FAQ Category: Hip

Shortness of breath, also known as dyspnea is a common finding in many older adults. It’s usually linked with a heart or lung problem, but not always.

Many hip fracture patients were very sedentary before their fall or fracture. The gradual decline of muscle function and deconditioning affects all the muscles. This includes the heart and respiratory muscles of the trunk.

The combined effects of sedentary lifestyle, deconditioning, and major surgery can cause new symptoms to develop. Rehab itself is probably more strenuous than your mother’s previous activities at home. It’s likely she didn’t do anything that made her short of breath.

Many older adults stop doing activities that bring on a bout of breathlessness. When they start increasing their activity level in rehab the cardiopulmonary system is stressed and dyspnea occurs.

Make sure you report this to the staff. Ask her doctor about it. New onset of any symptom of this type is a yellow flag that must be checked out.

Poor general health and nutrition are two key factors in many older adults’ recovery from injuries and hospitalization. Anemia and low folic acid levels often point to a chronic state of poor nutrition. In other words this has been present for a long time.

Folic acid is a synthetic (man made) form of vitamin B that is often added to food or taken as a supplement. B12 vitamin deficiency is another common nutritional problem in older adults. Because of a decline or complete lack of intrinsic factor in older adults, the intestines can’t absorb vitamin B12.

A recent study of nutritional and other factors affecting outcomes after hip fracture showed that anemia is linked with poor results of rehab. Blood transfusion early on in rehab may not be soon enough. Low levels of folic acid and serum (blood) albumin are also linked with poor results. Albumin is a type of protein in the blood. Measuring levels of albumin in the blood can be used as an indicator of kidney function.

More studies are being done to find out the best way to treat these deficiencies. Talk to your father’s doctor about this. Find out what steps are being taken to correct the nutritional deficiencies. Ask what you can do to help once he is discharged.

If you’ve had some imaging studies it sounds like a physician has started the diagnostic process. The next step is to go back to the doctor. You may need an MRA or magnetic resonance arthrography. A liquid dye is injected into the joint space. This allows the radiologist to see the outlines of the joint capsule that don’t show up otherwise.

One other step is to look inside the joint with an arthroscope. A long, thin needle is inserted into the joint. A tiny TV camera on the end of the tool allows the physician to view the joint.

This doesn’t always work without manipulating the joint first. Manipulation is done while the patient is sedated. The doctor moves the joint through its full range of motion. Some pressure may be needed to break loose any adhesions or bits of scar tissue holding the joint back.

Ask your doctor what your options are given your symptoms, history, and results of early imaging studies.

A functional leg length difference suggests that it isn’t the bones that are the problem. When one leg bone is longer than the same one on the other side, it’s said to cause a structural leg length difference. When they measure out to be the same from top to bottom then it’s called a functional leg length difference. Something in the soft tissue or contractile tissue is the problem. Often this is scar tissue or muscle tightness.

For some people a curve in the spine can cause one leg to seem longer than the other. Patients who have had a hip or knee replacement can develop a functional or structural leg length difference from the surgery. With time and a little attention, a functional leg length difference often resolves.

Careful measurement is needed to clearly identify a structural versus a functional leg length difference. The examiner must use the belly button as the starting point and measure down to the ankle bone on the inside. The same measure is taken on both sides.

Some people use the pelvic bone as the starting point but any pelvic tilt or muscle tightness will give a false reading. X-rays can be used to confirm clinical suspicions. Again careful measurements are needed when using X-rays to guide the process.

Actually it tells us your doctor knows a lot about what happens next. In the months after a hip replacement you’ll be busy with healing, rehab, and recovery. That’s not the best time to do something about a possible leg length difference.

About three to six months after surgery you should start to see a relaxation of the hip and leg muscles. Some doctors won’t even allow the patient to use a shoe insert or shoe lift until a full six months has passed.

Make sure your physical therapist knows this is a problem. The PT can often help bring about a change through stretching and/or strengthening exercises. Ask your doctor again what can be done if there’s still a problem at your six-month check-up.

Most patients like you with a minor leg length difference after a total hip replacement have very few (if any) symptoms. Even a moderate difference (up to three centimeters or 1 inch) is very manageable.

When there’s a severe difference (more than three centimeters) symptoms such as limping, pain, numbness, and loss of balance can occur. In older adults there’s even an increase in the amount of oxygen it takes to walk or do daily tasks using the legs. Changes in lung and heart function start to occur with a two to three centimeter leg length difference.

In the long run a leg length difference can cause the new hip to wear out sooner. Uneven ground reaction forces through the legs to the hips put added stress on the joint and surrounding soft tissues.

Sometimes something as simple as a shoe insert is all that’s needed. You can use up to three-eighths of an inch inside the shoe without changing the shoe or the walking dynamics. Ask your doctor to measure your legs to find out how much correction is needed.

Many people avoid seeing the doctor for what seem like simple injuries that will get better on their own. Often they do get better, but not without a price. Sometimes we end up with less motion and just accept that. One thing leads to another and later another injury pops up. Or we start to have back pain.

With musculoskeletal injuries a little care early on can assure a more normal healing pattern. For example, antiinflammatory drugs can help reduce how much swelling and pain there is. You’ll be able to walk more normally and keep from developing some uneven gait or postural habits.

A short course of physical therapy may also help. You’ll be examined for any muscle imbalances or weakness. Pain free motion can be restored. This is especially important during the healing phases so you don’t end up with a “frozen” hip or hip adhesive capsulitis.

Yes, in fact the first study of nine cases of “frozen hip” or hip adhesive capsulitis has just been reported. All but one of the patients was a middle-aged woman. This is typical of shoulder adhesive capsulitis, too.

Patients had pain and loss of motion in a particular pattern that identifies the capsule as the source of the problem. X-rays and MRIs were normal, making the diagnosis more difficult.

Treatment was with surgical manipulation. Under anesthesia, the hip is gently forced through the full range of motion. Adhesions are torn in the process without injuring the hip. Patients were able to recover full motion and function.

A year later they were still doing well. The author thinks with early diagnosis physical therapy to restore full joint motion may be all that’s needed. Get an early start while you can — check with your doctor or therapist as soon as possible about your hip.

Most likely you would be the ideal resident for an independent living (IL) residency. The basic idea behind IL is a place for older adults who want some assistance with daily living but can live and function on their own.

Each facility has its own guidelines called inclusion criteria. These include being able to care for your personal needs (bathing, dressing, eating) without help. The IL staff does not dispense medication so you must be able to manage your own medical needs. You must be able to move from one area (your room) to another (the dining hall). Having a cane shouldn’t be a reason to exclude you from the facility.

Most ILs have someone who takes care of your laundry and prepares at least two meals a day (often three). Light housekeeping is offered, sometimes at an extra charge. The main building(s) and property are all cared for so there’s no physical upkeep for the residents.

Visitors are always welcome. If you know of a facility near you or near a family member, call and ask for more information. Set up an appointment to talk with the social worker or director. Even if it doesn’t work out now, you can keep that information for future reference.

Some places have quite a waiting list so you may want to get on now. You can always change your mind if an opening comes up and you are no longer interested.

You may be quite right. In a small number of patients after total hip replacement the leg either is longer or seems longer. An X-ray and exam are needed to find out for sure.

If the leg is truly longer than the other one, the doctor will see this on X-ray. Sometimes this can happen because of the implant. Usually the patient has pain along the outside of the hip or around the incision. The pelvis drops on the short side to make up the difference. A shoe lift may be all that’s needed.

If the legs are truly equal in length on X-ray then the problem is considered called a functionalleg length difference. This means the soft tissues around the hip are tight or off-balance pulling the leg up or down. In these cases physical therapy may be helpful. An aggressive program of stretching and/or strengthening may restore limb length and function.

Make an appointment today with your orthopedic surgeon for a follow-up visit. This kind of problem should be addressed sooner than later.

Our sincere condolences to you and your family on your loss. Despite doing all the right things it seems your mother’s death shouldn’t have happened. Sometimes the immune system just isn’t able to hold off the pathogens that cause infections like urinary tract infections…even with antibiotics. All the body’s efforts to hold to a steady state called homeostasis fail and death occurs.

Timing may also be a key factor. Studies show mortality rates are lower when patients are given these two drugs preventively as in the case of your mother. However, if either one is given too late or not long enough, problems can occur. For example antibiotics must begin within four hours of the first incision.

Blood thinners must be given during the entire hospital stay. For some patients prevention must continue after hospital discharge. Lack of mobility is the biggest risk factor for deadly blood clots. Most older adults after hip fracture are in pain and move much less than before.

Even with the best precautions there are still a small number of patients who die due to infections, blood clots, or for unknown reasons. Doctors do everything they can to prevent this from happening.

Osteoporosis and hip fractures rank right up at the top. Experts predict the number of hip fractures per year will keep going up and up as the Baby Boomers age. Anyone born between 1946 and 1964 is a Baby Boomer so this trend is likely to continue a long time.

It’s already big business now. Hip fractures alone cost about eight billion dollars per year in the United States. Surgery, hospital costs, and nursing care are just the start. Half of all adults with a hip fracture can no longer walk alone. One-third becomes totally dependent in a nursing home.

Doctors and health care professionals are working hard to get the word out to help aging adults prevent falls and fractures. For more information on how to prevent osteoporosis and fractures contact the National Osteoporosis Foundation (http://www.nof.org) or the National Center for Injury Prevention and Control at http://www.cdc.gov/ncipc/factsheets/falls.htm.

Antibiotics have an important place when used right. They do nothing to fight a virus and should only be used to prevent or treat bacterial infections. Overuse of these drugs has led to more resistant forms of bacteria.

Doctors agree all patients with hip fractures should be put on preventive antibiotics. Antibiotics are used before or during hip fracture repair to prevent wound and urinary tract infections.

Motor nerve palsy after total hip replacement (THR) is relatively rare. Studies report one to four percent of the cases end up this way. There is some evidence to suggest it’s happening more often than it used to.

A recent study from the Mayo clinic thinks this may be related to the newer uncemented implants. Implant without cement requires more forceful pounding on the bone during the operation. The stress may put extra strain on the nearby nerves.

One other possible cause of the more recent rise in nerve palsies after THR may be the amount of leg lengthening that takes place. There aren’t any studies to show just how far the leg can be lengthened without problems occurring. The Mayo study showed nerve palsies with more than 3.8 cm of length added.

They suggested the nerve palsy can occur with a change in nerve length or by scar tissue forming in the area. Scarring can keep the nerve from gliding and moving even a little bit so that even minor amounts of lengthening become a problem.

Treatment may depend on which nerve was affected and whether you are having sensory or motor loss. There may not be much that can be done for the sensory loss. The motor loss (for example, muscle weakness, foot drop) can be helped but not cured.

Medication can be used to help with any pain. Shoe inserts called orthotics may help support the foot and ankle to help you walk better. For severe pain, neurolysis may be considered. In this operation, the nerve is cut or cauterized so that it no longer transmits messages of any kind.

Nerve repair takes a long time. Even though it’s been six months you may still see some improvement over the next six months. The average time until complete recovery is anywhere from 14 to 21 months. Some patients don’t recover at all. Others gain partial recovery. About one-third of the patients with partial or complete nerve palsy do have complete recovery.

The Mayo Clinic did a study recently that confirms what you’ve found out. They reviewed over 27,000 cases of total hip replacement (THR). >From that study it looks like the number of nerve palsies after THR has gone up since 1989.

The increase is enough to notice but it’s not dramatic. The overall incidence is still very low making this a rare complication.

Surgeons think the reason for the increase in number may be related to two things. First more patients are having hip replacement who wouldn’t have qualified years ago. Today’s newer methods make it possible to do a THR on someone with hip dysplasia or arthritis after a hip injury.

Second the newer cementless implants often require more pounding and hammering to get them in place. This may be too much stress and strain for the nearby nerves.

Complications are always likely when more complex patients with more challenging surgeries are being done. As surgeons become aware of the risk factors, efforts will be made to reduce problems even when they occur only rarely.

Actually, they can keep your leg numb but then you can’t walk on it and movement is important. The same peripheral nerve block used during the operation can be used afterwards as well.

The problem is there’s no way to separate out the sensory from the motor portion of the nerve. The patient’s leg is both numb and unable to move under voluntary control. Injury from an insensate leg is a real concern. And there is a risk for toxicity from the anesthesia to persist.

Patients must be selected carefully for this kind of treatment. Patient education is very important. For patients to go home with continuous nerve blocks there must be close supervision to prevent accidents and injuries.

Studies are underway to find drugs that can do exactly what you suggest. With a time-released capsule, patients could go home under their own steam but with far less pain. Nerve blocking drugs that last 48 to 96 hours would be very helpful.

Magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) are very similar tools. MRA is basically MRI for the joints. It is more accurate in detecting joint problems. MRI can confirm there’s a problem in the joint. MRA shows exactly what is the abnormality.

CT scans work well for bone lesions around the hip. CT scan shows places where the bone might have a tumor, abnormal anatomy, or necrosis (dead cells).

If you ever need surgery on the hip, advanced imaging studies of this type are very important. The more details the surgeon can see ahead of time, the better the surgical plan with no (or very few) last minute surprises.

Playing soccer may not be the issue. Studies show it’s the sports injuries players get that increase the risk of osteoarthritis. Ankle and knee injuries are common among soccer players. Since these two joints are in a direct line-up with the hip, it makes sense that such injuries can lead to arthritis later.

Another risk factor for injury and thus arthritis is left-leg dominance. At this point we know more about what isn’t a risk than what is. In studies of soccer players ages 12 to 18, there was no apparent increase in risk of injury linked with body size or type, balance, strength, or flexibility. Preseason play didn’t seem to make a difference either.

Good question and of course, it probably varies from person to person. The first thing to find out is if the problem is something that can be fixed with another operation. Perhaps the surgeon has already told you the implant needs revision.

In some cases patients wait so long to have the hip replacement that they can’t recover fully. More surgery may not make a difference. In other cases, the problem isn’t with the new implant. The person may have spinal stenosis or some other low back problem causing referred pain to the hip.

When a patient’s quality of life or activity level is severely affected, then something needs to be done. Pain can disrupt daily activities and lead to further problems. If you haven’t seen the orthopedic surgeon who did the first operation, it would be a good idea to make an appointment now before things get worse.