FAQ Category: Hip

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.

Board certification is an indication that the physician has kept up with his or her skills in a particular area of expertise. This could be hematology, internal medicine, oncology, orthopedics, pediatrics, or any number of other specialty areas of medicine.

Board certification in orthopedic surgery requires the physician to pass two different exams. The first is a written exam. The second part is a practice-based oral exam. Before taking the first part, the doctor must finish medical school and then a residency or fellowship.

After passing the written portion, they must practice for a minimum of 22 months before taking the second part of the test. Part II requires the physician to submit a list of all operations performed during a specific six-month period of time. These procedures must be verified by the clinic or hospital where the surgeon worked.

Each case is reviewed for patient outcomes based on pain, deformity, function, and satisfaction. Complications such as hemorrhage, infection, fracture, or delayed healing must be reported.

About 70 per cent of orthopedic surgeons take Part II within the first two years after finishing their training. Ninety-eight per cent (98%) finish Parts I and II by the end of their first five years after their formal training.

As you’ve discovered, there are different ways to repair a broken hip. This is based on a number of different factors. The location and type of fracture are two of the first and most important deciding factors.

Surgeon training, experience, and preference are also considerations. For example, younger orthopedic surgeons are more likely to use the nail and interlocking screw system. Older surgeons stick with the sliding compression hip screws.

The patient’s health and condition of the bones are two more variables. The presence of osteoporosis can make a difference in which type of fixation method is used. Some types of fixation implants are more likely to cause fracture as a complication. The surgeon does everything possible to avoid this additional problem.

And finally, there’s even a difference in how things are done from geographic area to area in the U.S. A review by the American Board of Orthopaedic Surgery showed that newer methods of practice tend to show up first in the southeast, south, and southwest regions. The northwest is often the last place to adopt new practice patterns.

No one is quite sure why surgeons in the South convert to new technologies faster than in the North and Midwest. It may be based on age of patients and/or the age of the surgeon. Research is ongoing to compare different approaches and find out which method works the best regardless of where a patient lives when the procedure is needed.

Post-operative recovery following hip joint resurfacing is under study right now. There aren’t too many details available to tell us how other patients are doing three months, six months, or one year or more after the procedure.

Pain that persists past the three-month mark is not considered normal. It’s more likely classified as chronic pain. Having enough hip joint motion to bend down and pick up items off the floor can be a problem for some patients. With the right rehab program, it should be something you can do.

Using a handheld device made especially for this task can help. But ideally, it would be better to gain enough motion and strength to accomplish this task on your own. And if you are having trouble putting on shoes and socks, it’s likely that there are other areas of function that are a problem, too.

A second phase of rehab may be needed for patients who have had a hip joint resurfacing procedure. Once you have been discharged from the hospital, you have a home program of exercises given to you by the physical therapist.

But three months later, your needs have changed. A follow-up evaluation would be helpful at that time to redirect patients and gear the home program towards improving function. The focus may still be improving strength, motion, and balance. But the outcomes can be measured in terms of what you can and can’t do.

Talk to your surgeon about your situation. Or visit your physical therapist for a follow-up appointment. Now that there isn’t an immediate concern about hip dislocation, your program can be modified to increase hip motion needed for bending activities.

Hip resurfacing arthroplasty 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.

Because the hip resurfacing removes less bone, it may be used for younger patients. Hip joint resurfacing is a good idea for those who are expecting to need a second, or revision, hip replacement surgery. The need for a revision operation increases as they grow older and wear out the original artificial hip replacement.

During the procedure, the femoral head is dislocated out of the socket. Special powered instruments are used to shape the bone of the femoral head so that a new metal surface will fit snugly like a cap on top of the bone. The cap is held in place with a small peg that fits down into the bone. The hip socket may stay the same, but more often it is replaced with a thin metal cup.

The patient must have enough healthy bone to support the cap. The metal materials hold up well under the increased activity of a younger adult group of patients. There is a lower risk of hip dislocation after joint resurfacing compared with a total hip replacement. This may be because the fit is so much closer and better for hip resurfacing.

There have been some problems with metal-on-metal hip joint resurfacing. For example, tiny pieces of metal can fleck off the implant with prolonged wear and tear. Those metal ions can create irritating debris in the joint contributing to increased wear and tear.

Long-term reports of metal-on-metal hip resurfacing are fairly limited in number. Future research efforts are needed to observe the natural history after hip joint resurfacing and report on long-term results.

One study after 12-months reported a 75 per cent satisfaction rate. But this means that one-quarter of the patients were not happy with the results. Factors contributing to suboptimal recovery are unknown. It could be a lack of rehabilitation after the operation. It could be a different type of rehab is needed for hip joint resurfacing.

Replacing part or half of the hip joint is called a hemiarthroplasty. Most often, the round head of the femur (thighbone) is cut off. A metal implant is used to replace the missing parts. The hip socket or acetabulum is left in place. With a total hip replacement (THR), both parts of the hip are removed and replaced.

Hemiarthroplasties are used most often for hip fractures, early stages of osteonecrosis, and some cases of hip dysplasia. Hemiarthroplasty works well with femoral neck fractures because the hip socket is undamaged.

It has the advantage of preserving the patient’s own acetabulum. This is important should the patient ever need a total hip replacement. Good bone stock is a key to success in future surgeries.

With either choice, (THR or hemiarthroplasty), there are risks for complications. The bone around the implant may fracture. The implant may loosen. Joint infection can occur.

But the most common problem is hip dislocation. The highest rates of dislocation seem to occur in patients treated by surgeons who don’t do a lot of these operations. The best results occur in high-volume clinics or hospitals with high-volume surgeons.

Hip dislocation is also more common after surgery to convert a hemiarthroplasty to a total hip replacement. If there is a greater risk of hemiarthroplasty failure with revision surgery, then a total hip replacement now may keep that from happening. It may be helpful to have an honest conversation with the surgeon about the pros and cons of each procedure. This may help you and your wife make the best choice for her.

Hip dislocation after a primary (first) or revision total hip replacement is a fairly common problem. Revision refers to any future operations to repair or replace the implant.

The rates of dislocation after hip replacement have improved over the years. It’s estimated that about one to three per cent of patients will have a dislocation after the first hip replacement. Three to five times that number will dislocate after a revision.

Surgeons are actively working with scientists to find ways to reduce this complication rate. The cost of this event is dramatic, both for the patient and for society.

It may be possible to prevent further dislocations with careful use of the leg. This means avoiding certain positions and movements. A rehab program under the supervision of a physical to strengthen the muscles around the hip is also in order. When structural instability is mild to moderate, then mechanical stability through proper tissue tension may be able to achieve the stability needed.

If hip dislocation still occurs after conservative care, further surgery may be needed. It may be possible to revise the hip again. However, many older adults refuse this option. Joint fusion is another final approach to consider. This is done most often when chronic dislocation develops, resulting in pain and increased falls.

Hip fracture in the older adult is common and can be very disabling. Early surgery and rehab seem to make a difference. But studies show that the prognosis is really made four to 12 months after surgery. A week (even a month) after surgery is too soon to tell.

There are some pre-op factors to consider. Research shows that the age, general physical and mental health, and nutritional status before hip fracture may likely determine the final outcome.

As might be expected, older adults who are inactive and who have other health concerns (e.g., diabetes, heart disease) may not get back to their previous level of daily activity. Those who are active and healthy before surgery have a better chance of recovery.

Many patients simply do not regain their previous abilities and may not even walk again. Up to half of all older adults who fracture their hips end up in a nursing home or extended care facility despite every effort at rehab.

There are many different types of fractures classified by location and specific type. For example, in the hip, the most common fractures in older adults affect the femur (thigh bone). These fractures include:

Failure to heal fully from a fracture is called a nonunion. Any fracture that hasn’t healed nine months or more after the original injury is considered a nonunion. X-rays usually confirm the fact that the fracture site is still visible. Little or no callus formation has occurred around the fracture line.

There are many possible reasons for nonunion. Age, general health, and nutrition are important factors. Patients who smoke and/or who have diabetes are known to have slower healing rates. Delayed healing is also more likely when there is a bone or soft infection at the site of the fracture.

Sometimes the exact cause for failed union just isn’t known. It could be the metabolic or physiologic traits of the patient. There may be osteoporosis present or an imbalance in the way new bone is formed. A lack of blood supply to the fracture can also contribute to delayed healing.

Nonunion femoral fractures may require surgery to bridge the gap and foster bone growth. A metal pin called an intramedullary nail may be inserted down the center of the bone. This will help stabilize the bone and the fracture site. A metal plate across the two sides of the fracture is another method of surgical repair. In some cases, bone graft is needed to help get the process started.

The procedure you are referring to is called an exchange nailing. The nail that is already present is removed. The canal where the nail was placed is now reamed out to make a larger diameter. Putting a larger nail in place helps stabilize the fracture.

Reaming the intramedullary canal helps stimulate bone union from both a mechanical and biologic perspective. The larger, stiffer implant stabilizes the bone. It also increases the contact area for bone growth around the pin. The bone that is removed during the reaming process can then be used as a bone graft around the fracture and pin sites.

Exchange nailing allows for early weight-bearing. The patient can move the leg and all the joints without restrictions. This helps restore function early. The technique is also less invasive than open incision procedures.

There are cases where serial reaming doesn’t work as a treatment for femoral nonunion. Studies show that as many as half the patients require another surgical procedure to achieve bone union. Open incision bone grafting may be needed instead for bone healing to take place.

Many older adults who survive a hip fracture are left with problems they didn’t have before the fracture. For example, they may have to use a walker or cane to get around. Walking and managing stairs can be major disabilities now. Dressing and undressing can be difficult. And some patients are unable to get back to their regular community or social activities. Recovery can take up to two years.

Most patients receive physical therapy while in the hospital. But PT after discharge isn’t always ordered or provided. Yet studies show that patients with this injury who have PT after going home are less likely to be rehospitalized. They are also less likely to die from complications of this condition.

The therapist will help the patient regain motion, balance, and strength needed to resume normal activities of daily living. These skills are also needed to get back to regular social activities. Breathing exercises and aerobic conditioning may help prevent problems such as pneumonia that can cause rehospitalization and even death.

Most states in the U.S. now have consumer access or direct access to PTs. This means you can contact the therapist directly without requiring a physician’s referral. The therapist’s evaluation will include screening for conditions that require medical attention.

After a few weeks of PT, many patients can be set up on a supervised home program they can follow on their own. The therapist will also help identify safety concerns in the home environment. Anything you can do to make sure safety feature are installed (e.g., lighting, tub bars) will go a long way to prevent future falls and subsequent fractures.

Many experts around the world agree now that regular physical activity and exercise is a must for good general health. This is especially important for specific conditions such as diabetes, colon and breast cancer, hypertension, depression, and osteoporosis.

The current recommendations are for 30 minutes of moderately to intensely vigorous activity every day. If you cannot meet this goal every day, then try for at least five days a week. Moderate to intense level of activity may not be achieved in the same way by everyone. What’s intense for you may not be intense for someone else. This is true even if you are the same age and in the same general condition.

There are two helpful tools used to gauge activity level. The first is the rate of perceived exertion (RPE). Patients use a scale from zero to 10 to rate their level of activity. Zero is no exertion or easy, while 10 is intense or very hard. The numbers between zero and 10 gradually increase in difficulty performing the activity or exercise.

Another method of measuring your intensity or level of effort uses metabolic equivalents (METS). One MET is equal to the energy used while sitting quietly. This is the resting metabolic rate. As the activity level increases, the MET goes up. In order to meet the moderate to intense level required for good health, a MET level of two or higher is needed.

You may want to ask your physician for more specific guidelines. She can guide you in how to apply either (or both) of these methods in your daily exercise routine and activities. Be sure and ask if there are any further restrictions in activity for the particular implant that you have.

More and more evidence points to the importance of regular physical activity to stay healthy. One reason pepole have a total hip replacement is to reduce pain. This usually leads to an increase in their activity level.

There’s also quite a bit of evidence to support the benefits of exercise for anyone with osteoarthritis. Fort the sake of all your joints, exercise is a good preventive activity.

Just being aware of the change in your focus and motivation is a good place to start. It may be helpful to join an exercise group to get you moving more. Or perhaps there’s a friend who would be willing to join you on walks. Many communitities have a mall walking program. Or look for an aquatics exercise program at your local YMCA or other health/fitness club.

Try to add one minute of exercise or activity to each day — even if it’s just walking around the block. By the end of a month, you will be up to 30 minutes each day. The goal is to exercise at a moderate intensity 30 minutes daily, five to seven times a week.

The description you are providing sounds like a possible impingement syndrome. Impingement means something is getting pinched or compressed.

In the hip, that something is usually some part of the soft tissue anatomy. It could be a tendon but most likely it’s the rim of cartilage around the hip socket.

Combining hip flexion, internal rotation, and adduction (movement across the body) presses the femoral neck junction against the superior labrum. If this motion causes pain, it is a sign of femoroacetabular impingement (FAI).

The labrum, a dense fibrocartilage ring that is attached to the hip socket may be torn. This ring gives the hip socket depth at stability. It has nerve endings that set up a painful response when it is impinged.

The first step is to see your doctor. A positive FAI test is usually followed by further evaluation of the hip. X-rays, MRIs, or even arthroscopic exam may be needed.

There are many possible causes of hip pain. Often what patients call hip pain isn’t coming from the hip at all. Pain along the outside or back of the hip may not indicate a problem with the hip. True hip pain tends to cause pain along the inside of the leg near the groin.

There are many structures in and around the hip that can be causing painful symptoms. These include the joint itself, the rim of cartilage around the joint (called the labrum), the bursa, ligaments, muscles, and tendons.

Sometimes pain coming from the sacroiliac joint or low back can be referred to the hip. Most of the time, pain in the general region of the hip is caused by the soft tissue structures around the hip. There may be tightness, laxity, impingement, weakness, or poor alignment resulting in hip pain. Less often, fracture, infection, or tumor may be the source of symptoms.

A medical examination may be needed to find out exactly what’s causing your symptoms. Your doctor will take a history, perform some standard tests, and possibly order lab work to look for inflammation or infection.

Based on the results of these tests, further work-up may be advised. A set of standard X-rays may be needed. MRIs or CT scans are reserved for cases where further detail is required to make the diagnosis.

Much has changed in health care delivery over the past 10 to 20 years. Patients are discharged from the hospital much sooner now. In the 1980s, the average stay for a hip fracture was 22 days. Today this has been pared down to only 6.5 days. This means the hospital therapist has much less time to help the patient regain motion and strength.

After discharge, the rehab protocol previously completed in the hospital may or may not be continued at home. If therapy is continued, patients may not be ready for an intense program before the number of days allowed by the insurance company or Medicaire is reached.

Six to 12 visits in six weeks after hip fracture surgery may not be enough to get older adults back on their feet and back to their previous level of function. It may be necessary and a good idea to invest in some additional sessions with the therapist.

Hip resurfacing with metal components was first approved by the FDA in 2006. The procedure is called a metal-on-metal hip resurfacing (MOMHR).

A study of more than 2,000 patients showed this treatment was safe and effective with good results after a five-year follow-up period. This procedure preserves bone and extends the life of the joint. Patients who have severe hip pain without severe joint or bone destruction may want to consider this treatment option.

With MOMHR, hip motion and function are restored more toward the normal biomechanics compared with total hip replacement (THR). And by saving as much bone as possible, you may be able to have a THR later if needed. Studies show that the more skilled the surgeon, the more bone is preserved.

The number of people of all ages (young and old) getting a total hip replacement (THR) has risen dramatically. This is linked to better techniques, improved surgical tools, and more advanced equipment that have been developed over the last 30 years.

People who were not considered for THR even 10 years ago can now have this operation. Obese, young, and elderly people can now successfully rehab and regain function with a new joint.

But there are some age-related risks that should be understood before having this kind of surgery. Older adults tend to have other health problems that can complicate recovery. Diabetes, cancer or the effects of cancer treatment, and hypertension are just a few of the more common conditions to consider.

Some older adults experience confusion or increased confusion after surgery. So far, we don’t know how to predict this or prevent it from happening. Any change in mental function complicates recovery.

For example, the patient may not be able to follow directions. Putting too much weight on the joint or moving the hip too far in one direction can cause it to dislocate. A decline in cognitive function can also slow down the rehab process.

But studies do show that many people 85 and older have had a successful rehab outcome. Their overall function improved after THR. They were able to return to their daily activities. Some can even participate in recreational activities that were impossible before the operation.

It may be best if she had a medical exam along with an evaluation by an orthopedic surgeon. The doctors can assess her level of risk based on several factors. They will look at her age and general health (both mental and physical).

Any other conditions present such as high blood pressure, diabetes, and obesity will be reviewed carefully. Other problems that can interfere with anesthesia such as sleep apnea or asthma do put the patient at increased risk of complications during surgery.

Studies show there is a trend toward a higher rate of wound infection among obese patients after THR. The rate of dislocation and blood clots does not appear to be any higher than in the average adult group.

Long-term results to show the effects of obesity on wear and tear of the implant are underway. Results for large numbers of patients aren’t available yet. When dislocation or loosening of the implant does occur, revision surgery is often needed. Results are less than ideal in obese individuals under these circumstances.

Your aunt may need a longer hospital stay and more rehab services. It may be necessary for her to go to a transition or long-term care facility before going home. All of these steps can add to the total cost of the procedure. This is an important, but often neglected, factor to consider.

Many obese adults who elect to have a THR despite these concerns report a very satisfactory outcome. The pain relief they get is often enough to help them increase their activity level. They can have improved function and remain independent longer.