FAQ Category: Hip

She may have what’s called a periprosthetic fracture of the femur. The femur is the thighbone. Periprosthetic means the fracture is in the bone next to the implant. The fracture is probably just below the implant and close enough to the hip to be generally referred to as a hip fracture.

Sometimes joint implants crack or fracture but these cases are usually referred to as implant failure rather than hip fracture. Fracture of the femur is not uncommon in patients with either a hip or a knee joint replacement.

Advancing age puts the older adult at risk for bone fracture. Many of the problems that come with aging are also risk factors for fracture. Other age-related risk factors include osteoporosis, diabetes, and arthritis. Anyone who is already experiencing problems with balance and falling is also at risk for bone fracture. Medications such as corticosteroids can weaken the muscles and bones putting patients at increased risk for falls as well.

Joint replacements can come loose and fail. Two reasons for this are infection and wear. Antibiotics mixed in with cement used to hold the implant in place have reduced the rate of infection.

Now, the most common cause of loosening is due to wear of the implant surfaces. Tiny bits of metal or plastic called debris flake off the implant. The bone around the implant starts to weaken. On an X-ray, it can look like there are holes in the bone around the implant.

At first doctors thought this problem was caused by the cement used to hold the implant in place. They called it cement disease. Today we know that the microscopic debris from joint replacements irritates the tissues around the implant. The result is a weakening of the bone. This condition is now called osteolysis.

Osteolysis (not cement disease) causes the implant to loosen over time. Movement of the implant inside the bone can cause hip and thigh pain and loss of hip motion. Research is ongoing to find a design for the implant that will stop the problem of osteolysis.

Activity, especially weight bearing is needed to maintain bone strength with or without a joint replacement. But after a total hip, the load and compression from activity becomes even more important.

This is because the implant itself changes the force and direction of load through the bone. The effect is called stress shielding. Studies show that the shape and density of the bone can even change as a result of stress shielding. Bone loss can occur, which would be a problem if your mother ever needed further surgery on that hip.

In general, there are so many health benefits from activity your mother should be encouraged to resume former activities and regain more function. She may need some help in this area. Perhaps there is an exercise group she could attend. Or maybe a membership at a local health club or YMCA would get her going in the right direction.

There isn’t a simple yes/no answer to this question. Many doctors caution their patients to avoid high-impact activities such as running and tennis. There’s some concern that the implant won’t last more than 10 to 15 years. That could mean another surgery on the same hip.

On the other hand, it’s clear that weight-bearing activities are important to maintain good bone strength and density. Studies show that patients who are less active and more sedentary actually lose bone. Bone loss around the implant can cause it to loosen and require revision surgery.

Your husband’s surgeon is probably the best one to ask this question. Knowing the type of implant and surgical procedure used can make a difference, too. When patients are educated and informed about their joint replacements, then they can make the best decisions about activity and lifestyle.

For active, healthy adults, being more active than is advised may improve their quality of life enough to make it worth the risk.

Maybe not! You may have a couple choices. The first is called a hemiarthroplasty. The surgeon removes the round top of the femur (thighbone) and drills out some of the bone down inside the shaft. Then a replacement top and stem are inserted down into the bone.

Or if you are younger than 60 and have good bone stock, you may be able to have a hip resurfacing arthroplasty (HRA). In this operation, just the top or cap of the femoral head is removed and replaced. It’s a lot like having a tooth capped by the dentist.

Your surgeon will be able to tell you both what is possible and what he or she can do. Not all surgeons perform all types of joint implants. Experience is important so it’s a good idea to go with what your surgeon is skilled at doing. If you are a good candidate for a HRA, then you may want to go to a center where this operation is done routinely.

It sounds like your mother had an operation called joint resurfacing. This type of operation has been around since the 1930s. It has come and gone based on problems afterwards and materials available. Most recently, new metals have made it possible to resurface the head of the femur (thigh bone) with good results.

Fracture (usually of the femoral neck) is the most likely complication of hip joint resurfacing. It happens in up to four per cent of the cases. Studies show fracture occurs most often in the first 100 cases done by a surgeon. Fracture rates go down as the surgeon becomes more familiar with this technique.

Causes of fracture are both patient and technique-related. Obesity, decreased bone mass, and arthritis make a difference on the patient side. Anyone with a femoral neck cyst should get a total hip replacement instead of resurfacing. Putting the implant in with too much of a tilt or twist can also result in fracture.

Women seem to have a higher risk of fracture after hip joint resurfacing. The reason for this remains unknown at this time. Short-term results of hip joint resurfacing are good to excellent. Long-term studies aren’t available yet. Total hip replacement may be needed by patient who have a fracture after resurfacing.

Only your surgeon can discontinue the use of your abduction brace. As you said, it is designed to help prevent a hip dislocation. After all you’ve been through, you don’t want to end up with a hip dislocation and another operation.

When the hip is replaced, many of the muscles around the hip are cut. This leaves your joint unstable and at risk for dislocation until everything heals.

Some doctors advise using an abduction brace for daytime wear. Most require an abduction pillow for sleeping at night. Keeping this position prevents the hip from popping out of the socket.

However, some new research has called the use of abduction braces and pillows into question. It seems that patient function is less with these devices. They may not be needed as much as was once thought.

New, less invasive surgery with smaller incisions and less damage to the muscles may be helping. Depending on the type of surgery done, some surgeons are doing away with this device. Even so, it’s best to check with your doctor before leaving the brace off.

You can expect at least as long a stay as before. Sometimes revisions have more complications and require transfer to a skilled nursing facility (SNF) before going home.

Some of the post-operative events depend on the general health of the patient and activity level before surgery. Patients with higher functional level coming into the hospital seem to do better afterwards as well.

It also depends on why he’s having revision surgery. Patients with a loose implant do better than those who have a joint infection. Age makes a difference: younger patients often go home sooner than older ones.

Each patient is different. The therapist will examine you and design a program to meet your specific needs. This can be based on your pain levels, range of motion, strength, and/or flexibility. Your personal goals will be taken into consideration, too.

Recent reports from physical therapists using manual therapy (mobilization and manipulation of the joint) show measurable changes right away. The therapist uses a combination of measures to know when to discharge the patient.

For example, patients are often discharged with a home program when the motion is the same on one side to the other or when the end of the motion feels ‘normal’.

If no change is seen after three sessions, the therapist may send the patient home with an exercise program. Progress may be rechecked in one to three weeks. Patients may decide for themselves if the pain is completely gone and they are able to get back to their daily activities.

Osteoarthritis (OA) is more of a condition than a disease. It occurs slowly over time as the loss of cartilage begins. The layer of bone just under the cartilage starts to harden, a process called sclerosis. Bone spurs start to form around the edges of the joint.

Patients affected by OA report pain, loss of motion, and loss of function. Hip OA can cause pain in the groin, thigh, and upper outer part of the leg. Pain can go from the hip down to the knee. Morning stiffness is common. Patients often have trouble putting weight on the affected leg.

Early identification and treatment may help patients stay active and avoid surgery for years. Exercise has been shown to reduce pain and disability. The use of manual physical therapy combined with exercise seems to give patients greater return of function that lasts longer.

If you haven’t already, talk with your doctor about the various treatment options. Find out what is recommended for you.

This is a good question and one you will want to discuss with your orthopedic surgeon. In general, the old saying applies: “If it’s not broke, don’t fix it.” You could possibly get another 10 or more years of good service from your current implant. Replacing the liner is a fairly simple thing to do compared with removing the implant and replacing it with another.

Your surgeon has probably already taken an X-ray and seen the liner changes. The X-ray will also show the condition of the bone. Good bone health and density is needed before a hip revision can be done.

It’s entirely possible that your joint replacement could last another 10 years (or more) with a new liner in place. Unless your surgeon advises otherwise, the simple liner replacement plan is best.

It may take some time to sort out what’s happening. When tests are negative, a wait-and-see approach can help as symptoms get better or worse naturally. If they get worse, the quality and type of pain or other symptoms may help define the problem. For example, pain that’s worse with activity and better with rest, points to a soft tissue or bone problem.

The doctor can use and repeat certain clinical tests to stress the tendons, bursae, joint, and ligaments. A repeat X-ray may be needed but other more advanced imaging studies may be better. For example, magnetic resonance arthrography (MRA) may help identify problems inside the joint. This is an MRI with dye injected into the joint to show any damage, tears, or degenerative changes of the cartilage lining the joint.

Knowing if the problem is inside or outside the hip joint can be helpful. Injecting a numbing agent into the joint can help answer this question. If the painful symptoms are eliminated with the injection, it’s considered intraarticular or inside the joint.

Sometimes arthroscopy is the only way to accurately diagnose the problem. A long, thin needle with a tiny TV camera on the end is inserted into the joint. The doctor sees what’s going on inside the joint up on a TV screen or monitor. This is an invasive test that requires surgery so it’s not the first test done.

Give your doctor and yourself some time to sort through various clinical tests to rule out one thing at a time. If symptoms get worse and no diagnosis is made, then perhaps a second opinion would be helpful.

Legg-Calvé-Perthes disease affects the hip in young children. For some unknown reason, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed. The bone in this area starts to die. The blood supply eventually returns, and the bone heals.

Patients with Perthes disease are at risk of having osteoarthritis of the hip later in life. Damage to the labrum, a rim of cartilage around the hip socket is common. Many patients with Perthes disease will need a hip replacement.

The more damage there is with Legg-Calvé-Perthes disease, the more problems occur later. As researchers find out more about these hip conditions, earlier and better treatment may make a difference.

If conservative care doesn’t improve your symptoms in two months’ time, then experts suggest surgery as the next step. The torn or damaged labrum is shaved and smoothed down. More advanced techniques may be required depending on the condition of the hip.

It used to be the average age of a total hip recipient was mid-60s or older. Because the typical implant lasts around 15 to 20 years, surgeons waited until patients were older before giving them a total hip replacement (THR).

That policy is slowly changing based on several factors. First is demand. As adults remain active longer, the need for joint replacement earlier is increasing. Second, the materials and methods used with THR have improved dramatically over the last two decades. Better and better long-term results are being reported. The age and type of patients eligible for THR is expanding every year.

According to a large 25-year prospective (looking back) study, the average age of patients getting their first THR has been around 69 years old. The age range was from 24 to 88 and older. If there are no complications, today’s THRs can last 25 years or more.

Some patients report pain, stiffness, and loss of physical function as time goes by. Most aging adults slow down their activity level anyway so the decline in function doesn’t impair their life style. Researchers hope that with improved implants, better long-term results will make it possible to stay active longer.

Long-term studies over 15, 20, and even 25 years are being reported more and more. The revision rate of the earlier implants may turn out to be higher than rates for implants used today. The materials, design, and even the surgery are much improved over even 10 years ago.

One study from the University of Iowa Hospitals and Clinics reported on 357 cases of total hip replacement (THR) done by one surgeon. All patients got the same kind of implant called the Charnley THR. This type of implant was put in using hand-packed cement. Today many implants are cementless or cemented in place with a cement gun for a better fit.

All of the patients still living had the implant at least 25 years. Many of the patients who had died still had the original Charnley implant at the time of their death. About 10 per cent of the patients had to have an implant revision because of infection, dislocation, or implant loosening.

At age 72, your mother’s implant has a good chance of outliving her. Revision or replacement of the first THR may not be needed. The new implant methods reduce pain, increase function, and improve quality of life for most patients.

Hip joint reconstruction can be a complex treatment for patients with developmental hip dysplasia. For someone with hip dysplasia, the acetabulum or socket is usually the problem. A shallow socket often leads to partial or total dislocation.

In young children, the surgeon tries to shape the socket to prevent dislocation. Now as an adult, part or all of the joint can be replaced. You may be a good candidate for an acetabular implant. Partial hip replacement of this type is called a hemiarthroplasty.

The surgeon will remove the socket and press-fit into the space a hemisphere-shaped cup. It’s made of a porous material to allow bone to grow in and around the implant. This helps lock and hold it in place. With a proper shaped socket in place, the head of the femur will stay in place. Further dislocations can be prevented.

Long-term results of cementless acetabular components in patients with severe developmental dysplasia have been tracked. Most patients have excellent results the first 15 years after getting the new socket. After 15 years, the number of patients who have problems goes up.

Hip arthroscopy has actually been around since the late 1980s. As technology has improved, arthroscopy has improved. Hip arthroscopy is easier to do now and less invasive than even five years ago.

Surgeons are starting to narrow down which patients are the best ones to have a hip arthroscopy. It works well for problems inside a joint that has very little arthritis. Any loose pieces of bone or cartilage can be removed with a hip arthroscopy. Tears of the cartilage called the labrum can be identified and repaired.

Other hip conditions investigated and treated arthroscopically include synovial problems, bone lesions, and septic or infectious arthritis. In the future, we may expect to see even more conditions diagnosed and treated arthroscopically.

Research will help show which patients have a good or poor response to this procedure. Patients can be chosen more carefully for a successful outcome.

It may be best for you to start by making an appointment with an orthopedic surgeon. Since some conditions are clearly identified with a physical exam or seen on X-ray, arthroscopy may not be needed at all.

If X-rays were the only imaging tests done, then you may need additional testing. Studies show that 75 percent of patients with hip pain have no X-ray findings. CT scans are used if there’s been an injury and the doctor suspects a bone fragment. Other conditions show up better with an MRI.

Labral (cartilage) tears may be seen best with a special gadolinium enhanced MRI. One other useful X-ray to detect labral tears is a fluoroscopically-guided injection of dye into the hip joint. If your doctor is unable to find the cause and symptoms persist despite conservative care, there’s one more test available.

Hip arthroscopy has been shown especially useful in identifying hip joint problems in young adults who do not have arthritic joint changes. Your next step should be to make a follow up appointment with your physician. Be patient as it may take a little time to find the underlying cause of your symptoms. A step-by-step approach is cost-effective and usually fairly accurate in the long-run.

Reoperations after total hip replacement (THR) are not uncommon. The most common reasons for reoperation are loosening of the implant, repeated dislocation, or bone fracture around the implant.

Most patients report minor trauma before bone fracture. Spontaneous fracture (no known cause) is more likely after revision surgery. Revisions are done to repair or replace the primary (first) THR.

Other reasons for reoperation can include nonunion of the fracture or refracture. Sometimes infection or fracture of the implant can occur.

Researchers are collecting data to help sort out who is at risk for implant failure or reoperation. One way to do this is to create a national patient registry. For example in Sweden, anytime someone has a total hip replacement, the surgeon must report information about the case to the Swedish National Hip Arthroplasty Register.

This registry has three separate databases. Each one collects slightly different bits of information. This allows researchers to group data together for easier analysis. Information can be used to identify who has a reoperation, fracture or refracture, or other complications.

Patient selection, implant choice, and experience of the surgeon all seem to be important factors in THR surgery. Your parents’ situation could be the result of one of these factors — or it could indeed be just a coincidence. We still don’t always know how to tell exactly what caused the problem in order to prevent it.

Several studies have confirmed your observations: the number of femoral (thigh bone) fractures after total hip replacement (THR) is on the rise. There may be several reasons for this change.

First of all, more people are having THRs. Good results from the surgery has also increased the number of people and types of problems that can be helped by THR.

Third, with more people having THRs, the number of revision operations is increasing, too. Patients who have had a THR 20 years ago are still alive and going strong. Increased physical activity decreases the life of the implant. Many of these patients have revision surgery to replace the first implant. Fractures are more likely and more common after revision surgery.

Finally, implant design may be a factor. A recent study from Sweden pointed out the fact that implants with a straight and short stem are more likely to loosen causing dislocation and/or fracture. Complications such as fracture and implant loosening may be further reduced with continued research and improved implant design features.