the end of the motion. Any blocks or resistance to movement caused by pain or a bone-on-bone sensation may be an indication of degenerative joint disease.

X-rays may still be needed if all these tests are positive. But if they are negative, it may rule out OA and X-rays can be avoided. It’s likely that your physician found enough suspicious test results to suggest further testing with X-ray imaging. Don’t be afraid to ask your doctor about her findings so far and express your concerns about radiation exposure.

For anyone with a total hip replacement (THR), hip pain is a red flag. Medical evaluation is important because of the risk of joint infection. Treatment depends on knowing if there is (or isn’t) an infection.

There are many possible causes for the pain you are having. They may or may not be related to the implant. The first thing the orthopedic surgeon will examine is the hip itself. Your history along with the clinical presentation are very helpful. But then the spine (above) and the knee (below) will be tested as possible sources of referred pain.

X-rays and lab tests may be needed to rule out a fracture, implant loosening or infection. Other possible causes include bursitis, ossification (bone formation in the muscle or surrounding soft tissue), or synovitis. Cultures of the joint taken directly from the area during surgery are the most accurate way to confirm (or rule out) joint infection.

But this type of testing is not practical for the patient who doesn’t have an infection or who doesn’t need surgery. And there is a fair amount of false-positive test results with intraoperative cultures due to errors in sampling technique.

Instead, the physician may rely on lab tests that are sensitive, reliable, and accurate with a low false-positive and high true-positive results. The following tests may be needed to evaluate for hip infection: erythrocyte sedimentation (SED rate), C-reactive protein (CRP), and synovial fluid white blood cell count (WBC).

Don’t wait to get tested. See your surgeon now. Early diagnosis can prevent a lot of complications from delayed treatment.

For anyone with a total hip replacement (THR), joint infection is a real possibility. And infection can lead to implant failure. Medical evaluation is important because of the risk of joint infection. Treatment depends on knowing if there is (or isn’t) an infection. But there isn’t one single or individual test that works best to diagnose or rule out infection.

The current standard for testing for joint infection is to remove fluid from the joint and test it for bacteria. Cultures of the joint taken directly from the area during surgery are the most accurate.

But this type of testing is not practical for the patient who doesn’t have an infection or who doesn’t need surgery. And there is a fair amount of false-positive test results with intraoperative cultures due to errors in sampling technique. Not only that, but sometimes patients are given antibiotics before the operation (affecting test results) and the surgeon doesn’t know it.

To avoid the high cost of multiple tests, it would be useful for the surgeon to know which tests to order. A recent study from Rush University Medical Center in Chicago showed that the results of three tests reviewed together make the diagnosis or infection reliable and accurate. The low cost and high specificity make these screening tests attractive and practical.

Here’s what they found:

Pain can be a big stumbling block to activity and quality of life. Hip replacements have become very common and very successful. Patients are able to perform daily activities, sleep better, and get around better.

The implants and techniques for putting them in have improved so they last longer with fewer problems. Relieving pain improves physical function and activity level. This is important in promoting general health and preventing specific diseases such as heart disease and diabetes.

The positive benefit of movement and activity on bone structure is very important for the older adult. Good bone health helps prevent fractures and falls, which can cause serious disability and even death.

You may want to just make an appointment with an orthopedic surgeon and find out what are your options. Knowledge and understanding of the process and expectations can help calm your anxious thoughts. Then you’ll be making a decision based on facts, not fears.

You can expect a period of some postoperative pain during recovery. The postoperative plan provides medications to help with the pain. The physical therapist will help you get up and get moving. That always helps alleviate pain and aching from stiffness.

Most patients report the postoperative pain is different from the joint pain they had before surgery. They say the new pain is much more tolerable and goes away with time and exercise.

There are international guidelines for physical activity and exercise designed to improve health. Ten years ago the recommendations were for 30 minutes (or more) of moderate-to-intense physical activity five times a week. Daily exercise at this level was considered even better.

These guidelines have been update in the last year. Now the American College of Sports Medicine and the American Heart Association suggest 30 minutes (or more) of moderate-intensity aerobic (endurance) physical activity. This should be done at least five days/week.

Alternately, vigorous-intensity aerobic physical activity for at least 20 minutes on three days of the week is advised. Combining these two recommendations is even better. Aerobic activity is defined as activity or exercise that raises your heart rate up within a target range.

The age-predicted method for calculating the predicted (maximal) heart rate is 220 minus your age. For example, for your mother-in-law at 77-years old, you would subtract 220-77, which equals 143 beats/min. She should exercise at a level that keeps her heart rate below this amount.

For an aerobic workout, it’s recommended that she exercise at a level that raises her heart rate to 80 per cent of her maximum heart rate. She should do this for 20 minutes. So for a 77-year old, that would be 80 per cent of 143 or 114 beats per minute. For very active, health older adults, a slightly different formula is used: 205 – 1/2(77). Using this formula, the maximum heart rate is higher (166 beats/minute).

It’s always advisable to have a physical exam by your primary care doctor before starting a new exercise program. He or she can advise you about what’s best for an older adult with some health problems. If she gets the doctor’s go-ahead, she could join a program designed for seniors (if one is available in your community).

Usually, even with advanced directives that spell out no heroic measures or do not resuscitate, there is nothing to prevent treatment to keep the patient comfortable. Sometimes that is medication for pain such as morphine.

In the case of a hip fracture, if no treatment is offered, the patient may become unable to stand and walk and become bedfast. That may not be in her best interest in keeping with the desire to provide comfort.

Intervention may be acceptable if it reduces or eliminates her pain and keeps her mobile thus preventing more serious complications such as a blood clot or pneumonia. Surgery may be necessary to pin the fracture site for potential healing. Although the surgery is invasive, it may not go against the intent of her wishes.

You may want to consult with a lawyer or patient advocate. Usually the hospital or health care facility has a social worker or case manager to help families navigate these murky waters. The Council on Aging may have a local office in your area. They can also offer you guidance and counsel in making this decision.

It’s not uncommon to have strength differences from side-to-side after a hip fracture. A strength-training program may help. But even more importantly, a balance-training program is needed.

Many times, strength-training is done in the seated position. This does not challenge the balance system, which is what is needed to improve balance. Improving balance also improves mobility and prevents falls that can lead to life-threatening or disabling fractures.

You can do some simple things to begin challenging and improving your balance. Stand on one foot and practice standing balance. At first you may need to hold on to a chair or countertop to avoid losing your balance and falling.

Keep your pelvis level (don’t let one side drop down). Doing balance exercises in front of a mirror can help. Gradually increase the length of time you can stand on one leg without putting the foot down. You can do these standing balance exercises when you are standing in line at the store, while on the phone, or even while brushing your teeth.

Combining balance activities with strength training is important. For example, while balancing on one leg, swing your free leg out to the side and back to midline. Do this 10 to 12 times before switching to the other side. This exercise targets the hip and buttock muscles for good pelvic stability needed for balance.

Your public library may have some good videos (or DVDs) with a home-based exercise program to improve balance. If you need more specific help, see a physical therapist. The therapist can assess your individual needs and show you a home program tailored to your needs. With occasional visits, the therapist can progress you through the program safely and effectively.

Uneven strength from side-to-side is fairly common after a hip fracture, especially among older adults. Studies show that a strength training program can make a difference. Low loads and resistance are usually used at first. This is to ensure safety and prevent further bone fractures.

In the average, healthy adult, it takes about six weeks of consistent exercise to make a change in strength and power. It may take longer in seniors who have had a bone fracture. It’s always best to have medical approval before starting a new exercise program.

Check with your orthopedic surgeon and schedule an appointment with your primary care physician. Your doctor will examine you and rule out any health problems that might put you at risk for heart attack, aneurysm, or stroke.

A physical therapist can provide you with an individually tailored exercise program. The therapist will be able to monitor your vital signs before, during, and after exercise to make sure your exercise program is safe but still effective.

Compliance and cooperation (following the program daily or as prescribed) will help you gain strength quickly. After six to 12-weeks of consistency, a maintenance program can be designed for use as long as possible.

Older adults with hip fractures require a multi-disciplinary approach. Often the fracture limits life expectancy and prevents the patient from returning home. Because the cost of treating patients with hip fracture is so high, everyone’ input is helpful in charting out a plan of care. This is done to benefit the patient without running up the cost of services.

Extremely elderly (defined as 90 years and older) often have multiple other medical problems. These comorbidities complicate the treatment and results. Over half of the adults in this age group with a hip fracture never return home. Twenty-five per cent end up in a skilled nursing facility. Twenty-five per cent don’t survive.

The fact that so many healthcare professionals are involved in your mother’s case is actually a good sign. That means all factors and variables will be considered. Her chances of recovery are greater with so much attention to her case.

Studies show that advanced age is a predictor of poor function after hip fracture. Although it is entirely possible that your husband will regain independent mobility, only two per cent of the population aged 90 and older are able to return to their prefracture level of independence.

Many older adults end up using a walker but are able to gradually progress in their rehab program to use two canes. Eventually, it may be possible to eliminate one cane and just walk with one assistive aid (or none at all).

The fact that your husband was still playing tennis suggests good health and good mobility. Both of these factors are in his favor in terms of recovery and rehab. If all goes well, he may very well be among the two per cent who regains his previous level of independence and function.

Hip joint resurfacing instead of a total hip joint replacement is fairly new. Resurfacing replaces the arthritic surface of the joint but removes far less bone than the traditional total hip replacement. It saves bone in the femoral neck but can put strain on the femoral neck leading to fractures.

There are two main groups of risk factors for fracture after joint resurfacing. The first has to do with the patient. Bone quality is important. Decreased bone-mineral density and cystic bone changes can contribute to weakened bone. The bone has a decreased ability to withstand forces leading to fracture.

Any changes in natural alignment of the hip can result in mechanical abnormalities. The most common of these malalignments are coxa varus (angled inward) and coxa breva (short femoral neck).

The second group of risk factors is related to the surgical procedure. Placement of the component is important. If the implant is tilted or angled too far in any direction, loading patterns change. The risk of fracture increases. The surgeon also uses a special technique called notching as part of the procedure. Studies show that notching reduces the bone’s resistance to fracture.

Sometimes it isn’t clear what went wrong. Efforts are being made to identify patients who are good candidates for joint resurfacing. Bone quality, general health, and past medical history are important features to consider. At the same time, surgeons are looking for ways to improve the implant and surgical techniques used.

Hip joint resurfacing has the main advantage of preserving bone in the neck of the femur (thigh bone). The main disadvantage is the risk of overloading the femoral neck causing fracture or loosening of the implant.

Patients are chosen carefully for this procedure to avoid these problems. But sometimes unexpected complications occur anyway. Joint resurfacing is fairly new, so we don’t know all the risk factors or variables that might lead to implant failure.

One new area of study has been to look at the amount of load placed on the femoral neck before and after implantation. It’s possible that too much load on the hip too early after the surgery could lead to fractures.

How much load the hip can take isn’t known yet. This could vary from patient to patient depending on their bone density, anatomical angles of the hip, and body weight. Studies are also being done to examine the effect of slight variations in the placement of the implant. Even a 10-degree rotation of the implant can make a difference.

More study is needed to look at patient risk factors and surgical techniques that might lead to hip fracture. Reducing these risk factors will help decrease the number of fractures and other complications of joint resurfacing.

A hip fracture is a break in the femur (thighbone) at the upper end of the shaft near the hip joint.

There are many subtypes of hip fractures. One of the most common is the intertrochanteric fracture. With this type of hip fracture, there is a break or fracture line between two bony bumps on the femur (thigh bone).

The larger bump on the upper outer part of the femur is the greater trochanter. The bump on the inside (medial) part of the femur is the lesser trochanter. A line between these two bumps forms the intertrochanteric line.

In reverse oblique fractures, the major fracture line extends from proximal-medial (upper-inner side of the shaft) to the distal-lateral (lower outer side). This means the fracture line goes in the opposite diagonal direction as the typical intertrochanteric fracture.

Treatment is usually with surgery to pin or fix the two sides of the bone in place while the fracture site heals. The surgeon monitors the patient carefully for any signs that the fracture is becoming (or has become) unstable (slips). If this happens, a second operation may be needed to stabilize the fracture site and prevent malunion or nonunion and any deformity that might occur with such a healing displacement.