FAQ Category: Hip

You may be experiencing a condition referred to as hip instability. Hip instability can include subluxation (partial dislocation), complete dislocation, and microinstability. The last classification (microinstability) is just what it sounds like — too much looseness in the joint but without a big enough shift in hip position to cause a subluxation.

Many people with hip instability have a known etiology (cause). It could be from a stretching of the ligamentous joint capsule that helps hold the hip in the socket. Or a tear in the labrum (fibrous cartilage around the rim of the hip socket). If there’s no known history of injury, then the condition is referred to as atraumatic (without trauma) instability.

With atraumatic hip instability, there may not be a specific injury but there is still usually a reason the problem develops. There could be an underlying systemic disease affecting the soft tissues (e.g., Ehlers-Danlos, Marfan, or Down syndrome). Abnormal anatomy of the bones or soft tissues could also contribute to the problem.

Whether or not you should be putting weight on that leg after a dislocation event is something many experts debate. Studies don’t show that weight-bearing leads to loss of blood supply to the hip — or even to another hip dislocation.

Even so, the best thing is to see an orthopedic surgeon and have him or her take a look at what’s going on. There may be a simple explanation and treatment for the problem. There may be an anatomical explanation for what happened (e.g., perhaps you have a shallow hip socket from birth or loose ligaments that have gotten overstretched).

Whatever the cause, the goal is to prevent further hip instability (dislocations). You may benefit from a short course of physical therapy. Even with hip capsular laxity (looseness), physical therapy to improve core (trunk and abdominal) strength can be helpful. But the first step remains to find out what’s going on and why this may have happened. Once that information is obtained, the course of treatment will follow.

According to a report from Italian orthopedic surgeons, hip replacement in adults who had Perthes disease as a child is technically challenging and difficult. But the procedure is entirely possible and good results can be expected!

In this study, the average age at the time of the hip replacement was 37.8 years. Patients included were as young as 19 up to 65 years old. The surgical success rate was impressive with 96.9 per cent implant survival after 15 years. Test scores for hip function were much improved from before to after surgery.

There were some complications with an overall complication rate of 12.5 per cent. Most of the post-operative problems occurred as a result of the procedure itself. There were two patients who developed permanent sciatic nerve palsy when the involved limb was lengthened surgically.

One patient had a hematoma (pocket of blood) that had to be drained surgically. And the femur (thigh bone) fractured in one other patient as the implant stem was being placed down inside the bone.

The authors concluded that hip replacement in adults who had Perthes disease as a child is possible. That’s good news for those who develop severe, disabling hip arthritis in their early adult years.

As the study showed, it requires experience and expertise on the part of the surgeon to perform this procedure. Much preoperative planning goes into a procedure like this. Careful examination of the patient and evaluation of imaging studies (X-rays and CT scans) is required. Patients face some risks of complications but if the people in this study are any indication, most will be satisfied with the reduced hip pain and improved hip function.

Legg-Calvé-Perthes disease (Perthes) is a rare disease that most often affects boys between the ages of 2 and 12. Girls can have LPD. The hips are the main problem. Sometimes both hips are involved, but usually only one side is affected.

With Perthes, blood flow to the ball of the hip is stopped and bone death (necrosis occurs. As necrosis spreads, the ball develops a fracture of the supporting bone. This fracture signals the beginning of bone reabsorption by the body. As bone is slowly absorbed, the body tries to replace it with new tissue and bone.

Degenerative osteoarthritis can occur with age in adults with Perthes. It seems to depend on two things. If the ball reshapes itself and fits into the socket, arthritis is usually not a concern. If the ball does not reshape well, but the socket’s shape still conforms to the ball, mild arthritis occurs in later adulthood. A flattened ball and shallow socket create the most significant problems later.

Total hip replacement is a challenge because of the odd shape of the hip and leg length differences. The surgeon must work around multiple different deformities affecting the femoral head and hip socket. Changes in the bone and soft tissues around the hip as a result of previous surgeries can also be a problem. Disruption of bone growth often results in a short femoral neck. Scar tissue can pose some technical pitfalls.

These challenges have not kept surgeons from trying to improve the total hip replacement procedure for patients with Pethes who develop secondary hip osteoarthritis. With some creative modifications (aligning femoral stems and placing cups on the socket side at just the right angle), it is possible to restore good hip biomechanics.

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

Because the hip resurfacing removes less bone, it may be preferable for younger, more active adults. A good candidate for joint resurfacing is someone who may need a second, or revision, hip replacement surgery as they grow older and wear out the original artificial hip replacement.

There haven’t been very many studies reporting long-term results following joint resurfacing for patients with Perthes disease. Surgeons are exploring this management approach because it saves bone, and increases hip motion. Converting to a total hip replacement later is also possible.

The downside may be that hip resurfacing won’t be able to restore normal joint biomechanics. If there is a leg length difference from childhood, then a hip replacement may be a better choice. Hip resurfacing can’t even out the length differences whereas a hip replacement can even out some of the difference.

Likewise, deformities of the hip aren’t as easily handled with joint resurfacing. You may end up having more than one surgery if things don’t work out as expected. The decision isn’t an easy one. Your surgeon is the best person to advise you. X-rays, CT scans, and other imaging studies may help shed some light on what is possible based on the shape and severity of any hip deformities.

Of course, there is always variability among groups of seniors following any surgery. In the case of recovery following total hip replacement, it appears there are two phases. The first occurs 12 to 15 weeks after the procedure. Rapid change in pain, motion, and strength occurs in the first three months and then starts to slow between 15 and 20 weeks.

By the end of four months, most patients have been discharged from treatment. They are well on their way to resuming all physical activities and exercise they are interested in. Thirty (30) weeks (seven and a half months) later, patients experience another leveling out as they are now able to walk again at a normal pace.

Physical function involving the legs continues to improve though at a much slower pace than early on. Balance and postural stability seem to take longer to recover. More physical therapy with a supervised rehab program may still be needed if you have not experienced good improvement or the results you expected.

Don’t be afraid to ask your surgeon how you are doing compared to others. If it seems (to you or to your surgeon) that you have fallen behind the expected time for recovery, it may be time to reevaluate or reassess your progress and perhaps alter the rehab program. Limping, loss of balance, and falls are three clear signals that you may need additional therapy to fully recover.

You’ll be relieved to know that the most common question patients have after hip replacement surgery is: “How am I doing compared to everyone else?” This seems to be the result of a natural human tendency not necessarily based on how competitive you are.

Most patients ask their surgeon or physical therapist this question sometime during the postoperative period. With information from a new study on recovery following a total hip replacement, there are some ballpark answers to this question.

For example, it appears there are two phases to recovery. The first occurs during the 12 to 15 weeks following the procedure. Rapid change occurs in the first three months and then starts to slow between 15 and 20 weeks.

By the end of four months, most patients have been discharged from treatment. They are well on their way to resuming all physical activities and exercise they are interested in. Thirty (30) weeks (seven and a half months) later, patients experience another leveling out as they are now able to walk again at a normal pace.

Physical function involving the legs continues to improve though at a much slower pace than early on. Balance and postural stability seem to take longer to recover. If you continue to follow the exercise program prescribed by your physical therapist, then by the end of 12 months (one full year), you should be fully recovered.

At that point, hip muscle strength, joint motion, and leg function should test within normal limits for your age. Patients who quit doing their exercises too soon often have muscle weakness and report falls two years after hip replacement.

The therapist can use several tools to measure how you are doing. A popular (valid and reliable) test of physical activity is the six minute walk test (6MWT). In this test, how far you can walk (and how fast) in six-minutes is measured.

For both men and women after total hip replacement, the peak distance walked occurs around that 30-week postoperative timeframe. Women don’t walk as far as men and their early recovery time is a little slower but in the end (a year later), walking ability evens out between the sexes.

Other measures may include whether or not you still need a walking aid (e.g., walking sticks or cane), your pain level, and how much medication you are still taking for pain. How well you can go up and down stairs is a functional skill of importance. Your ability to carry out daily activities may also be examined closely.

You can use these known guidelines to establish your own goals and check your recovery against the average. More physical therapy with a supervised rehab program may still be needed if you have not experienced good improvement or the results you expected.

Setting too high of expectations can discourage you — especially in those early weeks of recovery. Just compete against yourself rather than against others who may be ahead or behind you for specific (individual) reasons. Adopt a “can do” attitude, follow your therapist’s and surgeon’s advice, and give yourself the time you need to recover.

You didn’t say what went wrong with your father’s surgery and/or hip implant so we can’t comment on how things might be different for him if he had the same surgery today. We can tell you that over the last 25 years, many improvements have been made in hip replacement surgery.

Combined together, these changes have made this procedure much more successful resulting in a stable hip and a fairly easy recovery for the patient. Of course, any surgery has the risk of potential problems and complications. Your surgeon will go over these with you during your pre-operative visit.

Tell your surgeon about your fears, worries, and concerns. Being calm as you enter surgery is always better than being stressed-out and exhausted from your worries. Ask him or her to show you the type of implant that will likely be used. A mini-lesson on the advantages and benefits of the chosen replacement might also allay your worries.

Basically, there are six separate groups or classifications of hip implants. All six types have equally good rates of survival and success. By name, these include: 1) single wedge, 2) double wedge, 3) tapered, 4) cylindrical, 5) modular, and 6) anatomic. The tapered implant has three separate types: round, cone, or rectangle (referring to the top of the stem that fits into the round ball that replaces the head of the femur).

Each of the unique design features of these six types has important characteristics and purposes. The surgeon chooses the implant design that is best for each patient on a case-by-case basis. The different shapes allow for different areas of bone-to-implant fixation needed for a stable unit.

The shape of the stem (whether tapered, round, curved, or straight) also influences bone-to-implant fixation by changing the contact points between these two surfaces. For example, tapered stems are wider at the top and narrower at the bottom. Bone fixation is greater at the top where there is more surface to latch onto.

The bottom-line is like you, all patients want a hip replacement that is sturdy, strong, and holds up for many years. Both surgeon and patient want to avoid implant loosening, sinking down into the bone, or breaking. The overall goal of all implants (no matter what their design) is to make contact with the bone and stabilize the joint.

Probably the thing that has changed the most in the last 15 to 20 years is the shift from cemented to cementless implants. Around about 1995, the National Institutes of Health (NIH) said the research showed using a hybrid implant with one part cemented in and one part cementless was the way to go.

Gradually, with improved designs, materials, and surgical techniques, surgeons are now using completely cementless joint replacements in up to 90 per cent of all cases. Sometimes bone loss from osteoporosis and/or deformities dictate the use of a specific type of implant design and cemented fixation. But otherwise, there are six basic designs to choose from and all have equally good results.

With your previous surgery, these two factors (condition of the bone and alignment) may be critical or important enough to guide a specific implant choice. Your surgeon will be able to make that determination based on physical examination, X-rays, MRIs and/or CT scans.

It doesn’t happen very often but sometimes patients who have a total hip replacement end up having a second or (more) revision surgeries because of a failed implant. Even more rare is the occasional revision surgery that fails. And any number of failures (no matter how few) are unacceptable to the surgeon as well as to the patient.

Studies have shown that certain risk factors are linked with stem fracture. The most common of these factors are being overweight, high levels of physical activity, and malposition of the first implant. Implants have improved in design to help counter these problems but there are still a few now and then.

As you suspected, there are other possible risk factors to consider. For example, poor bone structure that cannot support the junction area of the stem might be an issue. Sometimes the problem is within the implant itself. With the modular implants, there are three separate pieces that fit together. The body, neck, and stem are held together with a modular connection and that connector has a taper junction and an engaged-fit junction.

Femoral stem fractures can occur as a result of a problem at these modular junctions. Implant manufacturers have worked with surgeons to find a design strong enough to withstand the forces at the intersection between two component parts.

When broken implants have been removed, they have found visible evidence of wear and tear on the implant stem near the junction. Fractures just above the body-stem junction (hidden under the main body of the stem) seem to be the most common. A force strong enough to bend the stem at that point contributes to fractures of this type.

The surgeon who removes your broken implant will be able to examine it carefully and see what might have caused the problem. The solution may be in choosing a different implant that will meet your specific needs.

You may want to let his surgeon handle this one. Just asking the question at a pre-op appointment may be all that’s needed on your part. If your father has some serious reservations about having the procedure, then it may be best to wait until he is ready for the operation. Sometimes what sounds like complaining is really an inner knowing that the upcoming surgery isn’t the right thing to do for that patient.

In answer to your question about risk factors for serious complications following hip replacement surgery, we can tell you the results of a recent study in this area. The surgeons who were involved with the study looked at the percentage of patients who died within the first 90-days following hip replacement. They also assessed how many patients developed serious joint infections during the first 10-years after getting the new hip joint.

They found a very low rate of complications. For a group of 83,000 Medicare patients, there was a one per cent mortality or death rate and a maximum of two percent for infection. The significance of the study was that it did identify the most important risk factors for both infection and death after hip replacement surgery. The patients were tracked for 10 years after the original surgery.

At the top of the list for joint infection was obesity followed by rheumatologic diseases, blood clots, anemia, diabetes, and heart arrhythmias. Risk factors for mortality (death) in the first three months following the procedure were metastatic cancer, congestive heart failure, dementia, and kidney disease. High cholesterol under control was actually linked with a decreased risk of mortality.

Depression and psychoses have a very limited role in complications following hip replacement. Panic attacks were not listed. Psoriasis might fall into the category of rheumatologic diseases but the diagnosis would be psoriatic arthritis, not psoriasis alone. Although your father has some questionable risk factors, his surgeon is really the one to make this judgment call. Encourage him to speak with his doctor and plan the procedure in the best time period given all the considerations.

We know that patients facing any joint replacement procedure are at increased risk of complications or problems. These adverse events can occur because of something that happens in the operating room or afterwards. The risk of infection, poor wound healing, blood clots, heart attack, and/or stroke increases simply by having major surgery. Other medical problems (referred to as comorbidities) also increase the risk of serious problems associated with the procedure.

According to a recent study, the presence of certain risk factors increases the chances of periprosthetic infection (around the implant) and even death after a hip replacement. In the first 90-days after surgery, up to one per cent of patients die as a result of complications. A slightly higher percentage (up to two per cent) of patients develops an infection in or around the implant during the first 10 years after surgery.

Besides hypertension, heart disease, high levels of cholesterol, and a past bout with cancer head the list of comorbidities that matter for hip replacement patients. And the list goes on: heart arrhythmias, lung disease, urinary tract infection, diabetes, obesity, anemia, rheumatoid arthritis, depression, and dementiahave been found in patients having a total hip replacement.

The same study already mentioned, pinpointed specific isk factors linked with death in the first three months following hip replacement. At the top of the list was the presence of metastatic cancer followed by dementia and congestive heart failure. Many patients had more than one health concern. The risk of combined medical conditions on mortality was not calculated but it is likely that having two of these conditions raises the risk even more.

The surgeons involved in this study agree that the numbers of patients who die in the first 90-days or who develop a hip joint infection in the first 10 years are small but important. That may be why you heard about it on television.

If you ever become a patient in the one to two per cent who develops these serious problems, it becomes a matter of great importance. Surgeons’ attention to these matters is appreciated by all patients undergoing hip replacement.

The choice of implant type, size, and design is usually left up to the surgeon. Many surgeons do discuss their decisions and the various options to choose from. Implant selection depends on a number of different patient and surgeon factors. On the patient side of things, your age, activity level, and the size and condition of your bones will all make a difference.

The type of arthritis you have may also play a role. For example, osteoarthritis is different than rheumatoid arthritis — the underlying causes, progression of disease, and medications used to treat these two conditions vary. And those differences can also have some influence on implant selection.

According to a study from Finland, over the years there have been 106 different stem designs recorded in use. Likewise, 110 different cup designs have found their way into use. Finland has the ability to count such things because they have a computer database called the Finnish Arthroplasty Registry. Almost every patient who has had a joint replacement from 1980 on have been included in this collection of information.

Information on the patient’s age, sex (male or female), diagnosis, type of implant, and surgical approach is entered into a computer database. The information is confidential as to the individual patient names. Having this type of information makes it possible for researchers to examine trends in treatment over time. Changes in surgical techniques, implant designs, and technology have the potential to also change results or outcomes. Keeping track of those changes and trends helps guide continued improvements in patient care.

One major decision is whether to go with a cemented versus cementless implantation. This decision is usually driven by your bone density. More and more surgeons are opting for the cementless type for several reasons. One of the most significant is the fact that removing the implant later (if that becomes necessary) is easier and destroys less bone in the process.

With the new porous surface and tapered stem design, going without cement is possible in patients with weak, brittle (osteoporotic) bones that would otherwise have to be cemented in place to hold them. When it comes time for your next appointment with the surgeon, don’t hesitate to ask what he or she is thinking in terms of an implant type for you.

Keeping track of number and type of joint replacements can be done in several different ways but in the United States, we don’t have every patient entered into a database like some other countries do. We can get information from hospital discharge data and Medicare part B that is helpful. Many times, this is limited to patients over the age of 65. It doesn’t include younger patients or people who have their replacements done in private orthopedic surgical clinics.

Some of the other countries such as Finland do have a national registry. This type of information is routinely collected and has been a clinical feature for over 30 years. Because their patient population isn’t so different from ours (socioeconomic, educational background, lifestyle), we can often make comparisons that could easily apply to our country.

A recent report was published using data from the Finish Registry that might answer your question. They ran a software program that pulled out how many hip replacements were done just for patients with rheumatoid arthritis. The time period information was collected from was from 1980 to 2006.

There were a total of 132,540 primary (first-time) hip replacements in the whole study (all diagnoses such as osteoarthritis, traumatic arthritis, rheumatoid arthritis). Breaking that down by age, the majority of those (86 per cent) were in adults 55 years old or older. That’s approximately 114,600 of the 132,540. And of the people in the 55 years and up group, only five per cent (about 6,000 patients) had rheumatoid arthritis as their main diagnosis. So you can see, this isn’t a rare group but fairly uncommon.

Those overall figures are lower than in the United States where over half a million hip replacements done each year. About five per cent of those will be in patients with a primary (main) diagnosis of rheumatoid arthritis (RA).

With the new, more effective medications to control the progression of joint destruction associated with RA, this percentage may not increase over time — even though more adults with RA are living longer with their disease. Over time, better control will yield better results and outcomes with less invasive treatment.

Most surgeons would agree that any concern a patient has is an important worry to solve. Understanding the process of what is happening to you is all part of patient education. So whenever possible, take your courage in hand and ask what’s on your heart and mind.

As you have just experienced, patients who have a total hip replacement can end up having a second or revision surgery because of a failed implant. Occasionally the revision surgery fails. And in rare cases, patients end up with three or four attempts at a successful hip replacement. Fortunately no one loses a limb because of these problems.

The surgeon does his or her best to find the right implant that will work for you. Bone loss from repeatedly inserting and removing implants can be a problem. The operated leg can end up being shorter than the uninvolved limb. Such a leg length discrepancy alters your biomechanics and gait (walking) pattern and can create additional pain.

To combat this problem, surgeons and manufacturers of joint replacements have worked together to design a modular implant. These implants are somewhat adustable to offset leg length differences from bone loss. This feature allows for improved joint movement that mimics normal motion more closely than previous less adjustable implants.

The modular units (like a modular home) come with interchangeable parts that can be assembled and adjusted at the time of the surgery. A prosthetic femoral stem component is made up of a body, a neck, and a stem. The height of the neck is adjustable (high or low) and the stem can be made longer or shorter according to what the patient needs. For patients with bone loss, the newer revision implants don’t require cement to hold them in place. Instead, the surgeon can use hardware or fixation devices such as pins, wires, and screws to secure them.

The separate pieces of the modular implant are held together with a modular connection and that connector has a taper junction and an engaged-fit junction. Femoral stem fractures are a problem at these modular junctions. Implant manufacturers have worked with surgeons to find a design strong enough to withstand the forces at the intersection between two component parts.

If you are not a good candidate for the modular implant (or any other appropriate implant for your situation), the surgeon could fuse the hip. Hip fusion stops all motion at the joint so although there are limitations in movement and function, the limb is saved. So don’t be afraid to ask your surgeon just what are your options and the most likely plan of care that best suits your goals, dreams, and desires.

First, let’s define osteonecrosis of the hip. An understanding of this condition helps explain why treatment is important and what treatment works best. Osteonecrosis of the femoral head refers to death of the round ball of bone at the top of the femur that fits into the hip socket. Another term used for osteonecrosis is avascular or ischemic necrosis. Avascular and ischemic both mean a loss of blood supply to the area is the cause of the problem.

All of the blood supply comes into the ball that forms the hip joint through the neck of the femur (the femoral neck), a thinner area of bone that connects the ball to the shaft. If this blood supply is damaged, there is no backup. Damage to the blood supply can cause death of the bone that makes up the ball portion of the femur. Once this occurs, the bone is no longer able to maintain itself.

When osteonecrosis (or avascular necrosis) occurs in the hip joint, the top of the femoral head (the ball portion) collapses and begins to flatten. This occurs because this is where most of the weight is concentrated. The flattening creates a situation where the ball no longer fits perfectly inside the socket. Like two pieces of a mismatched piece of machinery, the joint begins to wear itself out. This leads to osteoarthritis of the hip joint, and pain.

Treatment can range from minimal intervention for mild disease in patients with no symptoms to total hip replacement for those with bone death and deformity of the entire joint. Since you have “mild” disease, we will focus on that and with your interest in a nonsurgical (no surgery), nonpharmacologic (no medications) approach, here’s what we can tell you.

Experts say (from evidence in long-term studies) that nonoperative treatment for osteonecrosis of the hip has a very poor result. Conservative care begins with taking weight off the hip. This can be done using canes, crutches, walking sticks, or a walker. The idea is to slow the disease process and preserve the femoral head.

Does it work? Not very well. One-third of patients with early, mild disease can benefit from this type of treatment. The chances of this approach being effective are increased when the patient has a small lesion located on the medial side of the femoral head (side closest to the other hip). The majority (two-thirds) end up with a collapsed femoral head.

Other types of noninvasive treatment that have been tried with this condition include electrical stimulation, shock-wave therapy, and hyperbaric oxygen. These methods are designed to stimulate bone growth. Results are mixed and no one approach has proven perfect. So, these treatments remain in the category of experimental or “under investigation”.

Talk with your surgeon about your desire to approach this problem in a conservative fashion. Your diagnosis of “mild” disease gives you an advantage. Make sure you understand all of the pros and cons of any treatment you choose to follow. And consider long-term effects on your hip, your health, and your quality of life when weighing the plusses and minuses of conservative versus surgical treatment.

Perhaps a little bit of both. Patient satisfaction is important and a part of measured outcomes. Studies have shown that what patients expect heading into surgery can affect how happy they are with the results afterwards. For sure, everyone expects to have less pain — and many hope for a pain free hip.

Besides less pain, there is oftan an expectation that the patient will be able to return to participation in any and all activities without restrictions. This goal may be achieved but it could take much longer than the patient originally anticipated.

Medicine has become more competitive these days, too — more like a big business than ever before. That means there may be some competition for patients. And with the aging of American, it seems that more and more adults wtill have a total hip replacement at some point in their lives.

The economics of health care fit in here, too. Hospital administrators have been conducting studies on the economic impact of joint replacement. Some studies have focused on outcomes, discharge plans, and complications in an effort to streamline the expense of a total hip replacement while maintaining good results.

Your mother may have heard some reliable new information to base her concerns on. Surgeons agree there are still many problems to overcome when it comes to hip replacement surgery. Two of the biggest dilemmas faced right now are the increasing number of older adults who need joint replacements and fewer surgeons specializing in this procedure.

Some surgeons are shying away from hip replacement surgeries because of the high costs. There have been problems with the implants holding up. Product liability is a huge factor in this issue.

It seems like the outcomes of hip replacement are less predictable and worse now than ever before. One of the reasons for this may be the fact that so many surgical techniques are available now. Which method works best for each individual patient problem has not been determined. Problems such as bone deficiency, infection, and hip dislocation add to the many challenges faced by patient and surgeon.

There are also many more implant designs and materials to choose from. For example, more porous materials like titanium foam, cobalt-chromium foam, and tantalum foam are available. These materials make it easier for bone to fill in and around the implant to help hold it in place. The surgeon can also
use cement and/or bone grafting to help seal the implant in place. All of these efforts are geared toward one thing: preventing loosening of the implant — the most common complication of hip
replacement.

Research has focused on ways to prevent implant loosening. Some surgeons have advised their patients to limit physical activities the first 12 months after receiving a hip replacement. Others have suggested low-impact sports over high-demand activities. Some studies have concluded that patient selection is really the key factor here. By looking at who ends up requiring revision surgery, it’s possible to make some observations that might help.

Sometimes older adults have to come to their own conclusions about what they want and need. If they are afraid (as your mother seems to be) about problems and complications following surgery, they may not even be willing to discuss it with their doctors. Perhaps the best thing to do is encourage her to check out what she has heard with her medical doctor and see what he or she can offer. The decision to have a total hip replacement may take some time. A visit with her primary care physician or orthopedic surgeon is a good place to start.

Joint implant infections can have some very serious complications. The infection can destroy the bone around the implant. The result is a failed implant that must be removed and a revision (second) surgery done. Bacteria in the joint can also enter the blood stream and go to other areas of the body causing additional problems.

Of equal importance is whether the joint fluid was tested before antibiotics were given. It’s best to know exactly what pathogen (bacteria) is present before prescribing antibiotics. That way the most effective drug can be matched to the kind of bacteria present in the joint.

Sometimes as soon as there is a suspicion that the patient may have an infection, a broad-spectrum antibiotic is prescribed. Broad-spectrum means it is designed to kill a wide range of different bacteria. The hope is that the type of bacteria present will respond to the drug.

If the symptoms suggestive of infection do not resolve, the patient is taken off all antibiotics for a period of two weeks so that proper testing can be done. This period of time without antibiotics is called washout of antibiotics. Discontinuing the medication is important because taking antibiotics limits the number of bacteria present and prevents accurate testing.

There really are times when the use of antibiotics is appropriate and advised. Joint replacement implant infection is one of those times!

FAI occurs in the hip joint. Hip pain, abnormal joint mechanics, and loss of hip function describe the three most difficult problems with 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.

Current understanding of this hip deformity has resulted in surgery to correct the deformity. The short-term goals are to relieve pain and improve function. As you have found out, the long-term goal is to prevent hip osteoarthritis.

Any surgery for any problem comes with the possibility of complications or problems. Surgery to repair a femoroacetabular impingement is no different. Some complications occur during the operation itself (e.g., bone fracture, reaction to the anesthesia).

Others develop later during the postoperative period (e.g., infection, continued pain, blood clot formation). It’s even possible to develop long-term complications. The bone may fail to heal, blood supply may become compromised, or hardware may break or back out of the bone.

The whole procedure may fail to reduce pain and improve function. That means with repetitive load and use of the joint, cartilage destruction and joint degeneration may lead to osteoarthritis — the very thing you are trying to avoid.

It is good to be prepared for anything that might happen but expect good results. Ask your surgeon what he or she usually sees (if anything) with the particular surgery your son will have. Most complications are minor and easily corrected.

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.

Current understanding of this hip deformity has resulted in surgery to correct the deformity. The short-term goals are to relieve pain and improve function. The long-term goal is to prevent hip osteoarthritis. As you have found out, the exact surgical procedure depends on the type of impingement and location and severity of deformity. The surgeon will also decide whether the procedure can be done arthroscopically or if an open incision will be needed.

Failure is not always defined the same by different surgeons. And patients may view the results differently than surgeons do. In some cases, continued pain after surgery is considered a failure. Others count osteoarthritis requiring a joint replacement as a “what next”? kind of failure.

Some decisions depend on what type of complications might be present (e.g., infection, fracture, broken or bent screws, or loss of blood to the area). Revision surgery may be needed to address whatever problem develops. With complete failure, conversion to a total hip replacement may be an option.

Studies show that patients who already have severe arthritic changes at the time of surgery are the least likely to have a good result. Other pre-operative factors that could predict a poor result include older age and severe pain. Those findings suggest surgeons should give patients with these factors careful consideration before performing surgery to redesign the hip.

Fractures of the upper portion of the femur (thigh bone) that disrupt the blood supply to the femoral head can cause a problem called osteonecrosis (bone death). It sounds like that might be what happened to you with the hip fracture.

A labral tear is a different sort of injury altogether (i.e., different from hip fractures). The labrum is a thick rim of fibrous cartilage around the edge of the hip acetabulum (socket). It is there to increase the depth of the hip socket. The labrum also provides a seal to help protect the hip articular (joint surface) cartilage.

Until recently, very little was really known about the blood supply to this area. But now, thanks to orthopedic surgeons from the Iran University of Medical Sciences we have a better understanding of the location and pattern of the blood vessels to, in, and around the labru.

These surgeons teamed up with researchers from the Department of Anatomy at the Legal Medicine Research Center in Tehran (Iran) to perform this study. They examined the hips of 35 cadavers (hips preserved after death for study). They used a special colored silicone that was injected into the blood vessels around the hip labrum.

The donor hips came from 28 cadavers ranging in age (at the time of death) from 20 to 50 years old. Cause of death was unknown but there was no damage to the hips and no signs of previous surgeries to the area.

Twenty-four hours after the silicon injections, they carefully took the hips apart and examined the blood vessels (now clearly visible from the injected dye). They found the beginning point (source) of the blood supply to the labrum and followed it to its insertion site into the hip joint capsule.

For the first time ever, the vascular ring pattern around the labrum is clearly seen. This structure has been given the name: periacetabular vascular ring. Peri- means “around” and acetabular refers to the hip socket.

Seven of the hips had a visible labral tear. All specimens came from males. The presence of these labral injuries made it possible for the researchers to answer another big question. Is the blood supply to the labrum disrupted when the labrum is injured?

In all seven cases, the answer was No. The periacetabular ring was fully intact despite damage to the labrum. Osteonecrosis is not a typical problem after labral repairs. But you might feel better if you bring up your concerns with the orthopedic surgeon and hear what he or she might have to say about this worry.

It appears that if the loose connective tissue containing the vascular ring is not disrupted, then no damage is done to the labrum’s vascular supply. Every effort should be made to avoid damaging the periacetabular vascular ring. Labral repair with preservation of this capsular-sided connective tissue will enhance healing.