FAQ Category: Hip

There’s no way to know what’s causing the new onset of right hip pain without an exam and possibly some imaging studies. Anyone with unilateral (one sided) developmental hip dysplasia (DDH) can develop problems on the other side from uneven weight-bearing.

According to a new study from Denmark, it’s also possible you have DDH on the other side but just don’t know it. X-rays don’t always show the subtle changes that occur in the hip anatomy that come with DDH. A transverse pelvic CT scan may be needed to identify bilateral (present on both sides) DDH.

Treatment often depends on knowing the exact cause of a problem. Make a follow-up appointment with your doctor before jumping to any conclusions. It could be a simple mechanical problem that can be treated by physical therapy. You may have the start of arthritic changes that can be treated with medication and exercise.

Developmental hip dysplasia (DDH) is probably present at birth or occurs during development in the early years. A change in the normal anatomy results in a shallow hip socket. The angle or tilt of the femur (thigh bone) and rotation of the femoral shaft (long part of the bone) are also different from normal. The patient is at increased risk of partial dislocation called subluxation or even full dislocation.

According to at least one study, this condition occurs in about five to 13 percent of the adult population. The person may not even know it’s there until pain sends him or her to the doctor for an X-ray.

There is some evidence that dysplastic hips have an uneven load across the joint. The cartilage on the surface of the joint can get damaged directly. Abnormal stresses on the soft tissues supporting the joint can lead to wear and tear of ligaments and cartilage.

Damage to the cartilage around the rim of the socket changes the pressure inside the joint. Synovial fluid that lubricates the joint may leak out adding to the wearing away of the cartilage.

No one is quite sure if these changes always occur or how long it takes before they result in arthritis. One study from Denmark reported no adverse changes even after 10 years of untreated DDH. It may be best to treat the hip conservatively but keep contact with your doctor. Any change in symptoms should be re-evaluated sooner than later to prevent excessive damage.

Comparing the cost of operations like joint replacement from country to country is truly like comparing apples to oranges. First of all, when costs are reported they may include all costs. This can include the surgeon, hospital, anesthesiology, drugs, and rehab. Other registries with collected data don’t include the surgeon’s fees.

There is a difference in costs and billing between private and public systems. National health care is available in some countries, but not all. University hospitals may receive more funding to help offset the more complex patients they see.

And finally, the cost of the implants used varies from country to country. Studies show that at a time when overall hospital costs have gone down, the price of the implants has gone up. Some hospitals are even buying implants by the case to help keep the cost down.

As the number of adults needing joint replacements increases, the total cost is going to go up and up. Finding ways to avoid joint replacements and especially revision surgeries is the next goal of many researchers.

Many surgeons agree that it’s best to try and save the patient’s hip when at all possible. What they don’t want to see happen is a failed fracture repair that has to be operated on again.

In order to reduce costs and save stress on the patient, they try to pick the best operation to fit the patient’s needs at the time. This isn’t always easy to do. If a plate and screws are used to repair the hip (an operation called internal fixation), the fracture might not heal. The blood supply to the hip can get cut off leading to death of the bone called osteonecrosis. If that happens, the bone has to be removed and a hip replacement put in.

The surgeon will take all factors of the patient’s health and living situation into consideration. Will he be going home alone or is there someone who can help take care of him? What is his mental state? Is he at risk for falls and injury because of Alzheimer’s or some other form of dementia?

How old is the patient? How active is he? What is the condition of his bone? Younger, more active patients with good bone quality do better with internal fixation. Older, more brittle-boned patients may do better with a total hip replacement (THR). Studies show that in the long run, THR is more cost effective than internal fixation or a partial hip replacement.

Prosthetic arthritis is a very real condition. It is caused by erosion or damage to the joint cartilage. This type of problem occurs with a joint implant called a unipolar hemiarthroplasty.

The unipolar implant is one of the first type of partial hip replacements designed. It replaces the round head of the femur (thigh bone). It has a stem attached to it that goes down inside the shaft of the femur to hold it in place.

Younger, more active patients are more likely to develop this kind of problem. The implant moving inside the hip socket chips away small pieces of bone and cartilage leading to cartilage erosion also known as prosthetic arthritis.

A newer type of implant was made to try and avoid this problem. It’s called the bipolar prosthesis. Besides the femoral implant, a plastic-lined, metal cup is inserted into the patient’s own natural acetabulum (hip socket). Instead of just the femoral head moving in the acetabulum (unipolar implant), the bipolar allows for two points of motion. The femoral head moves and rotates inside the cup and the cup moves and rotates inside the acetabulum.

The bipolar hemiarthroplasty is more expensive but recommended for active patients younger than 65.

There’s no doubt that bone deficiency after failed total hip replacement is a challenge. However, surgeons say there are several choices at this point. The goal is to save the joint and its function.

Two implants available for this problem include the megaprosthesis and the allograft prosthesis composite. Each one is designed for a specific problem. Patients with large portions of bone removed due to bone tumor may be the best candidates.

The third option is to use a custom-made rod-shaped femoral stem that fits into what’s left of the femoral bone canal. According to a recent study of 16 patients with a problem like yours, there were 15 patients with excellent results. One patient had some problems after surgery that required another operation.

Reconstruction of joints with severe bone loss is a challenge but it can be done. Your surgeon will advise you based on what’s best for you. In some cases, fusion is the final option.

Patients with diabetes are at increased risk of infection in general. This is especially true if you are on insulin or have had diabetes for more than 10 years. Something as simple as pneumonia or a bladder infection can be life-threatening.

Joint infection after a hip replacement can’t be treated with an oral antibiotic. The hip joint has fairly poor blood supply normally. With a hip infection, the blood flow isn’t enough to clean the joint out and restore it to full function. Surgery to flush the joint and remove any debris is usually needed.

Without this kind of treatment, the joint infection can cause loosening and failure of the joint implant. All in all, it’s best to avoid these kinds of problems. The best way to do this is to maintain tight control of your blood glucose levels before, during, and after surgery.

Call your doctor at the first sign of hip joint infection such as hip pain, fever, or a sense of hip popping or clunking. In fact, monitor your health and report any signs of any kind of infection (cough, shortness of breath, frequent urination, painful urination, blood in the urine).

It shouldn’t. Many studies on animals and humans have confirmed that Fosamax, a bisphosphonate drug, helps build up bone. It’s used most often for patients with osteoporosis. But it may have some good uses for patients getting joint replacements.

Early studies on animals show that bisphosphonates used before and after joint surgery can build up and sustain bone growth. Improving bone mineral density helps stabilize the joint and prevent implant loosening.

It’s not clear yet just how this works or how much of the drug is needed. More studies are needed to gauge how long the effects will last. For right now it looks like there’s a good chance that bisphosphonates will extend the life of joint replacements.

You may be experiencing a condition called snapping hip syndrome. In medical terms it’s called external coxa saltans. The sound is caused by the iliotibial band (ITB) sliding over a part of the hipbone called the greater trochanter.

The ITB is a long piece of fascia (a thick layer of connective tissue) attached at the top to a hip muscle. It goes from the hip all the way down to the outside edge of the knee.

In between the ITB and the greater trochanter is a small, round cushion called the trochanteric bursa. As the ITB rubs over the greater trochanter, the bursa tries to cushion the friction. But repeated snapping back and forth can cause inflammation of the bursa called bursitis. When bursitis occurs the patient has both snapping and pain.

The first step may be to ask your dance instructor to watch how you are doing the barre or floor exercises that cause snapping. There may be an acceptable way to change your form. Stretching the ITB may also help. You can find a good series of stretches on-line at: http://www.nismat.org/ptcor/itb_stretch/. Doing something now before a painful response begins is always a good idea!

It’s not uncommon for adults with a hip replacement to need a revision. Bone fracture around the prosthesis (implant) or loosening of the implant can cause the loss of a good prosthesis.

One or both component parts (ball and socket) can start to sink down into the bone. Infection is another possible cause of implant failure.

The ideal situation is to have one hip replacement that doesn’t wear and doesn’t have to be removed and replaced. Loss of bone and shortening of one side compared to the other are often problems for patients like your neighbor. Many need to use a walker, cane(s), crutches, or even a wheelchair that they didn’t need before the revision.

Fortunately this doesn’t happen that often. Only about 10 percent of the patients who need a revision operation are having their third or fourth one. One-third of the patients are undergoing their second revision. Half are having their first revision.

According to a study from Canada, the wait time does not appear to be a risk factor for a poor result. Gender, age, and health are the biggest indicators of outcome.

For example, older men seem to have worse results when a second operation is needed after a hip replacement. Both men and women with other health problems are also at increased risk for more pain and less function after the operation. Diabetes, hypertension, heart disease, and cancer are just a few of the conditions that can contribute to a poor result with revision surgery.

One other factor is important in predicting the outcome of revision surgery for a loose or unstable hip replacement. The level of pain and physical function before the operation are key factors. Higher levels of pain before is often linked with greater discomfort after.

All this aside, your mother may have a perfectly normal recovery with no problems whatsoever. The time she waits may contribute to her deconditioning but shouldn’t affect the results of the revision operation.

The U.S. Department of Health and Human Services (HHS) (a federal or government agency) uses a variety of ways to collect and analyze health care data. There is a special group within HHS called the Agency for Healthcare Research and Quality (AHRQ) that does this job. One of their specific projects is to look at cost and use of health care services.

They use national statistics collected at the state and local level. There are even on-line systems designed to help doctors, hospitals, and clinics report information about patients, care, and costs. Patient information is private so no names or identifying information are ever included.

One of the largest databases on all patients in the U.S. is collected by the AHRQ. It’s called the Healthcare Cost and Utilization Project or HCUP. Information is collected regardless of insurance type, including patients who aren’t insured at all.

Two major factors account for the number of hip fractures in older adults, especially women over age 65. The first is osteoarthritis of the joints — wear and tear on the joints that seems to be part of the aging process for many adults. The second is osteoporosis (brittle bones), which often occurs as a result of menopause for women. Osteoporosis can also affect men in this age group.

Loss of balance and falls are a major cause of hip fractures. There are many risk factors for falls for both men and women. Muscle weakness and decreased reaction time when the balance is challenged are part of the problem. Medications that cause dizziness or dehydration can also contribute to falls.

Sometimes simple household situations can cause problems. For example slippery floors, throw rugs, animals under foot, or stairs without handrails can lead to falls. Problems with vision and hearing so common in older age can add to the risk. Use of alcohol or other substances is another risk factor.

Doctors, nurses, and physical therapists are working together to teach older adults about the dangers and risks that can lead to falls and hip fractures. Osteoporosis prevention for men and women begins with nutrition and exercise early in life. Staying active and doing specific balance exercises can also make a difference.

Both short-term (two years) and long-term (four years) studies show better results with total hip replacement (THR) for older adults who are healthy and active. They have less pain and return to a higher level of function compared to patients who have the hip repaired with internal fixation devices (screws, pins, plates).

Many elderly patients who have internal fixation for hip fracture end up with so many problems, they eventually have the hip replaced anyway. By the time they have two or more operations, their walking ability and quality of life have declined quite a bit.

Decreased activity puts them at increased risk for even more health problems. And they are even at risk for new fractures of the lower extremities. So although it seems like more trouble than it’s worth, hip replacement is advised over internal fixation for patients like your mother.

Many studies show that total hip replacement (THR) for some types of hip fracture gives superior results when compared to internal fixation. Any time screws, pins, or metal plates are used to repair a hip fracture, it’s called open reduction internal fixation (ORIF).

An ongoing study from Sweden compared 53 patients with THR to 49 patients with ORIF. Patients in both groups lived alone and could walk before their hip fractures. All were in good mental and physical health.

At the end of two years, the THR group had much better outcomes compared to the ORIF group. The same results were present at the end of four years. For example 42 percent of the ORIF group had hip complications requiring a second operation. This was compared to four percent of the THR group.

By the time the ORIF group was converted to a total hip, they had lost function, walking ability, and were having more pain than the THR group. Quality of life was also significantly reduced after so much pain, loss of function, and multiple operations.

You’ve just pointed out one of the major problems with self-report as a means of assessing function after hip fracture. Patients often over-report their abilities. Fear of losing their independence may be the reason for their over-inflated answers. Or they may not have made the mental adjustment yet to the change in the level of their daily function because they assume they will get it all back.

A new tool called The Lower Extremity Gain Scale or LEGS may help in this area. Patients must show the nurse or other health care worker that he or she can do nine activities. These include things like reaching for an item on the ground from a sitting position or getting on and off a toilet without help. Other dressing and walking activities are also part of the LEGS tool.

LEGS is a quick and easy test to give. It takes about five to 10 minutes. The patient has to actually do each activity, not just say ‘yes’ or ‘no’ that it’s possible. Each activity is timed. Extra points are given for doing the items without assistance. A low score may suggest the need for home health services including nursing and/or physical or occupational therapy.

You have several options that may help. Ask your father for permission to contact the home health care agency. Let him know gently what your concerns are and your desire to see him get back his full function as soon as possible.

Many patients lose function after a hip fracture. A year later they still can’t walk independently. Recovery of function is a very important part of hip fracture follow-up. But as many doctors and nurses know, asking patients about what they can and can’t do isn’t always the same thing as knowing what the patient is capable of.

Trained health care professionals know what to look for when watching a patient move about even just in the doctor’s office. How does she walk? Does she use a cane, walker, or crutches? How does she use them? The patient who depends heavily on a walker is very different from the person who simply carries a cane around.

Sometimes asking the patient about his or her social life is very revealing. Have you been to church or temple? Have you gotten back to your card parties? Played a round of golf yet?

Think back on the time your mother spent with the doctor. Based on the observations he or she made and/or any questions that were asked, would you still say the doctor didn’t get a good idea of how your mother is really doing?

If you still have concerns, don’t hesitate to contact the doctor’s office and share these with the nurse or physician. This is especially important if you think your mother needs further assistance. Home health or rehab may be needed if she isn’t regaining her former function.

There have been many changes and improvements in total hip replacements (THR) since the 1970s. Some of those are directly related to reducing the number of blood clots. In the 1970s doctors reported a rate of blood clots as high as eight percent. Today it’s less than one percent.

At that time preventive measures weren’t taken. For example, today drugs can be used to thin the blood and prevent excessive clotting. In patients with an increased risk anticoagulants can be used before, during, and even after the operation.

Other measures are also used now. Special elastic stockings and compression pumps are put on each patient’s legs to help pump the blood back into circulation. Leg exercises are also added and patients are up and walking within 24 hours of the operation. All these efforts have been shown to reduce the number and seriousness of blood clots.

Patients even donate their own blood in case a blood transfusion is needed. Doctors make every effort to prevent blood clots from forming or causing problems. Talk to your doctorabout your concerns. Find out what preventive efforts are routinely used in your area.

Don’t feel bad — you’re not alone. Many patients have complained about the TED hose. The very thing that makes them so difficult to get on is why they work so well: they are tight! This is how they provide compression to help keep the blood from pooling.

The ultimate purpose of the TED hose is to help prevent swelling and blood clots. Blood clots called thromboemboli (plural) can be superficial or deep. It’s the deep clots that are dangerous. They can break off and travel to the lungs or brain causing death.

So until the surgeon tells you it’s okay to stop wearing the hose, they are essential and must be used as directed. If you just can’t get them on at all, contact your doctor’s office.

A home health nurse or aid may be able to offer you some guidance and tips for getting them on easier. There is a special device that can be used to help you get started. These are often available at a medical supply store that sells wheelchairs, canes, bathtub chairs, etc.

When it comes to rehab after hip fracture, each hospital has its own algorithm or formula for decision-making. Some of this is based on what services are available. Does the hospital have a rehab unit? Would the patient have to be transferred? How far? Health care coverage (insurance or Medicare) is a factor.

The patient’s status is also very important. Patients with have advanced dementia may not be suitable for rehab. The same is true for someone who was wheelchair bound, weak, and deconditioned before the surgery.

Age is a factor but doesn’t limit patients from receiving services that can help them. For example, studies show patients 85 years old and older are less likely to have a good outcome. But this doesn’t mean that someone in this age range can’t do very well.

It may be best to talk with the hospital social worker assigned to your mother’s case. Find out how they make this decision. The family and family support is a very important part of the discharge planning.