FAQ Category: Hip

Hip fractures in older adults can be complex and challenging to treat and manage well. Fractures from a high-energy injury such as your father’s fall from a height can be accompanied by other injuries as well. Sometimes it takes some time for other problems to surface.

Any hip fracture can be the catalyst that causes loss of independence. Serious complications such as pneumonia, infection, and blood clots can compromise return to health. Your father will be under close surveillance while in the hospital until his condition is stable.

Most older adults have some form of osteoporosis. The bone loses mass and density and becomes more prone to fracture. This makes it difficult to stabilize the fracture with plates, screws, or pins inserted into or even through the bone.

There is some danger that the fractured ends of the bone may collapse toward or into each other. There is always a risk of nonunion. Nonunion means the bone doesn’t heal or healing is interrupted and delayed a long time. Sometimes scar tissue forms but without good bone repair.

You’ll need to speak to the surgeon to find out more specifically what the concerns are for your father. He may have just been referring to the general process of recovery and rehab. Or there may be something unusual about the type of fracture that puts your father at increased risk of delayed healing.

Hip joint resurfacing has gained in popularity over the last 10 years. With better implant materials and improved surgical techniques, the results have improved favorably.

In this operation, instead of removing the head and neck of the femur (thigh bone) and replacing them with a chromium, titanium, or ceramic implant, the surface is smoothed and capped. The same thing is done to the inner lining of the acetabulum (socket).

The procedure is much more difficult to do compared with a total hip replacement. But the surgeon is able to save more of the bone. This is important, especially in younger patients with osteoarthritis. They can always have a revision surgery later to replace the resurfacing liners with a total joint replacement.

The most common problem that develops after resurfacing is a fracture of the femoral neck. Loosening of the implant parts can occur. Infection or hip subluxation (partial dislocation) are also reported complications.

Most of these problems occur early on after the operation (within the first few months). Sometimes the resurfacing can be saved and no further operations are needed. But in other cases, a second (revision) surgery is needed. The hip may need to be completely replaced.

The incidence of serious complications of this type is fairly low. Skilled surgical technique and careful patient selection has led to reduced rates of fractures and higher rates of success.

Accepting activity restrictions can be very difficult when your livelihood depends on moving freely. Workers of all types may be at risk of losing their jobs from disability of this type. Even some older but still active athletes face this same situation.

Over the last 25 years, major advancements in the treatment of hip arthritis have taken place. Improved implant materials and design have greatly improved the results of surgery.

Hip resurfacing arthroplasty is a new type of hip replacement. It replaces the arthritic surface of the joint but removes far less bone than the traditional total hip replacement.

Younger patients prefer this operation. Since hip resurfacing removes less bone, it leaves patients with options for revision surgery later if needed. Many patients are able to return to their prearthritic activity level, even workers involved in heavy labor.

Studies show that complications after hip joint resurfacing range anywhere from zero to four per cent. Other studies support the idea that revisions of this type are caused by errors in surgical technique and patient selection.

For example, joint resurfacing is not advised in older, postmenopausal women. The bone is often osteopenic or osteoporotic (decreased mass) and may fracture at the femoral neck. Obesity is also a negative risk factor. Anyone with a BMI more than 35 is not a good candidate for this type of surgery.

Surgeons must be trained and experienced in using this technique in order to reduce the risk of fracture and other complications. Implant loosening, hip dislocation, and infection are the other most likely complications from this new procedure.

Other ways to avoid femoral neck fractures have been suggested. The implant must be positioned carefully. Any malalignment or imbalance can contribute to problems. Weak bone may not be able to support the implant with fracture as the result.

Most often complications are the result of several (if not many) factors combined together. The rate of complications declines with each surgeon with practice and experience. Patients with severe arthritic changes are usually treated with a total joint replacement, bypassing this step altogether.

The natural history and long-term results of Perthes disease (also known as Legg-Calvé-Perthes) are still largely unknown. Some studies following children with this condition into their later years have been done. Our current treatment for this condition is based on the results of those studies.

We know that the duration of the disease from start to complete healing depends on the extent and severity of the condition. As you might expect, the children with the greatest amount of damage to the growth plate have the worst results.

Age makes a difference, too. Younger children (less than six years old) with Perthes tend to have milder deformity compared with older children (10 years old or older).

One study from the University of Iowa showed that patients treated with range of motion programs had better motion and function at age 45. But 10 years later, there was significant deterioration of the hip. By the time these patients were 55 years old, 40 per cent of the group had a total hip replacement. And another 10 per cent had enough pain and arthritis to need a joint replacement, too.

Individuals who receive physical therapy do show improvement in hip motion and strength. Whether or not lifelong exercise makes a difference has not been studied.

It might be a good idea to see an orthopedic surgeon. An X-ray can show the current condition of your hip. A physical therapy exam can establish your levels of motion and strength. Any other loss of function or disability can be addressed with a specific rehab program.

Regular follow-up visits with both the surgeon and the therapist may help identify any developing problems and nip them in the bud.

Failure of joint replacement implants is often the result of fatigue failure. The component parts just don’t hold up forever. The stem of the femoral side of the implant is at greatest risk for fracture. Studies estimate this happens in less than one per cent of all cases.

Current devices have improved to meet the demands of a younger, more active group of adults in need of a hip joint replacement. Materials, design, and manufacturing of the implants have all advanced in the last 10 years. The risk of fatigue failure is less but the activity levels and demands of current patients has also increased.

More and more, younger adults are choosing to have a hip joint resurfacing procedure done instead of a total hip replacement. Hip resurfacing replaces the arthritic surface of the joint but removes far less bone than the traditional total hip replacement.

Resurfacing is a good option for some younger patients who are expected to need a second or revision hip replacement surgery. The resurfacing method gives greater function as they grow older and start to wear out the original hip replacement. Later, a total hip replacement is still possible.

The operation to remove a portion of the femur is called a trochanteric osteotomy. This is done to help give the surgeon better access to the hip joint. It’s a procedure used most often in complex cases requiring revision surgery of a total hip replacement already in place.

The trochanteric bone removed is reattached using a wire or cable system of fixation. Sometimes the device breaks or it isn’t tightened enough and the bone migrates (moves).

Trochanteric migration can be a major complication. It causes the hip muscles to lose their mechanical advantage. Walking without pain and/or a limp may become impossible.

The surgeon will use X-rays to measure how much the fragment has moved. Migration less than two centimeters can be watched and monitored carefully. If functional changes are already present, then surgery to stabilize the fixation is usually advised.

It sounds like your father has been given instructions called trochanteric precautions. These precautions include no active hip abduction and no weight on the affected leg for six weeks.

Such precautions are advised when a patient has had a trochanteric osteotomy as part of the revision operation. In this procedure, the outside edge of the femur (thigh bone) is removed. A large knob of bone at the top called the trochanter is part of the bone that is cut off.

The surgeon performs this type of osteotomy to gain better access to the hip joint. It is reattached with wires or cables. The instructions given are to help prevent nonunion and/or migration (movement) of the bone fragment during the healing process.

Hip muscles that attach to the trochanter can exert a tremendous pull on the bone. Until it has healed and re-united with the main part of the bone, compressive, shear, and load forces can cause problems.

Your father must be given as much information as possible to insure compliance with these instructions. The successful outcome of surgery may depend on it. Early breakage of the fixation system with migration can cause chronic hip pain, a limp, and an unstable hip.

Clicking of an artificial joint can have a few causes and most are benign or don’t cause any problems. After a joint is replaced, some clicking or popping may happen as the joint moves. Unless this is causing pain, there shouldn’t be any problem with it.

However, sometimes the clicking is a sign that the joint has moved or dislocated. For this reason, if your mother is having any pain, is unable to bear weight on the hip, or is otherwise uncomfortable, she should see her doctor and have the hip x-rayed to be sure about the cause.

Whether people should wait for replacements because of their age is debatable. Some doctors feel that if you put in a hip into a young patient, you are increasing the chances of the patient needing a second hip replacement when he or she gets older. However, there is also the quality-of-life issue that needs to be discussed. If someone is in tremendous pain and can’t function because of a sore hip, then a replacement might be called for.

Speak with your doctor and make sure that he understands completely how this is affecting your life.

There are many possible reasons for thigh pain. A problem with the implant (also called a prosthesis) is only one. Loosening of the prosthesis is the most common cause of thigh pain linked with a total hip replacement.

Other medical causes such as urinary tract infection, kidney stones, or disc herniation must be ruled out. Your surgeon is the best one to diagnose the problem. After taking a history and performing an exam, a simple X-ray may be all that’s needed.

If the problem is not coming from the implant, then other imaging and/or lab tests may be needed. Early diagnosis and treatment are always advised. Waiting too long can sometimes add complications that may be avoided with early intervention.

Zirconia ceramic replaced the alumina implants used back in the late 1980s. The ceramic implants had excellent mechanical properties and performed well. They were especially favored because if a crack formed, the material expanded and sealed itself.

Researchers have found that over time, the surface layer of zirconia can change. Contact with water or body fluids increases the grains on the implant surface.

This change decreases the stability of the material making it more likely to wear unevenly. Surface roughness increases. At the same time, crack formation or fracture is more likely.

A recent study of failed and removed zirconia ceramic femoral heads was done. The surgeons found that time was the greatest factor in implant aging. The longer the implant was in place, the more likely the surface layer would undergo changes in stability and wear.

There was no evidence that the patient’s age or weight were factors. Activity level was not linked to wear pattern either. Although these factors do not appear to affect zirconia ceramic implants, many other health benefits occur from weight loss and activity. Experts agree that keeping your weight under control and staying active is a recipe for improved overall health.

Total hip replacements come in two parts. There’s the cup to replace the acetabulum (socket) and the round head at the top of the femur (thigh bone) and femoral neck. These component parts can be made out of a variety of different materials.

Ceramic was first introduced about 30 years. It wears well but tends to fracture. Improvements in materials and design have increased its popularity again in the last few years. Ceramic-on-ceramic implants have the lowest wear rate but squeaking can be a problem.

Surgeons aren’t quite sure yet what might be causing this to happen. Not all patients are affected. And sometimes it goes away on its own. Studies so far suggest there may be two main reasons for this squeaking.

The first is a lack of lubrication in the joint. This is called dry joint. But what causes the dryness is still unknown. There are many theories so far. It could be the liner inside the socket is mismatched in size. Or ceramic particles may chip off the implant and rub inside the joint.

Most likely there are either many possible causes or several factors that occur at the same time resulting in squeaking. A solution to the problem hasn’t been discovered yet. Once researchers pinpoint the cause, then surgeons can find ways to avoid or eliminate the problem.

The type of materials used in hip replacements seems to make a difference in problems such as squeaking. Ceramic implants have the highest incidence of squeaking.

But squeaking happens with other types of implants. It may not be the material as much as it is the design of the implant. Researchers from the manufacturers of the implants and surgeons are working together to find the cause and solution to the problem.

In the meantime, that doesn’t help you with your squeaking problem. There are some patients who find over time that the squeaking goes away. It’s possible that the surface gets worn down enough to improve the fit of the joint. We don’t know yet how to predict who might benefit from time.

Some patients decide to have a second operation to revise the implant. The surgeon makes sure the component parts are not mismatched. Any evidence of impingement (pinching) of the implant is corrected.

Since you are not having any painful symptoms or loss of function, you may want to try the test of time first. Consult with your surgeon early on so that no delays occur later if you decide to have a revision operation.

X-rays are the key to making a diagnosis of hip impingement. With hip impingement, the head of the femur (thigh bone) bumps up against the lip or rim of the socket. A thin layer of cartilage called the labrum gets pinched in the process causing pain. This problem is often treated with surgery, so the imaging studies from all angles are essential.

There are three main ways X-rays can be taken. Each radiographic view offers a slightly different picture of the hip angle and shape. This information is important in diagnosing hip problems such as impingement.

The first is the anterior-posterior (AP) view. This is the view looking through the patient from the front to back. Second is the lateral view from the side. And third is the frog-leg lateral view.

In the frog-leg view, the patient lies on his or her back. The leg is flexed and abducted away from the body. The hip is externally rotated. The knee is bent so that the foot rests against the other leg. The frog-leg view has been shown to be a reliable way to diagnose hip impingement.

Hip impingement occurs when the head of the femur (thigh bone) butts up against the acetabulum (hip socket). In the process, the labrum gets pinched. The labrum is a thin layer of cartilage around the rim of the socket.

Anatomic changes in the femoral head and neck cause impingement. If the femoral head is flattened, it changes the relationship between the head and neck of the femur as it fits into the acetabulum.

Tears in the labrum or hip fractures that don’t heal can result in impingement. Childhood hip conditions such as Legg-Calvé-Perthes or slipped capital femoral epiphysis (SCFE) can lead to hip impingement.

Improved technology with MRIs have made it possible to study this problem more closely. As a result, we now know that many people who have no symptoms have femoroacetabular impingement.

Research is starting to show that patients who receive patient education and who are treated aggressively (early physiotherapy, pain medication before the pain is severe, etc), tend to recover quicker and more efficiently than patients who don’t have this preparation.

Your mother should meet with her surgeon to discuss the surgery and see what information she can get, when her physiotherapy will start, and learn if she should be taking medications before the surgery.

As you probably know, it’s hard to say who will recover how quickly from a surgery. With hip replacement surgery, a lot depends on if it’s a total hip replacement or a partial, and the approach and techniques your doctor uses. As well, recovery depends on how you were prepared for the surgery and how aggressive your rehabilitation is in terms of physiotherapy and pain management.

The best thing to do is to speak to your doctor and ask some of these questions:

What type of surgery are you going to do?

What is the general length of time your patients take to recover and walk with help (walker)? And to walk alone?

o your patients generally go straight home or to a rehabilitation hospital?

How do you manage pain in your patients?

Do you have a pre-surgery program for your patients to follow?

How quickly do you begin physiotherapy for your patients?

Hip pain and loss of motion from osteoarthritis (OA) often causes changes in the way people stand and walk. A secondary effect of this is back pain. The condition is known as hip-spine syndrome.

Hip-spine syndrome was first described in 1983. Most orthopedic surgeons are well aware of this phenomenon. Patients who have both hip osteoarthritis and low back pain (LBP) are treated first for the hip problem.

A small study of 25 patients showing the link between hip OA and LBP has been published. The patients reported significant improvement in back pain after a total hip replacement.

The authors took spinal X-rays before and after hip surgery. They hoped to be able to show changes in the spine to account for the improved pain and function after surgery. They were surprised that the X-rays were the same before and after the hip replacement.

More study is needed to fully understand the hip-spine syndrome. For now, we know this is a real condition, and it does get better after hip replacement. That’s good news for many older adults who suffer both hip and back pain.

This test may have already been done on your grandson. Many nurses and pediatricians in birth centers and at clinics automatically test for developmental dysplasia of the hip (DDH). It wouldn’t hurt to ask if it has been done.

A family history of DDH is a risk factor for this condition. Girls are at greater risk than boys, but boys can have DDH. In fact, these two known risk factors (gender and history) aren’t really good predictors. Only about one out of every 75 babies with a dislocated hip actually have either of these risk factors.

But early detection is helpful in watching the condition. Many times the child develops just fine and doesn’t need any treatment. But for those who end up with an unstable hip, early intervention can help prevent surgery later.

The medical record should indicate the results of this test. Perhaps you could suggest your daughter call and ask if the test was done and what the results were. If the test was not conducted, then it can be done at the next well-baby check-up. Encourage your daughter to take the new baby to all of these early appointments.