FAQ Category: Hip

Unless there are significant health issues, discharge to home may be the best way to go after a total hip or total knee replacement. A recent study from Canada showed that inpatient services cost six times more and don’t yield any better results. And the rate of infection is higher when patients stay longer in the hospital or transition unit.

The cost savings is even greater in the United States with inpatient services costing 10 times the home-based rehab. When beds aren’t available in the transition unit or rehab facility, patients end up staying in the hospital longer with even greater risk of infection and other complications (e.g., pneumonia, blood clots).

Many home health care agencies offer help beyond the physical therapy rehab services. Families who need assistance with personal care such as bathing, dressing, and other activities of daily living can benefit from this type of help.

There is some truth to your statement but not for reasons of gender discrimination. Hip resurfacing is a type of hip replacement that replaces the arthritic surface of the joint but removes far less bone than the traditional total hip replacement.

Special powered instruments are used to shape the bone of the femoral head so that the new metal cap will fit snugly on top of the bone. The cap is held in place with a small peg that fits down into the bone.

The acetabulum (hip socket) may remain unchanged. But more often it is replaced with a thin metal cup. The acetabular component is pressed into place in the socket. Friction holds the metal liner in place until bone grows into the holes in the surface and attaches the metal to the bone.

The patient must have enough healthy bone to support the cap. That is the real heart of the issue. Many women do not have strong enough bones to qualify for this surgery. Any sign of osteopenia (decreased bone density) or osteoporosis (brittle bones) excludes them from this approach.

The reason for this is that too many patients suffered from a femoral neck fracture within the first six months after joint resurfacing. They ended up with revision surgery to replace the resurfacing with a total hip replacement. Some men were affected, too. They were usually older, small-boned males.

The new joint resurfacing has made it possible for older adults who are active but hampered by arthritis to remain active. Some can return to work or sports participation pain free and functional for many more years.

It’s probably only a matter of time before researchers are able to find a way to include all patient groups in this treatment alternative. This will include men and women of all sizes and shapes.

You can have this operation done in the United States. But depending on where you live, you may have to do a little traveling. Surgeons at specialty centers such as at a joint replacement institute or institute for advanced joint procedures offer joint resurfacing.

Hip joint resurfacing is a type of hip replacement that removes the arthritic surface of the joint but takes far less bone than the traditional total hip replacement.

Special powered instruments are used to shape the bone of the femoral head so that the new metal cap will fit snugly on top of the bone. The cap is held in place with a small peg that fits down into the bone.

The acetabulum (hip socket) may remain unchanged. But more often it is replaced with a thin, metal cup. The acetabular component is pressed into place in the socket.

Some of the holdup in the U.S. can be attributed to the U.S. Food and Drug Administration (FDA) regulations. Devices from U.S. manufacturing companies must be approved by the FDA before they can be used routinely. This requires many studies on cadavers (joints preserved after death for study) and on humans via clinical trials.

Not until they are deemed safe and effective are these implants released for use in the general population. At the present time, there are at least two implants that have full FDA approval. Others are in line awaiting approval. Once that road block has been set aside, more surgeons around the U.S. will have the necessary training to perform this procedure.

The current thinking on this subject is that older patients don’t have the bone strength and density to hold up under joint resurfacing. The danger of a femoral neck fracture is too high. And older adults who are less active don’t need resurfacing. They can get a total joint replacement that will last them the rest of their lives.

But there really isn’t much evidence to support any of these arguments. A recent study compared results of hip resurfacing between two age groups. The first group was 60 years old or older. The second (larger) group was younger than 60 (between 18 and 59 years old).

Patients in both groups were operated on by the same surgeon during the same time period. They all received the same type of metal-on-metal resurfacing implant. Both the femoral and acetabular components were resurfaced. Results were measured using clinical outcomes such as pain and function, as well as comparing X-rays and complications.

The results were very similar for both groups. Recovery time was the same regardless of age. X-rays showed equal angles for the cup placement and femoral head and neck. These angles indicate accurate placement of the components needed for good results.

And the number of problems that occurred after the surgeries was also very similar between the two groups. The results of this study support the use of joint resurfacing for older adults. This is consistent with the few other studies that have also been published.

Failure rates and poor function of hip joint resurfacing is the same in older adults compared with younger adults. Quality of bone and deformity of the femoral head and neck are the major risk factors for poor outcomes. And at least from this most recent study, these are not necessarily linked with age.

Adults are living longer and staying more active suggesting the need for treatment alternatives such as joint resurfacing. Age alone should not be the sole determining factor of whether or not someone could benefit from this procedure.

The authors do point out that their results only extend for three years, so more time is needed to judge the final results. In time, you may see a more routine use of this procedure with all age groups.

Hip joint resurfacing is a type of hip replacement that removes the arthritic surface of the joint but takes far less bone than the traditional total hip replacement. Recovery may be faster after joint resurfacing for some patients.
The rehab protocol remains the same. The main difference is how fast you move through the progression from range-of-motion to strengthening and beyond. In some places, physical therapy begins pre-operatively.

You are evaluated for strength, motion, and function. And while you are free from the effects of anesthesia and post-operative pain, the therapist will teach you how to manage crutches (including stairs). This may be a review for you since you’ve had hip surgery before.

Even if you aren’t seen pre-operatively, you will be in physical therapy on the first postoperative day. Ankle and knee movements are used to help pump swelling out of the leg and to prevent the formation of blood clots. You’ll be wearing compressive stockings placed on your legs right after the surgery.

Exercises and walking with assistance are initiated. You probably won’t be putting your full weight yet on that leg, so you’ll need a walker, crutches, or canes at first. Eventually, you’ll progress to full weight-bearing without the use of any aids.

Hip strengthening exercises, endurance activities, and a program to restore joint proprioception (sense of position) will be added. When you are safe in putting full weight through the leg, several types of balance exercises can be chosen to further stabilize and control the hip. This usually happens around six weeks post-op.

Since you are familiar with a rehab program for total hip replacement, you won’t have any trouble adapting to a similar program following a joint resurfacing procedure.

Delays in surgery for emergencies like hip fractures are not uncommon. There are two basic reasons for this. One is patient-related. This refers to individual medical problems that might be present that could make anesthesia and surgery too dangerous at the time.

For example, extremely high blood pressure or uncontrolled diabetes puts a patient at risk for complications during or after surgery. Once those problems have been taken care of, then surgery can proceed.

The second most common reason for delays in surgery is system-related. This could be anything from the lack of an available operating room to inadequate support staff. If there isn’t an orthopedic surgeon, scrub nurse, or anesthesiologist available, then surgery is delayed.

Meanwhile, the patient is NPO, which is a Latin phrase (nil per os) that means nothing by mouth. No food or drinks are allowed to avoid any choking, vomiting, or complications during anesthesia. Of course, this policy can have the effect of dehydrating and weakening the patient. These are additional factors that make for potential problems recovering from surgery because of a weakened state.

The hospital staff tries to take all these things into consideration when planning and scheduling emergency surgeries. Sometimes delays are unavoidable. In other cases, the underlying cause for delays can be changed or modified. For example, if a hospital routinely has surgery delays greater than 24 hours, then resource management is an issue that should be addressed and changed.

It may be helpful to let the hospital administrator know of your family’s experience. This could bring about modifications that can help many patients.

Minor and major complications are fairly common after hip surgery for fracture. Prevention of problems like blood clots, wound infection, pneumonia, and urinary tract infection is up to the hospital staff to do their job well. But this doesn’t mean that you can’t monitor activities and ask appropriate questions.

For example, patients are routinely put on low molecular weight (LMW) heparins (blood thinners) to prevent blood clots. At the same time, compression stockings are put on the patient’s legs to help keep swelling down and blood flow smooth and clot free. Ask what medications he’s on and observe to see that the stockings are worn as recommended.

It’s important to get the patient up and moving as soon as possible. Families can certainly help with this. With nursing approval, walk with your father around the room, to the bathroom, or around the hospital floor.

A physical therapist will likely be seeing your father early after surgery. The therapist will instruct him in the proper way to get up out of bed, transfer to and from chairs, and walk with a walker, crutches, or cane. Find out what you can do in between PT sessions.

Always wash your hands when entering the room. This helps prevent the spread of bacteria that can cause infections. Ask each member of the health care team to do the same. In many facilities, gloves are put on when coming into the patient’s room so handwashing is not required. However, if the health care provider comes into the room with gloves already on, then hand (glove) washing is still required.

There may be a link between cancer and hip fracture in the early years after having cancer. Metabolic changes after chemotherapy and radiation therapy increase the risk of fracture. But after five years, the risk of hip fracture in cancer patients actually drops below adults the same age who have never had cancer.

The reasons for this aren’t clear yet. Some experts think that whatever made it possible for the person to be a cancer survivor is also working in their favor in the case of hip fracture.

Some of the risk of bone fracture in cancer patients may be linked to the type of cancer, presence of bone metastases, and effect of treatment on the bones. If you are concerned about your bone health and risk of fracture from osteoporosis, falls, or secondary to metabolic changes associated with cancer, see your physician for an evaluation.

If you are osteoporotic, there are medications that can help prevent bone fracture. Take a look at some of the other risk factors and modify anything you can. For example, patients who remain independent ambulators (walkers) without an assistive device of any kind do the best in the long run. Staying fit and active is the best medicine for many health problems including fracture prevention.

Age, mental function, and general health at the time of a hip fracture are key factors in recovery for older adults. Preinjury walking ability and physical function are also important. And these were likely affected for your father by the first fracture.

Setbacks are common in the elderly after hospitalization for serious illness or injury. Early, subtle signs of cognitive changes may become more obvious under the influence of stress, fatigue, and medications. The patient’s recovery pattern may vary from the first hospitalization to the next.

Hip fractures in particular are notorious for creating permanent disability among previously independent adults. Half of all adults over the age of 65 with a first hip fracture do not return home. Instead, they remain institutionalized in a skilled nursing or extended care facility.

The presence of dementia is a risk factor for prolonged recovery and failure to return to an independent living situation. But sometimes what looks like dementia is nothing more than the adverse effects of medication and drug interactions. Something as simple as dehydration can also be a significant factor.

Your father’s delay in recovery may not be as obvious to the nursing and hospital staff. As family members, your awareness of such changes is important. Feel free to bring your concerns to the case manager, social worker, physician, or nurse assigned to your father. This could speed up an early diagnosis of a potential problem and bring about a faster recovery.

The first thing to be sure is that the testing is accurate. Testing joint motion can be very subjective depending on how it is done and who does it. If the same person measures joint motion each time, intrarater reliability of the test is important. Intrarater reliability refers to the ability of a single individual to complete the test the same each time.

If different people are testing your father’s hip joint motion, then interrater reliability is important. This refers to the test being done the same way from person to person. Interrater reliability is the term used to describe test-retest when performed by different individuals on the same patient.

Patient pain levels can vary from day-to-day, too. A measurement on one day may not be the same as on the next if the pain goes up or down. Assuming there is a true general trend of joint motion loss, the first step is to see his doctor. There may be an adjustment needed in medication that can help make a difference. Or there could be some other explanation for what’s going on.

If no medical treatment is warranted, then referral to a physical therapist may be needed. The therapist is well acquainted with ways to help arthritis patients maintain and even regain range of motion. Not only that, but they will pay attention to strength, motor control, and joint proprioception (sense of joint position). Each of these components is important to function and preventing disability.

Testing motion of the hip in particular can be affected by position of the pelvis and low back. Using some means of supporting and stabilizing the pelvis and spine assures that the measurements are accurate. If this isn’t done, the pelvis can angle in one direction or another giving a false impresssion of hip or leg motion that really isn’t accurate.

Given the fact that this was a preoperative measurement suggests the need for reliable, valid, and accurate measurements. Post-operative rehab depends on knowing before and after measurements and gaining improved motion before discharging the patient home and/or progressing the exercise program.

Performing the test the same way each time with each patient is essential to assure standardized measurements. Even with this special methods, measurements can vary from day to day and from therapist to therapist. Keeping a consistent record helps the patient and the therapist at least see general trends in motion.

Hip pain is the number one reason people choose to have a total hip replacement. But patients are advised that the pain is not automatically gone after surgery. Some patients report that it still hurts but “feels better” because it’s a different kind of pain. The arthritic joint pain is replaced by a sore, aching, muscular pain and stiffness.

With time and by following a specific rehab program, the pain, soreness, and stiffness gradually decline. The hope is that as the painful symptoms decrease, your mother’s function will improve. Usually walking distance and speed are used as the main measure of improvement.

Be aware that after joint replacement many patients rate their function as much lower than it really is. This is likely due to the effect of pain. Even a small amount of pain can color how a person views his/her own function. It may take awhile before pain, perception, and function level out.

You have just described a dilemma faced by many family members of someone who has had a total knee replacement or total hip replacement. The reason for the apparent difference between perceived function and actual function appears to be one thing: pain.

And even as the pain subsides (decreases), patients don’t always recognize or report a sense of improved function. They may be able to walk farther and faster, but even a small amount of pain makes it seem like less. There are many ways to help patients see themselves in a more positive (or realistic) light.

Special tests of function can be given to the patient by the physical therapist. Walking, function, and activities of daily living can be measured. Once the patient sees the functional score on paper, they may see themselves more as they are and perhaps improve their overall outlook.

Another tool is a journal or log of daily activities. This can include how far they walked (or how many minutes they walked). Number of stairs, amount of time on a stationary bike, and even daily activities accomplished can be recorded and compared week-by-week.

With time, it’s possible that things will still smooth out. By now, your wife has completed the standard rehab program. Continuing with a fitness program or regular exercise of some type is always advised. Keeping a log of the advances made in the fitness routine is another measurable way to chart progress.

You may be suffering from a condition called lateral hip pain or greater trochanter pain syndrome. This is a fairly common problem. And, as you and your sister have discovered, it’s especially common in postmenopausal women.

Besides lying on the already painful side, activities that make the pain worse include standing or sitting for more than a few minutes, walking up or down stairs, or walking for more than a few minutes. Sitting, resting, and pain relieving medications seem to make it feel better.

The cause of lateral hip pain could be an inflamed bursa (bursitis), tendinitis of the gluteal (buttock) muscles, or tendinosis (degeneration) of the same muscles.

Diagnosis of the problem can take some time. We have a few reliable clinical tests to use when sorting out hip pain. Sometimes MRIs offer useful information. But many times nothing unusual shows up on MRIs for patients with lateral hip pain. And there are just as many patients with pathologic changes on MRI who have no symptoms.

It may take a period of trial and error with treatment (medications, physical therapy, exercise) before symptoms improve. Don’t assume this is just a problem of aging. Pain of any kind can reduce your quality of life. It’s best to get a diagnosis and then decide on the best course of action.

Hip bursitis can be difficult to diagnose accurately in some patients. Often there is really more than one problem going on. Osteoarthritis, bursitis, and tendon pathology can all occur at the same time with overlapping signs and symptoms.

Some experts say that bursitis never occurs alone. They believe bursitis is just one of several problems that occur together. In fact, they suggest that bursitis is a sign that tendon and joint degeneration are occurring.

And to make matters even more confusing, many people with bursitis don’t have any symptoms. So finding reliable test measures and symptoms to confirm a diagnosis of hip bursitis can be a challenge.

As you have discovered, sometimes bursitis shows up on an MRI, but not always. Pain with palpation over the greater trochanter may be the most reliable clinical sign of bursitis. The greater trochanter is a large bump that can be felt along the side of your hip. Large and important muscles connect to the greater trochanter.

The bursa is designed to provide a buffer or cushion between the tendons of muscles and the attachment of the tendons to the bones. Overuse or misalignment of the gluteal muscles can cause irritation and inflammation of the bursa. The end-result may be painful and persistent bursitis.

Sometimes a trial and error process is required to figure out exactly what soft tissue structures are getting pinched or pushed. When tests aren’t clear as to the problem, then treatment may be started. The diagnosis is made after a specific treatment is successful.

Perthes disease (also known as Legg-Calvé-Perthes syndrome) is a degenerative disease of the hip joint. There is a loss of blood supply and bone mass to the blood supply of the head of the femur (thigh bone) close to the hip joint.

Without proper treatment, collapse of the femoral head can occur. Deformity in this area may lead to osteoarthritis in adults. More recently, it was discovered that changes also occur in the shape and angle of the acetabulum. The condition is called acetabular retroversion. The acetabulum is the hip socket. Retroversion refers to the changes in orientation of the socket.

Apparently, these changes don’t occur during childhood. They develop after skeletal maturity is completed. Researchers are just beginning to pay closer attention to this feature in adults who had Perthes as a child. Studies will be done to find out ways to keep it from happening.

Patient compliance is an important factor in the success of hip joint replacement. There is a certain amount of post-operative pain to deal with. An aggressive rehab program is needed for a successful outcome.

But many patients find that the post-op pain is different and even easier to deal with than the pain they experienced before surgery. They feel better and are more willing to move. As a result, they automatically become more compliant and cooperative.

The newer surgical techniques for hip replacement also help speed up recovery. Smaller incisions, less damage to the soft tissues, and less time to complete the surgery are all possible now.

And patients aren’t held back from what they want to do. They are told not to treat the hip as if it might break. They are free to put weight on that leg. They can get rid of any walking aids (canes, crutches, walker) whenever they feel ready to do so.

Each patient must make his or her own decision about the timing of joint replacement surgery. Educating patients about what to expect can help overcome fear-based hurdles. Success rates are high and complications low with experienced surgeons.

Patients report a much smoother ride these days following total hip replacements. Pain control begins in the operating and recovery rooms. This is called perioperative management. Improved analgesic and anesthetic protocols have changed the way this surgery is done.

For example, patients receive antiinflammatory and sustained-release opioid (pain) medications before the operation. Some surgeons use an indwelling catheter (tube) into the hip area to deliver a local anesthetic (numbing agent). This is kept in place for the first two nights after surgery.

After the operation, a combination of medications may be used to control pain, improve function, and restore natural sleep. These include acetaminophen, a nonsteroidal antiinflammatory, and the sustained-release opioid. A short-acting opioid may be added for any break-through pain.

Doctors have found that if pain can be controlled from the beginning, patients do much better. It’s possible to avoid the pain-spasm cycle that prevents movement and function. Patients are no longer encouraged to tough it out. Less pain means more function and a faster recovery.

For some people who require a hip replacement, there is another option called a metal-on-metal hip resurfacing. This particular procedure allows the patient to keep part of the hip and the joint part is resurfaced to allow easier, pain-free motion.

This procedure is often considered a viable alternative for younger patients who doctors are reluctant to perform a full replacement on because of age.

In the musculoskeletal part of the body, it’s not uncommon for a problem in one area to refer pain to another area nearby. Usually the nerve supplying the problem area also controls the site of the referred pain. Because the nerve affects more than one body part, messages via the nervous system don’t always get interpreted correctly.

Doctors and therapists know that when a patient presents with pain in any of the joints that they must consider the joint above and the joint below the painful one as a possible source of referred pain. In the case of the hip, this means checking the low back area and the knee as possible sources of the real problem.

Press-up (extension) exercises are often used in people with disc-related or nonspecific low back pain. Nonspecific means the cause of the problem is unknown. In many cases, the patient history and results of some simple screening tests point to the real problem area.

Press-ups to improve lumbar extension often reduce low back pain. These exercises can also eliminate hip pain when the true cause of the pain is coming from the low back area.