FAQ Category: Hip

It might help you to understand potentially where the physician is coming from on this issue. Research has shown that there may be a link between steroid injections before hip replacement and serious hip joint infection after the procedure. One study reported a 30 per cent rate of hip infection after hip replacement when a steroid injection was given before the procedure.

Since that time, there has been increased attention on the part of orthopedic surgeons when considering steroid injection into the hip. The concern for joint infection after replacement is very real. Experts recommended using caution and good clinical judgment when using steroid injections to relieve hip pain for osteoarthritis. And surgeons were advised to avoid using this technique within a two-month period of time before hip replacement.

But the subject is controversial as a recent study showed. In this study from Newfoundland, surgeonstook a look back over the records of 96 patients evaluating whether or not a steroid injection into the hip was linked with infection after hip replacement. They conducted the study because of the previous reports that this may be the case. And since steroid injections are often used to diagnose the problem and then used as an alternative to surgery, this information is important.

Anyone who has suffered enough hip pain to end up with a hip replacement doesn’t need the extra aggravation of a joint infection that requires another surgery. In this study, there were two groups of patients evenly matched by age, sex (male or female), diagnosis, and year of surgery. All of the patients had a hip replacement (referred to in medical terms as a total hip arthroplasty or THA). One group had steroid injections two to six months before the replacement surgery. The second (control) group did not have any steroid injections into the hip.

There was no difference between the two groups in regards to hip joint infection after the hip replacement. In fact, there were no differences in relation to any complications (e.g., dislocation, fractures, need for revision surgery). Based on these results, the question was discussed — steroid injection before hip replacement: yes or no?

The authors made several suggestions. First, a reminder that there are many potential reasons why a patient may develop joint infection after hip replacement. Nutrition, comorbidities (presence of other illnesses or diseases), and type of body (size, shape) are just a few considerations.

Second, their study was fairly small so different results might be found with a larger sample size. Only 15 of the 96 patients had an injection two months before the surgery. Again, this may be too small of a sample set to show significance. And only one surgeon performed all of the injections using the same technique(s) with each patient. Special care was given to keep everything sterile in order to reduce the risk of infection. Any of these (or a combination of these) factors could have contributed to the positive results.

The authors concluded that previous reports of infection after hip replacement linked with preoperative steroid injections must be taken seriously. Steroid injections into the hip before total hip replacement are not contraindicated. But until researchers are able to clearly identify cause and effect, and risk and benefit of this treatment, it is best to continue following current precautions.

With this knowledge of the overall situation, you may want to talk with your physician about his hesitations in your case. Use the next visit to weigh pros and cons of steroid injection use and discuss all your options. A win-win situation is possible when both you and your physician agree as to the best treatment approach for you based on all factors.

Steroid injections into a painful, arthritic hip are used as a diagnostic tool as well as an alternative to surgery. On the diagnostic side, if an injection directly into the hip reduces pain and improves motion and function, then it is clear the problem is coming from the joint and not the surrounding soft tissues. Sometimes a single injection is enough to give the patient months of relief, thus delaying the need for invasive surgery.

Whenever considering the use of steroid injections, the physician must carefully weigh the pros and cons, risks and benefits, and advantages and disadvantages of this treatment. Some studies have suggested a link between steroid injection into the hip before hip replacement and serious deep joint infection after hip replacement. One study reported a 30 per cent rate of hip infection after hip replacement when a steroid injection was given before the procedure.

Since that time, there has been increased caution on the part of orthopedic surgeons when considering steroid injection into the hip. The concern for joint infection after replacement is very real. Experts recommend using caution and good clinical judgment when using steroid injections to relieve hip pain for osteoarthritis. And surgeons are advised to avoid using this technique within a two month period of time before hip replacement.

Steroid injections into the hip before total hip replacement are not contraindicated. Proper patient selection and good, sterile technique when administering the injection(s) are probably two very important factors. Ultrasound or fluoroscopy (real-time X-rays) to make sure the injection goes into the hip may improve accuracy and outcomes. Special care must be given to keep everything sterile in order to reduce the risk of infection.

It was recently reported that hip replacements due to primary osteoarthritis are less likely among American Hispanics and African Americans compared with whites of European ancestry. People of European descent are the only ones who develop primary osteoarthritis (OA) of the hip.

You heard correctly that individuals who are of African or Asian lineage are much less likely to develop this condition. In fact, according to current research, primary osteoarthritis is completely absent in true Asian and African people. Only those adults who are a mixture of African (or Asian) and European develop primary OA.

Primary osteoarthritis of the hip refers to loss of joint space from a degenerative process affecting the hip joint cartilage. It only occurs in adults 55 year old or older. It is not caused by previous hip problems in childhood like Perthes disease, trauma, developmental dysplasia, or slipped capital femoral epiphysis (SCFE). Other potential causes for the arthritic changes are also ruled out (e.g., rheumatoid arthritis, Paget disease, sepsis).

Naturally, after making this discovery that there is a difference in rates of hip replacement between Europeans and non-Europeans, the scientists started looking for an environmental or genetic explanation. They used data from family and twin studies to look for factors that might explain the European versus non-European differences in rates of hip osteoarthritis. They did not find any environmental risk factor that could account for these differences. But there were some genetic links.

Putting this finding into statistical terms, here’s what they found. Primary hip osteoarthritis is the reason for 65 to 70 per cent of all hip replacements (around the world). And 100 per cent of those hip replacements are in people with European ancestry. Intermarriage among Europeans and Asians or Africans eventually (over 20 generations) results in the same risk for osteoarthritis as among those who are 100% European.

Based on Medicare data for hip replacement surgeries, African Americans account for only half the number of joint replacements. Their ancestry consists of 20 per cent European DNA. American Hispanics with 50 per cent European DNA have up to one-half the rate of hip replacements as European-descent whites.

The lower rate of hip replacement among African Americans may be an indicator of differences in health care by race. Studies show that African Americans have just as much hip osteoarthritis as white (caucasian) Americans. But with only half as many hip replacements, the search is on for why the discrepancy.

There may be an environmental factor but this has not been identified yet. More study is needed to sort through all the possible reasons for these differences. The ultimate goal is to find ways to prevent osteoarthritis — and in populations with equal disease, provide equal treatment regardless of race or ancestry.

It turns out that primary osteoarthritis is considered a genetic disease — but only among people of European descent. People who are of African or Asian lineage are much less likely to develop this condition. In fact, according to recent research findings, primary osteoarthritis is completely absent in true Asian and African people. Only those adults who are a mixture of African (or Asian) and European develop primary OA.

Primary osteoarthritis of the hip refers to loss of joint space from a degenerative process affecting the hip joint cartilage. It only occurs in adults 55 year old or older. It is not caused by previous hip problems in childhood like Perthes disease, trauma, developmental dysplasia, or slipped capital femoral epiphysis (SCFE). Other potential causes for the arthritic changes are also ruled out (e.g., rheumatoid arthritis, Paget disease, sepsis).

Naturally, after making this discovery that there is a difference in rates of hip replacement between Europeans and non-Europeans, the scientists started looking for an environmental or genetic explanation. They used data from family and twin studies to look for factors that might explain the European versus non-European differences in rates of hip osteoarthritis. They did not find any environmental risk factor that could account for these differences. But there were some genetic links.

Putting this finding into statistical terms, here’s what they found. Primary hip osteoarthritis is the reason for 65 to 70 per cent of all hip replacements (around the world). And 100 per cent of those hip replacements are in people with European ancestry. Intermarriage among Europeans and Asians or Africans eventually (over 20 generations) results in the same risk for osteoarthritis as among those who are 100% European.

Curiously, having osteoarthritis (OA) in any part of the body (e.g., hip, knee, hand) does NOT increase the risk of developing arthritis in any other part of the body. So having hip OA does not mean you will be getting knee arthritis later (or vice versa). But if you are of European ancestry, having a family member develop osteoarthritis does increase the likelihood that you might develop it, too.

According to a recent review article by a group of orthopedic surgeons from The Ohio State University, satisfaction rates with hip and knee replacements are good-to-excellent for most patients. Satisfaction with results has steadily improved over the years thanks to modern surgical techniques, surgical tools, surgeon expertise, and overall improved care.

However, anyone going into surgery of any kind must be aware that problems can develop. Just what are the risk factors that put patients in danger of complications, problems, and adverse events associated with total hip arthroplasty (THA)? Heart disease is the number one health problem that complicates elective surgery.

Three-fourths of all major problems after joint replacement surgery (hip or knee) are directly linked with the cardiovascular system. High blood pressure, blood clots, valve disease, heart attacks, previous history or heart surgery such as the implantation of a stent or balloon angioplasty top the list of significant (and potentially life-threatening) risk factors.

Other health conditions surgeons must watch for in patients considering total hip replacement include rheumatoid arthritis (RA) with psoriasis (skin lesions increase risk of infection, drugs for poor wound healing), organ transplantation, alcohol abuse, HIV, obesity, blood clotting disorders, and eating disorders or malnutrition. Even things like dental disease (cavities, abscesses, gingivitis) can put you on the sidelines.

And there’s more! Tobacco use (especially smoking), kidney disease, sleep apnea, history of cancer, long-term use of steroid medications, diseases of the blood vessels in the legs, diabetes, and lung diseases must all be taken into consideration as potential risk factors. The authors carefully describe the details of each category of risks and the possible influence these factors have on adverse events after hip replacement.

Finally, it may seem like anyone of any age can get a hip replacement. But older age does put adults at increased risk for medical complications (and death) associated with joint replacement. Sixty-five years of age seems to be the cut-off point for low-to-high risk. Risk starts to increase after age 65 to the point that by age 85, the risk of death after hip replacement is nine times higher in adults 85 and older.

Paying attention to risks before agreeing to perform surgery is called risk stratification. This is something surgeons are giving more and more attention to as older adults who have multiple health problems ask for joint replacements.

Having heard all the possible things that can go wrong, please know that surgeons and hospital staff do everything they can to prevent problems and minimize complications. In fact, with the new upcoming pay-for-performance Medicare program to control costs, surgeons will be penalized for poor results and rewarded for good outcomes.

That means patient selection (choosing patients likely to have the best results) will become increasingly important. And the opposite is true, too — identifying patients at increased risk for complications with surgery will dictate who might not qualify for the procedure.

The final challenge for surgeons in this regard is the fact that less than half of all patients who end up with life-threatening complications after surgery have any obvious risk factors beforehand. More studies are needed to provide an evidence-based risk stratification model that can be used to prevent and reduce all post-operative problems, but especially life-threatening complications.

Your safety is your surgeon’s number one priority. Patient satisfaction is important, too. Be sure and have a frank discussion with your surgeon about your goals and concerns so that you can go into this with confidence that everything will be done to meet your expectations.

Many more older adults are choosing joint replacements in order to stay active longer. In fact, it is anticipated that there will be an almost 200 per cent increase in the number of hip replacements done in the United States over the next 20 years.

But not everyone who wants a new hip is a good candidate for surgery or in particular, hip replacement surgery. In a recent review article, surgeons from Ohio State University presented what is currently known about risks related to total hip arthroplasty (THA, another name for total hip replacement). The information they presented may help you better understand what may have happened in your husband’s case.

First, studies show there is up to a 7.4 per cent risk of major problems during or after surgery. And more significantly, there is even a 0.8 per cent risk of death after joint replacement (hip or knee). Patient selection (choosing patients likely to have the best results) is always important in any surgical procedure. And the opposite is true, too — identifying patients at increased risk for complications with surgery will dictate who should be turned away.

Just what are the risk factors that put patients in danger of complications, problems, and adverse events associated with total hip arthroplasty (THA)? Heart disease is the number one health problem that complicates elective surgery. Three-fourths of all major problems after joint replacement surgery (hip or knee) are directly linked with the cardiovascular system. High blood pressure, blood clots, valve disease, heart attacks, previous history or heart surgery such as the implantation of a stent or balloon angioplasty top the list of significant (and potentially life-threatening) risk factors.

Other health conditions surgeons must watch for in patients considering total hip replacement include rheumatoid arthritis (RA) with psoriasis (skin lesions increase risk of infection, drugs for poor wound healing), organ transplantation, alcohol abuse, HIV, obesity, blood clotting disorders, and eating disorders or malnutrition. Even things like dental disease (cavities, abscesses, gingivitis) can put a person on the sidelines.

And there’s more! Tobacco use (especially smoking), kidney disease, sleep apnea, history of cancer, long-term use of steroid medications, diseases of the blood vessels in the legs, diabetes, and lung diseases must all be taken into consideration as potential risk factors.

Finally, it may seem like anyone of any age can get a hip replacement.

But older age does put adults at increased risk for medical complications (and death) associated with joint replacement. Sixty-five years of age seems to be the cut-off point for low-to-high risk. Risk starts to increase after age 65 to the point that by age 85, the risk of death after hip replacement is nine times higher in adults 85 and older.

Paying attention to risks before agreeing to perform surgery is called risk stratification. This is something surgeons are giving more and more attention to as older adults who have multiple health problems ask for joint replacements. Patient safety is everyone’s concern.

But less than half of all patients who end up with life-threatening complications after surgery have any obvious risk factors beforehand. To use a gambling term — that certainly “ups the ante.” More studies are needed to provide an evidence-based risk stratification model that can be used to prevent and reduce all post-operative problems, but especially life-threatening complications such as your husband suffered. We offer our sincere condolences and hope this information may help you.

In the past, there has been a routine practice of prescribing prophylactic (preventive) antibiotics for patients with joint replacements having dental work done. The goal was to avoid infection, which can have serious complications for anyone with a joint replacement.

Bacteria in the mouth can travel through the bloodstream and seems to have a preference for the joints. Once a joint with an implant is infected, serious damage and destruction can occur. Another surgery may be needed to clean the joint or even to remove and replace the implant.

But as you probably already know, the overuse of antibiotics has resulted in stronger, more resistant bacteria called superbugs. And as you have experienced yourself, the destruction of the “good” bacteria in the gut from overuse of antibiotics has other consequences as well (e.g., overgrowth of yeast).

Since only two per cent of the people who have hip, knee, or spine implants develop infections, there has been some concern raised. For example, should everyone with a joint replacement be on preventive antibiotics before having dental work done? Some studies are showing that dental procedures don’t really increase the risk of infection. So the current recommendation is that each patient must be considered on a case-by-case basis.

The challenge for your dentist is to figure out which patients are at increased risk for infection. More research is needed to see if taking prophylactic antibiotics reduces the chances of serious implant complications when certain risk factors are present.

It may be that rates of bacterial infection vary depending on the dental procedure being done. For example, it would seem that pulling a tooth or more invasive procedures might have a higher risk rating. But some people develop infections just from flossing or brushing their teeth (or even chewing, which we do on a daily basis).

Studies looking for individual risk factors (e.g., age, sex, number of dental procedures done) that might explain these differences have yielded contradictory results. Some researchers have looked into various types of antibiotics used to see if that might make a difference. Others have examined the use of different topical antimicrobials (mouth rinses) and how many times it is necessary to use them to prevent infection. Right now, there isn’t enough conclusive evidence to recommend for or against the use of oral antimicrobials.

With so much left unknown (inconclusive, indirect, or inadequate evidence), dentists must evaluate the risks and benefits of each dental procedure for individual patients who have joint replacements. Patients, physicians, and dentists must work together to come to an agreement about what is best for each one and plan treatment accordingly.

You might want to ask your dentist to give you an idea of his or her thinking in your case. Let him or her know your situation and together work out a solution that is best for you.

Surgeons planning a second or revision surgery after the first total hip replacement must consider many factors. The biggest and most important one is bone loss. There are several different reasons for this bone loss. It sounds like you may have bone loss from the radiation treatments. But there are other reasons for implant failure that require revision surgery. Loosening of the implant, hip instability (partial or complete dislocation), osteolysis (bone loss) around the implant, and periprosthetic (around the implant) infection.

As you can see from the list, bone loss is a big problem that must be addressed whenever a second surgery is planned. In fact, it’s not just bone loss but also bone quality or density (called bone stock) that must be considered. And there are different patterns of bone loss from patient to patient. So, it’s never a one-surgery-fits-all kind of problem.

Each patient must be carefully evaluated before surgery (pre-operatively). X-rays and CT scans provide the surgeon with details needed in the planning process. Is there infection that must be dealt with? What’s the patient’s general health? (Is the patient healthy enough to have another major surgery)? How much bone loss was caused by the first surgery? Is there already a leg-length difference that could get worse with a second (revision) procedure where more bone will have to be removed?

Other factors the surgeon must look at include the presence of cement and/or hardware (metal plates, screws, wires) that must be removed; location of blood vessels, nerves, and ureters (tube from the kidneys to the bladder) in relation to the acetabulum (hip socket); and scar tissue from previous surgeries. In your case, any damage from radiation for cancer in the pelvis must be assessed.

The surgeon will look for any differences in leg length from one leg to the other that may need correction. There are different ways to correct this problem such as an osteotomy (removing portions of bone) to alter the angle of the bone or to lengthen the femur (thigh bone). An osteotomy can help make up for significant leg length differences.

With bone loss, it may be necessary to use bone grafting in the reconstruction of the hip. That’s another layer of consideration. The surgeon will try to find ways to aid you in gaining the best results for the longest period of time. If there is severe bone loss, new hip implant may have to be custom made to fit you.

In severe cases, the surgeon has to find inventive and creative ways to attach the implant. When the bone quality is so poor or the defect so large that there’s no place to firmly anchor the component part, a special triflange component is used. This device is specially made to bridge large gaps in the bone.

And to add to the surgeon’s challenge, cost considerations, the ability of your body to create bone ingrowth around the implant to secure it, and the long-term effects of stiff metal interfacing with living bone must all be reviewed and evaluated.

Revision of an original (primary) hip joint replacement can be a complex and challenging procedure for the surgeon, especially when any of the factors affecting the bone discussed here are present. Every effort to manage patient pain is usually made using conservative means before considering revision surgery. And efforts to salvage the joint are thoughtfully considered before recommending revision surgery.

It sounds like your surgeon is reviewing all of these important points and will get back to you with his or her recommendations. Hopefully, this information will help you ask further questions and participate in the decision-making process.

Hip Joint replacements are becoming common place these days. Last year, there were 300,000 total hip arthroplasty (THA) procedures done in the United States. And that means an anticipated higher number of revision (re-do or second) surgeries. Surgeons planning a second or revision surgery after the first total hip replacement must consider many factors. The biggest and most important one is bone loss.

But to better understand your mother’s situation, it might be helpful to know why a revision surgery is planned. The major reasons primary (first or original) hip replacements fail requiring revision surgery include 1) aseptic (without infection) loosening, 2) hip instability (partial or complete dislocation), 3) osteolysis (bone loss) around the implant, and 4) periprosthetic (around the implant) infection.

As you can see from the list, bone loss is a big problem that must be addressed whenever a second surgery is planned. In fact, it’s not just bone loss but also bone quality or density (called bone stock) that must be considered. And there are different patterns of bone loss from patient to patient. So, it’s never a one-surgery-fits-all kind of problem.

Each patient must be carefully evaluated before surgery (pre-operatively). X-rays and CT scans provide the surgeon with details needed in the planning process. Is there infection that must be dealt with? What’s the patient’s general health? (Is the patient healthy enough to have another major surgery)? How much bone loss was caused by the first surgery? Is there already a leg-length difference that could get worse with a second (revision) procedure where more bone will have to be removed?

Other factors the surgeon must look at include the presence of cement and/or hardware (metal plates, screws, wires) that must be removed; location of blood vessels, nerves, and ureters (tube from the kidneys to the bladder) in relation to the acetabulum (hip socket); scar tissue from previous surgeries; and damage from radiation for cancer in the pelvis.

Every effort to manage patient pain after hip replacement is made using conservative means before considering revision surgery. When the problem is infection, other treatment should be tried first (e.g., antibiotics, debridement). When weakness is causing pain and difficulty walking, physical therapy should be provided. But in the end, when all other efforts to salvage the joint fail, revision surgery may be necessary.

If your mother will allow it, perhaps a visit with her to the surgeon’s office may help answer your questions. There’s nothing wrong with exploring all treatment options before a second operation and she may need and appreciate your concern on her behalf.

As you have discovered, when joint replacements are put in place, they can be cemented in place or the surgeon can use a cementless type that fills in with bone. Both are still commonly in use but many surgeons have switched to all cementless. They made this switch to avoid implant loosening, which is more common with cemented implants.

Loosening aside, the question of whether cemented survive longer (and better) than cementless has come up many times. We found a big study looking at all the published articles (called a systematic review) combining data from many smaller studies, (called a meta-analysis) may provide some answers.

Researchers from the Rothman Institute of Orthopedics at Thomas Jefferson University Hospital in Philadelphia took the time to examine the literature and analyze the combined results. Out of 3,488 potential articles, 81 met the necessary criteria to be included.

About half (45) were studies on the long-term results using cementless acetabular (hip socket) components. One-third (29) reported the long-term outcomes of cemented acetabular parts. And the rest (7) compared the two together. All acetabular implants were made of polyethylene (a type of plastic).

Although this study only looked at cemented versus cementless implants, it is clear that whether or not a component part survives (and how long it holds up) isn’t only dependent on the cemented versus cementless factor. There are other variables that can affect acetabular survival.

Some are based on the component itself such as surface finish, how long the polyethylene itself lasts (i.e., shelf life), and the method of sterilization for the component part. Some are patient-based influences including bone quality, patient activity level, and patient size (body mass index). And there are surgeon-based factors (e.g., level of experience and expertise, type of surgical approach used for the procedure).

Very few of the articles of high enough quality to be included adjusted or controlled for these other variables. That is a major limitation in answering the question of how using a cemented versus cementless implant compares when it comes to survivorship. There are just too many other variables that could be making the difference.

With that fact in mind, you will want to know there were no major differences observed in revision rate between these two types of implants (based on the cement versus no-cement factor). And revisions because of aseptic (without infection) loosening were equal between the two groups. However, more cemented acetabular components were still in place 10 years or more after implantation indicating longer survivorship of the cemented cup.

Age may be something important to consider. When comparing revision rate between cemented and cementless cups, they found an interesting phenomenon. Younger patients did better with uncemented cups. Older patients had better results with the cemented cups.

The results of this systematic review and meta-analysis suggest that despite improvements in cementless implants, their durability and survivorship doesn’t match cemented implants. Thus, the literature does not yet prove the superiority of the cementless acetabular component over the cemented type.

There have been many controversies and debates over post-operative effects from cemented implants for total hip replacements. Revision rates and survivorship have been compared recently for cemented implants versus cementless implants. It appears that cemented implants may last longer than cementless ones. Perhaps long enough to form bone osteolysis in the nearby bone.

Bone osteolysis and neurologic problems from the cement have been explored in the past, so we have some information to offer about this. Osteolysis refers to the breakdown or dissolving of bone. For some time, it was thought that perhaps the cement used to hold hip replacement implants in place was responsible for pelvic osteolysis. This problem was referred to as “cement disease.” But over time, studies showed that bone osteolysis developed just as often in patients who had cementless components.

Eventually, it was discovered that wear on the polyethylene (plastic) cup used to replace the hip socket was part of the problem. Increased fluid flow into the joint causing expansion forces in the joint was determined to be another factor contributing to bone osteolysis around the hip replacement.

There may be other factors involved with your particular cadaver. But without full medical records, this is only conjecture and speculation.

FAI refers to femoroacetabular impingement (FAI). Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. Femoroacetabular tells us the impingement is occurring where the femur (thigh bone) meets the acetabulum (hip socket). There are several different types of impingement. They differ slightly depending on what gets pinched and where the impingement occurs.

Repetitive pinching of the labrum (rim of fibrous cartilage around the hip socket) can lead to more injuries of the joint and eventual arthritic changes. The condition affects many athletes who are interested in getting back to a pre-injury level of sports participation.

Many orthopedic conditions can be treated conservatively (without surgery) and that is often the first step with femoroacetabular impingement (FAI). Antiinflammatory medications are often prescribed. Activity modification is advised. Exactly what and how to change your activities is usually determined by a physical therapist.

The therapist also helps the patient regain soft-tissue mobility, hip muscle strength, neuromuscular control, and postural balance. Core training, adjustments in posture, and improved control over movements can cause changes in spinal and pelvic alignment. Even small improvements in the position of the lumbar spine and pelvis can reduce the amount of impingement present.

Currently, there aren’t enough published studies providing evidence that nonoperative management of this condition is effective. That doesn’t mean it isn’t helpful — we just need more research in this area to prove it. Patients who have a favorable outcome are pleased with the results and report high patient satisfaction. Treatment failure is most common among patients with significant early osteoarthritis.

If nonoperative care does not yield the desired results, then surgical correction is an option. Surgery can be done with an open incision or with the less invasive arthroscopic approach. The surgeon’s choice depends on the patient’s age, type and severity of impingement, and amount of damage to the hip cartilage. The main objectives of surgery are to relieve pain, improve function (including return to daily and/or sports activities), and prevent hip arthritis.

Femoroacetabular impingement (FAI) is probably the most common cause of early cartilage and labral damage in the hip of young athletes complaining of hip pain. The ability of these areas to heal is limited by the lack of blood supply. Early intervention is important to avoid early joint degenerative changes and arthritis.

Treatment (whether conservative or surgical) can help correct the problem, thus relieving pain and preventing further damage to the hip joint. With correct treatment early on, up to 90 per cent of athletes affected by FAI can return-to-sports successfully.

FAI is probably the most common cause of early cartilage and labral damage in the hip of young athletes complaining of hip pain. But it’s not really new — it’s just that the condition has been given a name that your father may not have heard used.

Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. Femoroacetabular tells us the impingement is occurring where the femur (thigh bone) meets the acetabulum (hip socket). There are several different types of impingement. They differ slightly depending on what gets pinched and where the impingement occurs.

There is new information to suggest that recognizing, understanding, and addressing dynamic and static mechanical factors associated with FAI is a key to successful treatment results. Dynamic factors include the loss of normal structure and joint mechanics that cause the pinching. But other associated dynamic mechanical factors are being highlighted for the surgeon’s consideration.

These include the extra-articular (outside the joint) factors associated with impingement. This can include anatomic changes such as femoral retroversion, femoral varus, trochanteric impingement, and impingement of the anterior inferior iliac spine.

Static factors (the way the hip is formed) cause increased abnormal stress and uneven load between the femoral head and the hip socket during standing activities. These include hip dysplasia, femoral anteversion, and femoral valgus. In many cases, there are combined patterns with both dynamic and static effects contributing to injury patterns with FAI.

Many orthopedic conditions can be treated conservatively (without surgery) and that is often the first step with femoroacetabular impingement (FAI). A physical therapist helps the patient regain soft-tissue mobility, hip muscle strength, neuromuscular control, and postural balance. If your painful symptoms are not relieved by this approach or if the X-rays show progressive degeneration of the hip, then surgery may be required.

Surgery can be done with an open incision or with the less invasive arthroscopic approach. The surgeon’s choice depends on the patient’s age, type and severity of impingement, and amount of damage to the hip cartilage. The main objectives of surgery are to relieve pain, improve function (including return to daily and/or sports activities), and prevent hip arthritis.

With correct treatment early on, up to 90 per cent of athletes affected by FAI can return-to-sports successfully. The important ingredient to successful surgical treatment is careful attention to all aspects of the deformity. This includes recognizing static and dynamic mechanical factors (often present at the same time) and addressing them during the surgical procedure.

Osteolysis or bone loss after total joint replacement (knee or hip) can be a problem. Tiny flecks of bone and debris from the backside of the implant lead to osteolysis. Over time the implant can come loose or the bone can fracture.

Not everyone with osteolysis has symptoms (pain, swelling, loss of motion), especially early on. The only way to know for sure if there is any bone loss is to take an X-ray. Osteolytic lesions look like someone took a bite out of the bone. But X-rays are only a two-dimensional view of a three-dimensional object. So although they show there is a problem, X-rays aren’t enough to tell the surgeon the full extent of the defect. More advanced imaging (CT scans or MRIs) may be needed.

Routine screening for osteolysis is recommended starting five years after total hip arthroplasty (THA or replacement). Follow-up X-rays are advised every two to three years after that for as long as the patient has the implant. Anyone at risk should be monitored even more closely.

The patients at greatest risk of osteolysis are those who are younger and more active. Men tend to fall into this category more often than women. Because this type of osteolysis is linked with wear debris, it takes time to develop. That’s why routine screening isn’t recommended until five years out. And, of course, as more time passes, the risk increases.

Certain types of implants are more likely to shed metal debris with use. The first ultra-high molecular-weight polyethylene (UHMWPE) implant components (parts) used tend to wear out faster than the newer highly cross-linked UHMWPE implants. So anyone with the conventional UHMWPE should be assessed for sure.

What happens if osteolysis is detected? Well, no immediate treatment is needed. The patient is followed more closely (every four to six months) instead of every two or three years. If there are signs that the lesion is getting larger or worse, then the patient may be a candidate for surgery. Serial (repeated) X-rays shows the rate of progression (how fast and how much worse the osteolysis is developing).

With the newer materials for hip implants, the risk of osteolysis is less. Talk with your surgeon about your concerns for this (and other) potential problem(s). It’s good to be realistic about what to expect but remember, most of the things we worry about never happen.

You are exactly right and thank you for the warning. All patients should be aware that the risk of osteolysis (bone loss) increases over time after hip (and knee) joint replacements. The main reason for this is wear and tear as a result of an active lifestyle. Men tend to be affected more often than women.

One other risk factor is the type of implant used. Certain types of implants are more likely to shed metal debris with use. The first ultra-high molecular-weight polyethylene (UHMWPE) implant components (parts) used tend to wear out faster than the newer highly cross-linked UHMWPE implants. So anyone with the conventional UHMWPE should be assessed for sure.

Not everyone with osteolysis has symptoms (pain, swelling, loss of motion), especially early on. The only way to know for sure if there is any bone loss is to take an X-ray. Osteolytic lesions look like someone took a bite out of the bone. But X-rays are only a two-dimensional view of a three-dimensional object. So although they show there is a problem, X-rays aren’t enough to tell the surgeon the full extent of the defect.

That’s where CT scans and MRIs come in. Sometimes both types of imaging studies are needed. That’s because they show different structures: CTs scan the bones whereas MRIs are better at showing changes in the surrounding soft tissues.

But does everyone need all of these tests? Not really. The timeline (beginning five years after the patient gets the hip) is the first criteria for testing. Other risk factors mentioned (age, gender, activity level) must be taken into consideration as well.

Anyone who is concerned about this problem and/or who may be at increased risk should talk with their surgeon about their need for follow-up X-rays. Since these kinds of complications don’t develop until five years or more after the joint replacement surgery, earlier screening is not likely necessary.

Defects, holes, or lesions of the articular cartilage (surface of the joint) can be treated with a surgical procedure known as microfracture. The surgeon creates tiny holes in the surface of the joint at the site of the problem area. Blood seeps through from the bone marrow and stimulates a healing response. As you have seen, this technique has been used for the knee.

There have been a couple of small studies reporting results from using this same technique with the hip. Specifically, microfracture was used with full-thickness acetabular cartilage defects.

Full-thickness means the damage done to the surface of the joint went clear down to the bone underneath. These are called osteochondral lesions. Acetabular refers to the acetabulum, the hip socket. In each case, the reason the patients all had this type of damage was because of a condition known as femoroacetabular impingement or FAI. This might be similar to your situation as you described your problem as a “funny-shaped” hip.

Femoroacetabular impingement (FAI) occurs in the hip joint. Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. Femoroacetabular tells us the impingement is occurring where the femur (thigh bone) meets the acetabulum (hip socket).

There are several different types of impingement. They differ slightly depending on what gets pinched and where the impingement occurs. Over time, this pinching or impingement of the labrum can cause fraying and tearing of the edges and/or osteochondral lesions at the impingement site.

There aren’t very many studies reporting the results of using microfracture for hip osteochondral lesions. We found two studies that have been published. The surgeons evaluated the effectiveness of the microfracture treatment by performing a second arthroscopic examination some time later.

In one study of 20 patients with osteochondral lesions associated with femoroacetabular impingement, all but one patient had a good result. The repair tissue was rated as “good quality” and filled in 95 per cent of the defect. The one “poor” result had only one-fourth of the lesion filled in and that with only fibrous cartilage, not true, healthy osteochondral tissue.

In the second study, there were only nine patients but again, 95 per cent fill-in. There have been many other patients who have had this procedure but not with a second-look follow-up arthroscopic examination to see the actual results.

The evidence so far suggests that microfracture for acetabular (hip) cartilage lesions can produce good results. This procedure can be considered for some patients with femoroacetabular impingement who develop painful osteochondral lesions. It is a simple and cost-effective surgical approach to the problem with good results.

Defects, holes, or lesions of the articular cartilage (surface of the joint) can be treated with the surgical procedure you referred to and known as microfracture. The surgeon creates tiny holes in the surface of the joint at the site of the problem area. Blood seeps through from the bone marrow and stimulates a healing response. This technique has been used for the knee and is starting to be used for the hip as well.

Postoperative rehab protocols have not been fully developed since this is a fairly new procedure. But the published studies done so far are using the same principles as with knee microfracture.

Patients are kept on a continuous passive motion (CPM) device for the short time they remain in the hospital. This is usually 24 to 48 hours. The application of cold is also continued until discharge from the hospital to home.

You would most likely see a physical therapist right away in the hospital. You won’t be allowed to put any weight on that leg for the first six weeks while healing gets started. Range of motion exercises for the hip and leg are followed by exercises to improve strength. Six weeks after surgery, you will begin to put partial weight on the leg and gradually increase to full weight-bearing over a period of 10 to 14 days.

Current programs in place keep patients in therapy for three months. Gradually over time the program is progressed to work on endurance and coordination. You can expect to regain full motion, strength, and function during that period of time. Hopefully, the procedure will be successful and you will be pain free as well!

Total hip (and total knee) replacements are becoming commonplace among American seniors. Complications are always a possibility after any surgery. Infection is one of the most common problems. Current studies suggest that up to two per cent (two out of every 100 patients) develop a joint infection after a total hip replacement.

The ideal treatment is with antibiotics early on to nip the problem in the bud, so-to-speak. Most surgeons prefer to put their patients on intravenous antibiotics for six weeks. Since it is difficult to insert the line into the patient everyday to accomplish this, they use something called a peripherally-inserted central catheter or PICC line.

Peripheral lines mean the needle with an opening/plug is inserted up by the collarbone or chest area. A tube called a catheter inserts into the PICC to administer the drug daily. Then the tube is taken off leaving the base unit in place (now plugged up) and ready for the next dose. In many places, the patient can actually self-administer the daily antibiotic. Since this is a six week course of treatment, home care with a PICC line is very helpful.

There has been at least one study done showing that intravenous antibiotics can be given for two weeks and then the patients are switched to an oral (pill by mouth) antibiotic. Early studies show this method is effective and the infection does not return. More studies will be needed before this becomes a standard treatment method.

Tha major concern here is to clear up the infection once and for all. It would be unfortunate to replace the infected joint only to have the same thing happen a second time. Intravenous antibiotics go directly into the blood and are more powerful and effective than the oral (by mouth) pill form. At least that is the current thinking for acute (early on) infections.

An update on the treatment of post-operative infection following hip replacement was recently published that may have some useful information. There are some new developments and advances in this area. One question being investigated is: since there are so many different ways to approach the problem: which treatment gives the best results?

Treatment for this problem is usually surgery including one (or more) of the following procedures: 1) irrigation and debridement, 2) one-stage exchange, 3) two-stage exchange, and 4) resection arthroplasty. Here’s a brief summary about the role and results for each one.

With surgical irrigation and debridement the surgeon uses a saline solution to irrigate or wash away as much of the infection as possible. Then any infectious or dead tissue is removed (debrided). The failure rate for this type of treatment is pretty high, so this treatment method is rarely used by itself.

Instead, the one- or two-stage procedures are combined with irrigation and debridement. Once the surgeon has cleared out the infection, then the implant can be removed, antibiotic treatment applied, and the implant replaced. In a one-stage procedure, this is accomplished in one surgery. The best patient for a one-stage exchange is the person with an acute infection (early after the first surgery to put the implant in). In these cases, there hasn’t been enough time for the implant to form bone around it, locking it in place.

Later infections or chronic infections (infections that have not responded to treatment and are still present months after the first surgery) are being treated with a two-stage procedure. In such cases, irrigation and debridement are done, then a portion of the implant is removed. The surgeon leaves behind the cemented area. This approach helps reduce how much bone has to be removed.

In the two-stage procedure, a special spacer is inserted into the area where the top of the implant has been removed. The spacer keeps the femur (thigh bone) from sliding up into the acetabulum (hip socket). The spacer is covered in an antibiotic. Later (when the infection is cleared up), the spacer is removed, the area is irrigated and debrided, and a new implant is put in place once again.

For all patients regardless of procedure approach, intravenous antibiotics are an essential part of the treatment. Infection after hip replacement can be a challenging problem to treat — especially if it’s not caught early and becomes chronic. The hope is that with newer techniques, post-operative joint infections of this type will respond faster and better with improved outcomes.

We will defer to the wisdom of a recent publication comparing the bearings of today’s choices in hip replacement bearings. In this report, orthopedic surgeons compared the 10-year results when using metal-on-metal bearing versus ceramic-on-ceramic. They also compared the survival rates of these two types of alternative bearings with the more traditional metal-on-polyethylene (plastic) bearings. Each type of bearing has its own advantages and disadvantages.

For example, ceramic materials are at risk for fracture. Metal bearings cannot fracture but they are more likely to loosen requiring a second (revision) surgery. Metal bearings can release tiny particles of metal into the joint, which does not happen with ceramics. Well, to clarify that last point a bit, ceramic debris is possible — it’s just much less than with metal bearings. And the body does not seem to react to ceramic wear particles like it does to the less biocompatible metal debris.

Complications associated with different bearing couples were also reported on in this study. Blood clots to the lungs or in the legs (that could travel to the lungs, heart, or brain) were the biggest concern. Most of the blood clots occurred in patients receiving the metal-on-polyethylene (MoP) implant. But this may not have as much to do with the implant materials as it does with the (older) age of the patients receiving this type of implant.

Other complications were broken down into two main groups: surgical complications (e.g., nerve damage, infection, dislocation, implant fracture) and medical complications (e.g., pneumonia, heart attack, urinary tract infection). Medical complications occurred two and a half times more often than surgical complications.

The need for revision surgery was different among the three types of bearings. Loosening and dislocation were reported in the metal-on-metal group. Fracture of the implant was the main reason for revision of implants with ceramic bearings. Dislocation and infection were reported in a smaller number of patients with ceramic bearings. Metal-on-polyethylene had the least number of revisions due to loosening, infection, or bone fracture around the implant after a fall.

What are some patient recommendations that can be made from these findings? As mentioned, metal-on-metal bearings are more likely to loosen and wear out compared with bearings made of ceramic materials. Therefore metal bearings with polyethylene liners are recommended for older, less active individuals who are going to want this surgery to be their last.

The best bearing surface for younger, active patients will have to be decided on a case by case basis. The surgeon and patient should consider all the pros and cons of the different types of bearings (metal-on-metal, metal-on-polypropylene, ceramic-on-ceramic). The choice of bearings is made according to age, activity level, bone density, and relative risks and advantages of metal-on-metal versus ceramic-on-ceramic bearings. Potential complications must also be examined and every effort made to prevent any anticipated problems.