FAQ Category: Hip

Without knowing your mother-in-law’s history and knowing anything about her hip, it isn’t possible to tell if the second revision surgery is a good idea. However, revision surgeries are done to remove the broken piece, regain lost motion and reduce or eliminate pain. When the surgeon feels that surgery will help with one or all of those goals, then it could be an option, if the patient agrees.

In order to do revision surgery, the patient must have enough healthy bone available to attach to the prosthesis. If your mother-in-law’s doctor is suggesting surgery, it is likely that he or she feels that your mother-in-law has the bone that is needed.

Without knowing more about your father, his hip problems, and the study goals, it isn’t possible to say why your father should or shouldn’t participate. However, speaking about studies in general, there are advantages to participating if you meet the requirements.

When people participate in studies held at academic centers and hospitals, they are usually exposed to intense scrutiny. They are examined thoroughly before the study and during the study. In non-study situations, a patient may only be seen briefly by his or her surgeon, with some follow up. For patients in studies, they are seen more often by doctors and nurses who work within the study and are often available to answer questions and troubleshoot if there are any problems.

The major drawback that some people see with studies is that the study subjects, the patients, don’t usually know what treatment they are getting, the new one that is being tried, or the old one, or a sham treatment – depending on what the trial is. Ultimately, the decision has to be the patient’s.

Hip replacements are done for a variety of reasons but, unfortunately, not everyone who needs one can have one.

Total hip replacement surgery is major surgery that requires going under general anesthetic and going through a recovery process. People with certain medical conditions may not be considered good candidates for going under anesthetic and others may be considered too high a risk for complications to have surgery. Finally, if working through the recovery process may be too difficult for a patient, his or her surgeon may decide against doing the surgery.

Hyaluronic acid injections are used for hip and knee arthritis in an effort to reduce pain, improve motion, and delay surgery. There are several ways to do the injection: the backflow method, fluoroscopy, and arthrography.

The backflow method introduces the needle into the joint and a small amount of saline (salt) solution is first injected into the area and then withdrawn to confirm correct needle placement. If the surgeon is unable to aspirate (pull back out) the injected saline, the needle is not in the joint.

Fluoroscopy is real-time X-ray. The surgeon can see on a screen exactly where the needle is in relation to the joint as it moves through the skin and down through the soft tissues to the joint. Arthrography (arthrogram) relies on a dye injected into the joint to show that the injected agent actually made it inside the joint. Arthrography requires the use of fluoroscopy to see the contrast medium.

A recent (small) study of adults (men and women) with hip osteoarthritis found that for the most accurate placement of the needle, surgeons had to use both fluoroscopy and arthrogram. Obesity wasn’t an issue in terms of accuracy in needle position as much as having some outside guidance such as these additional techniques offer. In fact, the majority of patients with hip osteoarthritis are often overweight to obese.

Remaining active is an important part of losing weight. And losing weight is an important way to help reduce the stress on your joints. So interventions like hyaluronic acid injections can be very helpful for the overweight patient who wants to avoid joint surgery for as long as possible. Don’t be shy about asking your physician for some details on how the procedure is done on someone your size. Patient understanding of and cooperation with surgical procedures is am important part of the treatment.

There are many instances when surgeons find it necessary to place a needle into the hip joint. Sometimes it’s to diagnose a problem. In other cases, it’s to treat the problem. For example, hip injections have been used to treat a painful hip after surgery, to deliver steroids to reduce inflammation, or antibiotics to fight infection.

In all cases, a needle is used to withdraw fluid from or deliver agents to the joint. Doing the procedure without the benefit of imaging to guide needle placement is called blind injection. How accurate is this technique? Can a surgeon really point and shoot — that is to say, can the surgeon use anatomical landmarks to accurately place the needle in the joint? The authors of a recent study say, not without some imaging assistance.

In their study, blind injection was accurate in placing the needle two-thirds of the time. But interestingly, only half the time did the injected agent show up inside the joint on arthrogram (dye injected into joint to show uptake of the injected agent). The chances of getting the agent inside the joint were definitely better when using fluoroscopy to guide the process.

Blind injection relies on something called backflow. The backflow method used with blind injection to confirm needle placement introduces the needle into the joint. A small amount of saline (salt) solution is injected into the area and then withdrawn to confirm correct needle placement. If the surgeon is unable to aspirate (pull back out) the injected saline, the needle is not in the joint.

According to this same study, backflow was not reliable. In about 18 per cent of all cases, backflow was positive (suggesting that the needle was in the right place to deliver the agent) but the arthrogram was negative: no agent was actually in the joint. In these cases, the backflow method showed a false-positive response. And there were many other times (almost 80 per cent of all injections) when the arthrogram showed a correct needle placement but the backflow response was negative (not present). This is an example of a false negative.

The authors concluded that even though it is possible to perform a blind injection accurately, it is not a reliable technique. Backflow cannot be relied upon either. The expense saved and protection of the patient from X-rays may not be worth it if the procedure is a failure. Using fluoroscopy isn’t enough either. It may show that the needle is correctly placed but doesn’t definitely prove it as this study demonstrated. The most accurate technique may be using both fluoroscopy and arthrography.

Standard precautions following a total hip replacement usually do include avoiding bending the hip more than 90 degrees. That usually means not bending forward from the waist over the legs or lifting the leg up past 90 degrees. There is also a limit on how much hip rotation is allowed.

The concern is for safety and avoiding dislocation of the new hip implant. Studies show that hip dislocations after a hip replacement occur in two to four out of every 100 patients treated this way. To help patients avoid this unpleasant complication, movements that could stress the hip are avoided. A raised toilet seat is used for the first four to six weeks.

Riding in a car is avoided. But with pillows and proper positioning, patients are allowed that one car trip from hospital to home. You will also likely be sleeping with a wedge strapped between the legs. Again, this is to keep the legs in the right position to avoid dislocating the hip. You’ll only be able to sleep on your back while the wedge is in place.

Restrictions of this type aren’t always needed. With today’s minimally invasive surgical techniques, some of these restrictions can be lifted. Your surgeon will give you your Dos and Don’ts based on the type of procedure done and type of implant used. Patients who follow what their surgeons tell them to do have the lowest rate of problems.

Anyone who has had a hip replacement knows that there are certain precautions that must be followed to avoid dislocating the new hip. But there is some suggestion that maybe those precautions aren’t really necessary after all.

With today’s updated surgical techniques and less invasive procedures, perhaps the risk of a hip dislocation just isn’t as real as it once was. Surgeons from Lehigh Valley Hospital in Allentown, Pennsylvania conducted a recent study that showed the restrictions placed on some patients getting a total hip replacement might not be necessary.

Half their patients were placed in the standard restrictions group. They had to avoid bending the hip past 90 degrees and couldn’t ride in a car for the first month following surgery. The other half were in the early group. There were no hip flexion or car riding restrictions placed on these patients. They were told not to cross the legs but could bend at the waist or from the hip as long as they were comfortable doing so. They could even sleep in any position they wanted without even a pillow between the legs. Sitting on a toilet could be done without the special raised toilet seat required in the standard precautions (restricted) group.

All patients in both groups had the same hip replacement operation (a modified anterolateral procedure). A single surgeon who specializes in total hip replacements performed all the operations. The patients were matched between the two groups for age, socioeconomic background, and size (body mass index).

The early group did better in all ways and with no more complications than the standard restrictions group. There were no hip dislocations reported in either group. The early group switched from a walker to a cane sooner than the restricted group. The early group got rid of the cane sooner. They stopped walking with a limp significantly before the restricted group. They were back behind the wheel driving much sooner, too. All-in-all the early group was so successful, the authors ended the study and switched all of their appropriate patients to an early rehab protocol.

The key here is the careful selection of patients and using a minimally invasive surgical procedure that doesn’t cut through all the muscles around the hip. It is best to follow whatever guidelines the surgeon provides on a patient-by-patient basis. With younger, healthier adults getting hip replacements with minimally invasive techniques, it’s likely that the extreme restrictions of the past will be replaced with a more accelerated rehab process. That includes fewer restrictions and means a faster pace of recovery.

With the new focus on evidence to support the use of procedures like blind injections (given by visual guidance only), there’s plenty of proof now that you only have a 50-50 chance of getting the agent into the joint. And that’s true even for very experienced physicians who give 100s of injections.

With the availability of advanced imaging techniques like real-time X-rays and ultrasound, researchers have been able to study the accuracy and reliability of different techniques for intraarticular (into the joint cavity) injections.

And now they know that even some imaging-guided injections don’t truly hit the mark. It can look like the needle is in the correct position even with fluoroscopy. But follow-up arthrography shows it’s not in the joint after all. Arthrography requires injecting a special substance or contrast dye into the joint space. It allows the physician to see soft tissues and joint structures as well as needle placement and delivery of the injected material.

A physician who is concerned about accuracy and positive results will use both imaging and arthrography when performing hip injections. It sounds like you are in good hands with the new surgeon. Give it a try at least once and see what you think!

Intra-articular (into the joint) injections of the hip can be helpful in alleviating painful symptoms from osteoarthritis. Careful technique is required on the part of the physician performing the injection. Blind injections (guided only by vision and touch) are less expensive than injections performed with imaging. Blind injections can be done right in the physician’s office. And the patient isn’t exposed to radiation. But blind injections are not advised. For complete accuracy, imaging and arthrography are required. Arthrography is the use of a contrast dye injected into the joint to show that the injected agent actually made it into the joint.

Studies show that with blind injections you have a 50-50 chance of success. Using the blind technique with any success is like tossing a coin and shouting heads or tails and then being right (or wrong). Using previous X-rays isn’t helpful because arthritis changes the shape and structure of the joint. In other words, it could be a different looking joint even from the last time it was X-rayed.

And most of the X-ray techniques are real-time, which means the surgeon sees in 3-D, the joint, the soft tissue structures in and around the joint, and the needle placement as it advances forward through the soft tissues into the joint space. Talk to your orthopedic surgeon about your concerns. Find out how much radiation you would be exposed to and what other options you may have. Some physicians are using ultrasound now instead of X-ray imaging. There’s no exposure to radiation and it can be followed up with arthrography to ensure 100% accuracy.

Bone turnover refers to the death of old bone cells and birth of new bone cells, a natural process that occurs in all adults. After menopause, there is more bone resorption (death) and less new bone formed resulting in a net loss of bone density and strength. That’s why taking bisphosphonates is recommended. This drug is supposed to reduce the risk of bone fractures by inhibiting (stopping) bone resorption. By preventing bone cells from being broken down, bone density and therefore bone strength, can be maintained.

But some women on Fosamax develop a stress reactions or even a complete hip fracture. A stress reaction is a microscopic disruption in the bone. The bone has not widened, separated, or moved apart as is usually seen with a true break. Given enough compression and load on the weakened bone, a stress reaction can progress to a complete break. These stress reactions aren’t always painful. So when a fracture develops, the physician should X-ray the opposite side to see if any stress reactions are developing.

Women like your mother who have had one fracture under these circumstances who later report thigh pain on the other side may be experiencing the first symptom of an impending hip fracture. In anyone taking bisphophonates for osteoporosis, this single symptom should be taken seriously.

X-rays are usually used to determine the condition of the bone and presence of emerging fracture on the other side (opposite hip to the broken one). Bone scans and/or MRIs may be ordered when X-rays are normal but the history and exam are suspicious. Some experts suggest stopping treatment with the drug and referring the patient to an endocrinologist for a more thorough work-up. The endocrinologist takes a closer look at the patient and helps make a decision whether or not bisphosphonates can still be used after these hip fractures.

There has been a concern raised lately about the use of medications called bisphosphonates for postmenopausal women with osteoporosis. This drug is supposed to reduce the risk of bone fractures by inhibiting (stopping) bone resorption. By preventing bone cells from being broken down, bone density and therefore bone strength, can be maintained. But reports of problems with the long-term use of these medications have caught the attention of the medical community.

Although there have been reports of adverse events linked with bisphosphonates, these are rare and may not be typical of the average person taking bisphosphonates. Long-term use (more than five years) appears to be one factor. Other individual patient factors are unknown. Clearly, only a small number of women on Fosamax develop hip fractures.

Because the effects of a fracture can be very disabling, routinely stopping this medication in everyone taking it is not recommended. Each case must be reviewed on its own merits. We advise all individuals taking any type of bisphosphonate to discuss this question with their doctor.

Cementless implants are press-fitted into the bone. They are held in place by the porous (roughened) surface of the implant next to the bone. During the natural process of healing, the inflammatory process brings new blood cells to the surgical site and the stem cells form new bone cells to fill in and around the implant. Growth factors speed up the whole process.

The gel you saw is considered osteoinductive which means it fosters bone growth. It contains proteins that act as growth factors to stimulate bone growth. This new gel is made up of bone chips, platelet-rich plasma (the growth factors), and bone marrow. Bone marrow contains stem cells that can form into any other cell, including new blood and bone cells needed to form new bone tissue.

The gel is made up of the patient’s own bone cells, bone marrow, and growth factors. When the old, arthritic hip joint is taken out, the bone marrow from inside the upper shaft of the femur is collected. The top of the femur and the hip socket (also removed in preparation for the new implant) are ground up and used as bone stock.

The bone is rich in bone cells that promote bone growth. The bone stock also contains morphogenic protein, another type of growth factor. Once the gel is all mixed up, it is smeared all over the implant socket and stem before inserting these into the patient’s hip.

With the osteoinductive gel, the hope is that the process will not only be faster, but also provide joint stability sooner. That could mean patients can get back to full function as soon as possible with fewer complications.

Cementless implants are used now whenever the patient has good bone stock. The surface of the metal parts is porous or textured. It looks like coral. Bone can grow into the metal pores and bond the implant. But it takes longer for the joint to become stable compared with cemented implants. That’s where the osteoinductive gel comes into play. Osteoinductive means it helps foster bone growth.

With the osteoinductive gel, cementless implants can get integrated into the bone much faster. In doing so, the risk of fibrous (scar) tissue filling in between the implant and the bone is much less. That creates a more solid, stable joint to handle weight-bearing loads of adults who want to move, walk, and play! Biologic fixation is improved with the bone stimulating gel, which in turn, decreases the risk of implant failure.

You can expect faster functional and clinical recovery within six months. Right after surgery, your surgeon may recommend a period of protected weight-bearing (using crutches or a walker). This gives the bone time to attach itself to the implant. This protected weight bearing helps to ensure there is no movement between the implant and bone so a durable connection can be established. But that doesn’t mean you’ll be down and out of the action.

A physical therpaist will work with you right from the start with muscle strengthening exercises. You may get up standing and just put weight into the joint during the first 24 hours. Walking with an assistive device usually begins within 48 hours. If you are active, strong, and stable, you maybe able to use crutches rather than a walker. You’ll need some type of assistive device for the first few weeks to month. Patients are usually allowed to go from two crutches to using only one crutch at the end of the first four weeks. A single crutch may be used for another couple weeks up to a month (depending on your progress).

A recent study comparing results for patients who received cementless implants with and without the gel showed that the gel group doubled their function in the first 40 days. There was a gradual progression of improvement from then up through the first six months. Similar results were observed in the control group (no gel) but with a lower level of improvement noted in the first 40 days. In both groups, functional improvement reached a plateau and did not change further by the end of the 12-month post-operative period.

Artificial hips, like most other man-made objects, may fail from time to time. It’s unfortunate, but it does happen. They may fail due to a design flaw, a problem in manufacturing, or even surgical error. When this happens, it’s important that the manufacturer knows because news has to be sent out to the orthopedic surgeons who use the devices and the hospitals and clinics who order them.

Every person who has anything artificial implanted into their body, be it an artificial hip or a breast implant, has a chart of their surgery. The serial number of the implant is noted in that chart – and every implant has a serial number. By identifying the type of implant (name of the implant and the manufacturer), we can pinpoint which doctors and hospitals use them. Then, we can narrow down who may have received the implant by matching serial numbers.

Hip replacement surgery is becoming increasingly common. While at one time, it may have been thought that one replacement is as good as the next, surgeons and researchers have learned that there is no one-size-fits all hip replacement.

Surgeons make the decision of what type of implant to use based on a few different factors:

– how big is the person having the surgery
– how much of the hip is being replaced (partial versus total)
– in what condition is the patient’s bone
– how active is the patient/how old is the patient
– what is he or she most familiar with in terms of how often they’ve used what type of implant.

There are different problems that can cause groin pain. Before making a decision about your training regimen, see a sports medicine specialist for an examination and diagnosis. If you have a simple tendon strain, the treatment approach is very different from a sports hernia or stress reaction (fracture).

An X-ray can rule out (or confirm) the presence of any bone fractures. Stress reactions are not visible for six to weeks after the damage has been done, so there may be a lag time before this diagnosis can be made. Another imaging study that might offer some useful information is a contrast MRI. A dye is injected that is taken up by the tendon where it inserts into the bone. Damage to the tendon fibrils leave the soft tissue edges open so that the dye seeps into the area. Not all tendon problems show up on MRIs, so this test is not 100 per cent accurate.

There are some simple clinical tests the physician can use to pinpoint the problem. Reproducing your pain by pressing on the adductor longus, the most common tendon involved in groin pain, is a sure sign that the problem is extra-articular.

Extra-articular means the pain is coming from outside the hip joint. Two other tests are helpful: resisting movement of the adductor muscles and assuming a position that stretches the muscles. Pain with either of these tests helps confirm the adductor muscle as the most likely cause.

Once the diagnosis has been made, then your physician can advise you as to the best treatment or management approach. This could involve a period of rest and avoidance of weight-bearing activities. Or it could mean a change in your training protocol. Depending on how far away the triathlon is, you may still be on target after rest and recovery. Continuing to repeatedly stress the area is usually not advised.

Studies on the use of steroid injections for groin tendon problems are not plentiful. Research shows that one to three steroid injections of soft tissues for acute and/or chronic inflammatory pain can be beneficial. More than that and the risk outweighs the benefit because steroids are known to break down collagen fibers that make up tendons and muscles.

But if you obtained pain relief the first time and it lasted eight weeks, chances are a second injection might resolve the problem for you. Some of it may depend on your activity level and any anatomical or postural issues that might be contributing to the problem.

Some additional testing might be helpful. MRIs with contrasting dye can offer useful information. If you are a competitive athlete (participating in your sport four or more days each week), your risk of recurrence is much higher. This is likely because your activity level is high enough to repeatedly cause microtrauma of the affected tendon(s). A positive MRI showing uptake of the dye into the damaged tendon is a predictive factor for symptom recurrence in competitive athletes.

For recreational athletes (participating in any sports activity less than four times per week), the MRI findings are not as predictive. Some folks don’t have any sign of tendon pathology on the MRI but still get pain relief from the steroid injection. With a lower activity level and greater ability to rest between sports activity, recreational athletes seem to benefit from the injection regardless of the MRI results.

Anticoagulation with Coumadin is a way to thin the blood and prevent blood clots that can travel to the heart, lungs, or brain and cause stroke or death. There’s a lot of debate yet about the best way to handle situations like you described.

Should patients on long-term anticoagulation therapy come off it before surgery to reduce the risk of bleeding? If so, how soon should the dosage be tapered and eliminated? Is three days enough? Does it take five days? Ten days? Different surgeons elect to follow different protocols based on personal experience and professional judgment.

A recent survey asking surgeons just what their policies were in this area showed that about half the surgeons stopped the drug right before surgery. About 11 per cent waited at least five days and another 10 per cent waited 10 days. Twenty per cent operated immediately without changing the anticoagulation medication usage or dosage.

There’s enough evidence now to show that any delay in surgery for problems like hip fractures increases the risk of serious postoperative complications, including death. If it’s an elective procedure and there’s time to taper off the Coumadin, then that’s what most surgeons instruct their patients to do. Different decisions are made when it’s an emergency situation.

Older adults with hip fractures often have an underlying diagnosis of osteoporosis (brittle bones). As you have indicated, we know that complications associated with hip fractures in this age group are common — and can be deadly.

Pneumonia, heart failure, infections, and pressure ulcers (bed sores) head the list of problems that some seniors face when a hip fracture occurs. And according to a recent report from the Washington University School of Medicine, a delay in surgery increases the risk of complications even in healthy patients.

What can be done to reduce the number and severity of complications related to surgery for hip fracture? First, it’s clear from studies that a delay in surgery can make things worse. Even a 24-hour delay increases the risk of death. The longer the delay, the greater the risk of pressure ulcers.

What’s causing the delays? One of the significant factors contributing to delays in surgery is the insistence on cardiac testing before surgery. In an effort to prevent heart attacks and other cardiac complications, this practice may increase the risk of such problems. Treating the heart conditions before having surgery seems like it makes good sense. But, in fact, studies show that testing doesn’t really change how these patients are treated — it just delays the surgery they were admitted for in the first place.

A second, important risk factor for poor outcome after surgery for hip fracture is malnutrition. Decreased bone mass is often linked with poor nutrition. And with an inadequate diet comes weight loss and no fat to protect the bones when a fall occurs. Not only that, but malnutrition also leads to poor wound healing and an increased risk of those pressure ulcers already mentioned.

What can be done when the patient comes in to the hospital with osteoporosis and a hip fracture? Isn’t it already too late to make a difference? Evidently not, according to several studies that showed using intravenous nutritional supplementation followed by vitamins taken by mouth can really make a difference. Nutritional consultation with a specialist is also advised. A nutritional expert can help with the immediate concerns about malnutrition as a risk factor for complications but also set up a plan for home once the patient is discharged. This step is essential in preventing future health problems of all kinds.

Another important risk factor for complications associated with hip fracture surgery is low hemoglobin. Hemoglobin helps carry the oxygen you need in every cell of the body. Without enough hemoglobin, anemia develops. This particular risk factor has many causes to watch out for. Besides the obvious loss of blood from the surgery, there can be internal bleeding from the GI tract.

Many older adults have bleeding ulcers from taking antiinflammatory drugs for their arthritis. Smoking adds to the risk of GI bleeding. One-third of all patients having hip fracture surgery end up needing a blood transfusion. What can be done to prevent bleeding problems? The research supports using a drug called proton pump inhibitor (PPI) right after surgery for anyone with risk factors for GI bleeding. Surgeons are also advised to do everything possible to avoid/reduce bleeding during the operation. This is possible now more than ever before with today’s minimally invasive surgical techniques.

There are other measures that can be taken to decrease postoperative problems after hip fracture repair. These include protective padding over bony prominences to prevent pressure ulcers, antibiotics to prevent infections, and proper pain management to prevent stress-induced heart problems. Preventing blood clots through the use of medications, compression stockings, and pneumatic pumps applied to the lower legs for at least the first 24 hours is standard practice.

You can take a look at these suggestions and compare them with standard operating procedures already in place within your facility. Any areas that are lacking can be reviewed by staff and administration for consideration and implementation. Gathering evidence from research and identifying best practice is a great way to get started when evaluating your own policies.

Preoperative testing is not uncommon before surgery — especially for older adults who are at risk for complications from surgery. The surgeon wants to do everything possible to reduce those risks and assure the best results possible.

Some of the more typical tests are to assess heart health and the risk of cardiac complications. Anyone with a history of unstable coronary syndrome, heart failure, valve disease, or problems with heart rhythm (arrhythmia/dysrythmia) will likely have a preoperative cardiac evaluation.

The presence of any infection such as urinary tract infection or upper respiratory infection (e.g., pneumonia) will also increase the risk of serious complications after surgery. And by serious, we mean that studies show the death rate is higher for patients with these kinds of health concerns.

Malnutrition is another problem that can affect the results of surgery. Nutrition experts have found that older adults who break a bone due to osteoporosis (brittle bones) often have low bone density because of a poor diet.

On the other hand, there is some evidence that delays in surgery needed to repair a hip fracture can also represent a risk factor of its own. Even patients who are health going into the surgery are at an increased risk of infection and death when there’s a 24-hour delay. And delays also increase the risk of pressure ulcers (bed sores) in anyone who is malnourished.

As a family member and advocate for your father, you can ask for an explanation for the delays and express your concerns. There may be other reasons why the operation has not taken place yet. Hospitals deal with limited staffing over the weekends, limited numbers of operating suites, and prioritizing surgical cases based on severity and availability of surgeons. All of these factors could have a role in your father’s current situation.