FAQ Category: Hip

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.

With every new surgical procedure come refinements and improvements in the technique by surgeons who have the experience and expertise to try something different. In a recent study, one orthopedic surgeon from the Cincinnati Orthopaedic Research Institute took on hip joint resurfacing as his project. He worked diligently over a two-year period of time to reduce the size of the incision required for this operation until it could be considered minimally invasive. He reported on the results of doing it this way compared with similar patients who had a total hip replacement.

Hip resurfacing is done by entering through the hip from the back (posterior direction), cutting through the hip capsule, and usually, cutting through the hip muscles in order to pop the hip out of the socket. It’s necessary to dislocate the joint in order to gain access to the round head of the femur. It’s the head of the femur that’s shaved smooth and rounded in preparation for a metal cap that is placed over the bone. The cap is held in place with a peg that fits down into the bone.

Essentially, that’s what joint resurfacing is all about. It means less loss of bone and a chance to preserve as much of the natural hip joint as possible until the inevitable total joint replacement is required. Hopefully, the conversion to a total hip replacement will be some years down the road. Younger adults who are more active and who only have arthritis in one hip are the best candidates for hip joint resurfacing.

In this study, Dr. M. L. Swank performed an equal number of total hip replacements and hip resurfacing procedures and compared the results in his patients. Over time, he was able to use a smaller and smaller incision with less and less disruption of the surrounding soft tissues. The early resurfacing surgeries used a 4.5-inch long incision. That was reduced by almost a full inch over time. The total hip replacement was still possible with a much smaller incision (two inches).

By the end of the study, Dr. Swank was able to avoid dislocating the joint by splitting the gluteus maximus (buttock) muscle and using the gluteus minimus to form a pocket. The head of the femur could be slipped into that pocket to perform the procedure. A similar approach was used to perform an equal number of total hip replacements. Although the hip was dislocated in order to cut off the femoral head and replace it, the resection was done under the skin. In the traditional, standard surgery, the head of the femur is popped out of the opening made by the incision and then a saw used to cut through the bone.

Doing it this way made it possible (in both the resurfacing and the total replacement) to access the head of the femur without cutting through all of the soft tissues. In theory, the advantage for the patient is a smaller incision, less pain afterwards, and faster recovery of strength, motion, and function. Dr. Swank was able to demonstrate exactly that but it might be awhile yet before this approach is adopted as the standard procedure for hip joint resurfacing.

Your surgeon may be willing to consider something like Dr. Swank’s approach if you ask him or her about it. The bottom-line is that you want your surgeon to use the methods he or she is most comfortable with for the best result possible. Decreased pain, increased motion, and improved function are the results you are looking for — however the surgeon accomplishes this!

It is possible to perform a total hip replacement from an anterior (front) approach as well as from the side lateral or posterolateral (halfway between the back and side). But over the years, studies have shown the best results and easiest access is from the posteriolateral direction.

Some of the success with this incision location is the fact that it gives the surgeon access to the entire joint. It also makes it possible to put the implant in its best location for optimal motion and function. Even a degree or two off in one direction or the other can cause long-term problems. To avoid that, the surgeon likes an open enough incision and open wound site to see what he or she is doing.

The posterior approach also makes it possible for the surgeon to size up the bone and choose the best size of implant for the patient. Getting a just the right size implant on the femoral side and placing it in the optimal location is key to full, pain-free motion. Newer techniques are being developed all the time. One surgeon has already mastered a minimally invasive technique for hip joint resurfacing.

Using a three and three quarters- to four-inch length incision, the head of the femur can be accessed and cut off all inside the body. There’s no need to pull the head of the femur out of the open wound site to gain access to the arthritic component. Muscles are split in two rather than cutting them off and moving them out of the way. The joint capsule still has to be cut through to get to the joint, but these other refinements in surgical technique certainly reduce the overall trauma.

After surgery, your hip will be covered with a padded dressing. Special boots or stockings are placed on your feet to help prevent blood clots from forming. A triangle-shaped cushion may be positioned between your legs to keep your legs from crossing or rolling in.

Physical therapy treatments are scheduled one to three times each day as long as you are in the hospital. Your first session is scheduled soon after you wake up from surgery. Your therapist will begin by helping you move from your hospital bed to a chair. By the end of the first day, you’ll be up and walking using crutches. By the end of the second day, you’ll cover longer distances with greater ease. Most patients are safe to put comfortable weight down when standing or walking. However, if your surgeon used an uncemented prosthesis, you may be instructed to limit the weight you bear on your foot when you are up and walking.

Your therapist will review exercises to begin toning and strengthening the thigh and hip muscles. Ankle and knee movements are used to help pump swelling out of the leg and to prevent the formation of blood clots.

This procedure requires the surgeon to open up the hip joint during surgery. This puts the hip at some risk for dislocation after surgery. To prevent dislocation, patients follow strict guidelines about which hip positions to avoid (called hip precautions). Your therapist will review these precautions with you during the preoperative visit and will drill you often to make sure you practice them at all times for at least six weeks.

Some surgeons give the OK to discontinue the precautions after six to 12 weeks because they feel the soft tissues have gained enough strength by this time to keep the joint from dislocating. On the basis of some preliminary data that suggests these precautions are not needed, some surgeons give their patients permission to be as active as they feel is tolerable. No restrictions are given even from day one.

You’ll want to discuss this with your surgeon and find out what his or her protocol is for the procedure, especially given your age, general health status, and overall health and function.

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 patients who are expected to need a second, or revision, hip replacement surgery as they grow older and wear out the original artificial hip replacement.

Usually the patient’s natural hip socket is left alone, or sometimes a thin plastic liner is put inside the socket to smooth out the surface. Most of the time, the round head of the femur gets the resurfacing. Special instruments are used to shape the bone of the femoral head so that a new metal cap can fit snugly on top of the bone. The cap is placed over the smoothed head like a tooth capped by the dentist. The cap is held in place with a small peg that fits down into the bone. The patient must have enough healthy bone to support the cap.

A recent study from the Joint Replacement Institute at St. Vincent Medical Center in Los Angeles, California was designed to compare the results between joint replacement and joint resurfacing. They wanted to look at patient characteristics called demographics such as age, gender, general health, height, weight, and so on. A second measure used in the comparison was the preoperative clinical condition of the patient: joint range-of-motion, strength, and function. And then, of course, the results or final outcomes from the surgery were compared. Patients were followed for two to four years to give an idea of what were the mid-term (intermediate) results.

The patients having hip joint resurfacing were more often men, an average of three inches taller and 10 to 20 pounds lighter, and had arthritis only in one hip compared with the total hip replacement group. The hip resurfacing patients were in better overall, general health compared with the total hip replacement group. And patients in the resurfacing group were younger than the other group by a good 10 years.

In order to keep all things as equal as possible, the patients in both groups attended physical therapy and followed the same rehab program. Activities were not restricted in any way. Patients were told to do whatever they felt up to. According to the results of tests performed on patients in both groups, the hip resurfacing group got better faster, had less pain right away, and reported higher activity levels compared to the total hip replacement group.

A closer look at the two groups showed that the total hip group gained more motion because their loss of motion before the surgery was so much greater than the hip resurfacing group. In the end, the two groups had the same hip motion in all directions. And although the hip resurfacing group got faster pain relief, they didn’t always get complete pain relief. More of the resurfacing patients still reported pain during the follow-up period. The total hip replacement patients were more likely to be pain-free at the two- and four-year follow-up visit. But that might also be because they were older and less active.

It’s natural to see the better results for hip resurfacing and think, Ah ha! That’s the better operation to have! But, in fact, the results of this study support the continued careful selection of patients to have this procedure. The good results may be more likely attributed to patient characteristics than to differences between joint resurfacing versus joint replacement. Younger, more active, healthier patients received the hip resurfacing and that seems to be reflected in the results as well. Statistical differences in joint motion and risk of dislocation weren’t observed between the two groups.

The hip is a fairly complex joint. Problems that often seem like they are in the hip really originate from the low back, sacroiliac joint, and even the knee. True hip pain usually occurs in the groin and front of the thigh. But even knowing the problem is in the hip doesn’t identify the true cause. It could be the soft tissues in and around the joint, the articular cartilage inside the joint, or the rim of cartilage around the rim of the hip socket called the labrum.

When the labrum is tored, frayed, or damaged in some way, it can get pinched between the head of the femur and the acetabulum (hip socket). This pinching or impingement is what causes the groin pain, loss of hip motion, and sometimes grinding, catching, or locking sensation with certain hip motions.

Labral tears can be especially difficult to diagnose because there are often other changes going on in the hip at the same time. The physician relies on a standard physical exam, history, and then special tests to sort it all out. Joint range-of-motion, strength, and a postural assessment provide helpful information. The patient’s report of what makes it better and what makes it worse is also very useful.

There is also a pain test that can be done. The surgeon injects a numbing agent similar to novocaine into the hip joint. If the pain goes away, it’s an indiction that the source of the pain is coming from inside the joint. If the pain doesn’t go away, it could still be something around or just outside the joint.

But X-rays and sometimes MRIs are often needed to confirm the presence of a torn labrum. And even then, it isn’t until the surgeon performs an arthroscopic exam that the true extent (and possibly cause) of the problem are uncovered.

The labrum is a dense fibrocartilage ring around the hip socket. It is firmly attached to the bone and serves to deepen the socket, giving depth and stability to the hip joint. Everyone with normal anatomy has this feature. Labral tears can occur as a result of femoroacetabular impingement (FAI). That’s a description of what happens if the head of the femur (thigh bone) butts up against the hip joint cartilage and pinches the labrum. Impingement means pinching.

Normally, the femoral head moves smoothly inside the hip socket. The socket is just the right size to hold the head in place. If the acetabulum is too shallow or too small, the hip can dislocate. In the case of femoroacetabular impingement, the socket may be too deep. The rim of the cartilage hangs too far over the head. When the femur flexes and rotates, the cartilage gets pinched. This causes deep groin pain with activities that stress hip motion. Prolonged walking is especially difficult.

Hockey players (especially goalies) stay in a flexed position for much of the game. This repetitive hip flexion can set up a situation where impingement and then labral tearing can occur over time. But impingement can also occur in the aging hip. Small structural changes (probably present at birth) in the hip progress over time, creating impingement that leads to joint arthritis.

And some more recent research has shown that the labrum is key in keeping a tight seal on the joint so the synovial (lubricating) fluid doesn’t leak out. Any damage to the labrum can disrupt this seal, adding to the risk of joint wear and tear.

The surgeon who is evaluating you may be able to give you an idea why you developed this problem. X-rays of the bones and MRIs of the joint and surrounding soft tissues may help identify which structures have been altered and why.

Hip dysplasia is a condition in which there is a disruption in the normal relationship between the head of the femur (thigh bone) and the acetabulum (hip socket). Usually, the acetabulum is too shallow or sloping rather than a normal cup shape. It cannot hold the femoral head in place. Hip subluxation (partial dislocation) and even full dislocation can occur.

The condition can be present at birth or develop in the early months to years of life. Conservative (nonoperative) care is possible when this condition is identified early in life. But sometimes, it’s not possible to keep the femoral head in good contact with the acetabulum. Then surgery may be required.

Hip replacement is usually not the first procedure used for this problem. An open reduction is a surgical procedure used most often in children two years old or older when hip dysplasia has not been corrected. During this operation, the surgeon removes any abnormal tissues that are keeping the femoral head from fitting inside the acetabulum and cuts any tight ligaments in the joint capsule around the hip joint. The surgeon may perform a tenotomy during the surgery to cut the tightly contracted tendons or muscles in the hip area. This relaxes the tight structures around the hip joint and allows the hip to be placed in the socket.

Other more advanced procedures may be required. An operation called derotational osteotomy may be needed. In this surgical procedure, the femur is cut and rotated to make it easier to keep the femoral head inside the acetabulum. When this procedure is done, the soft tissues loosen up and the forces of the muscles tend to keep the femoral head reduced.

But when all else fails, a hip replacement may be the only way to correct the problem. Ceramic-on-ceramic bearings are used most often on young, active patients but complications such as squeaking or other noises are possible. For a while, it was thought that the ceramic implants had a very low rate of noise-making (less than one per cent). But a recent study showed that when specifically asked about this problem, up to 10 per cent of the patients who were surveyed reported noises. Squeaking was the most common, but there were reports of grinding, popping, and snapping.

Some patients aren’t bothered by the noises — or at least not enough to have a second (revision) operation. But with chronic dislocations, it may be necessary to swap out the ceramic-on-ceramic implant for one that has metal-on-polyethylene (plastic) or even a ceramic-on-polyethylene interface.

The surgeon who has been following you will probably be the best one to advise you. Given your age and the diagnosis of hip dysplasia, there are likely other complicating factors to be considered.

You can certainly bring it to the attention of the nursing staff who will know whether or not to pursue the problem further. Although it is not a normal result of hip replacement, it can be considered a postoperative complication. It occurs in one to 10 per cent of adults with hip replacements.

There’s no evidence to suggest that the noises mean the implant will fracture or fail sometime in the future. But it’s the type of thing that should be noted and followed or monitored carefully. There usually isn’t any pain associated with the noise, which is why the residents may not have noticed it.

For most patients who develop noises after having a hip replacement, activities that reproduce the noises include bending and walking (most common), but also climbing stairs, exercising, during sexual activity, and when putting on pants. Some of the patients can make the noise by stepping up on a low stool. This is actually called the squeak test. Evidently, combining a flexion-to-extension movement of the hip with a weight-bearing load is enough to recreate the problem. That’s most likely what you are observing when the residents are stepping up into the dining area.

With the recent effort to reduce the length of hospital stays, physical therapists are exploring the most effective ways to treat orthopedic patients. The standard rehab program after hip or knee joint replacement includes a mix of exercises to improve circulation and to prevent blood clots and other complications. Other goals include improving motion, strength, and function (especially walking).

Aquatic therapy after hip replacement may fill the bill nicely. Aquatic (pool) therapy is defined as physical therapy that is performed in the water. There are good reasons to consider using aquatic therapy after joint replacement. Aquatic therapy uses the resistance of water instead of weights. With the reduced load provided by the buoyancy of the water, certain exercises (e.g., squats, step ups, walking without a cane or walker) can be started sooner in water than on land. Circulation is also improved leading to faster tissue healing and reduced swelling.

A recent study from Australia looked at the benefit of aquatic therapy in the early days after joint replacement. Physical therapists randomly placed patients getting a hip or knee replacement into one of three different treatment groups. The goal was to find out what kind of treatment is best in the early days after orthopedic surgery.

Everyone in the study either had a hip or knee replacement. They each received the standard postoperative hospital care by a physical therapist for the first three days after the operation. After that, the patients were randomly assigned to one of three groups.

Group one continued with the standard care. This included circulation and deep breathing exercises, transfer practice, gait (walking) training, and practice going up and down stairs. Stretching and strengthening exercises were also done daily. Group two received a nonspecific water therapy session each day they were in the hospital. Group three had one standard physical therapy treatment each day and attended aquatic therapy everyday while in the hospital.

The only reported difference among groups in this study was hip abductor muscle strength. Hip abductor strength is important for trunk and hip stability and normal a gait (walking) pattern. Patients in the specific aquatic therapy program had the greatest improvement in strength.

When all other variables were compared among the groups, the aquatic group had the best short-term improvements. At the end of six months, there was no difference in outcomes from one group to the next. There were overall trends that seemed to support the idea that aquatic therapy was slightly more beneficial than either land-based or nonspecific water-based exercises.

You may be able to start swimming early on after your surgery. But you’ll need to check with your surgeon. Some rehab programs have an aquatic program specifically geared toward postoperative orthopedic patients. Keying into specific muscle groups needing strengthening after each type of surgery may be to the patient’s advantage. It might be best to go through a rehab-specific program before just resuming swimming laps. That way you’ll get the best of both worlds — the pleasure of getting back in the pool while performing exercises just for your new situation.

It looks like the law of supply and demand is at issue here. Simply stated, more people will want and need a hip or knee replacement than there are surgeons to provide them. Right now, almost three-fourths of a million adults in the United States get a new hip or knee every year. That number is expected to top one million very quickly. It is predicted that by the year 2016, half of all patients who need a hip replacement won’t be able to get one. And three-fourths of all patients seeking a knee replacement will be on a waiting list for a very long time.

There are two groups who are going to be affected the most by this problem: adults in the 45 to 54-year age group and adults older than 80 years. In both cases, increased activity and desire for improved quality of life are the reasons behind the increased demand. Emotional health, social function, and physical comfort are all affected by the pain of an arthritic joint.

That 45- to 54 year age category is an interesting one. Right now, that’s the fastest growing group of patients seeking the services of an orthopedic surgeon for joint arthritis. And the group is growing in number by leaps and bounds. By the year 2030, the number of folks in this age range will increase from 59,000 to one million.

Surgeons, health care administrators, and physical therapists are all working together to find ways to reduce hospitalization and complications after orthopedic surgery. Total hip and total knee replacements are so common now that they have become the focus of attention in this area.

A faster approach to rehab and recovery called the accelerated protocol has been developed for total joint replacements. The idea is to shorten the time to recovery. The goal is to reduce costs without adverse effects on the patient’s recovery.

There are many ways in which the accelerated treatment plan is different from the standard postoperative care. Right from the start, the accelerated group is treated together. Together, as a group, they receive information and patient education about the procedure before hospitalization. The standard protocol calls for individual patient information one-on-one the day of the surgery.

Patients in the accelerated group are all placed together in one separate part of the hospital surgical ward. In the standard approach, joint replacement patients are put in rooms randomly on the Med/Surg floor. One nurse is in charge of the entire rehab team of nurses, physical therapists, and occupational therapists. In the standard care approach, each health care professional works independently and there are various nurses in charge.

Accelerated patients begin rehab with the physical and occupational therapists on the day of surgery. Daily goals are preset. Therapy is intense and designed to get them up and moving as quickly as possible. Movement (mobility) and exercise are performed eight hours daily. The standard group doesn’t start until the first day after surgery and they go gradually at their own pace. Mobilization is limited to four hours each day. In addition, a special focus was placed on fluid intake for the accelerated group, including two protein drinks each day.

Studies have been done comparing the results for the two groups. Measurements taken and compared have been based on length of hospital stay, health-related quality of life, and any adverse effects. In a recent study from Denmark, these measures were obtained for the first three months after surgery. Costs associated with each approach were added up and compared for a year after the procedure.

Evidence from this particular study points to the use of an accelerated pathway after surgery for both hip and knee replacements. The benefit to society in terms of cost savings and to the individual patients is evident.

You’ll probably want to ask the orthopedic surgeon this question. He or she may have a general idea given the condition of your mother before surgery, the type of surgery being done, and the philosophy behind their rehab program.

Studies show that if things go smoothly, there are no complications or problems to delay recovery. The wound heals nicely, there are no infections, no blood clots, and no need for readmission to the hospital. When readmissions do occur, they tend to take place within the first month after the operation.

Some surgeons follow a standard rehab protocol but others have now adopted a more accelerated (faster) approach. Patients move through rehab with an aggressive program of mobility and exercises. They tend to do things with a group of patients having the same surgery rather than following a single or solitary path. By doing so, they regain motion, strength, and function much faster.

If your mother is in good health and moves through rehab quickly, she could be discharged early. She can go home and continue her exercises and navigate her daily self-care and household activities with less and less help. Expect at least a one to two week period of time providing assistance at home. With any complications or set backs, this time period could be extended up to a month or more.

Total hip replacements are well designed but still only last 10 to 15 years for the average patient. Younger, more active patients put more stress on the implants than older, sedentary adults. So if the implant only lasts a decade or so, another surgery is going to be needed. With each operation, there is a small amount of bone loss and the potential for problems. Studies have shown surgeons the need to evaluate each patient carefully and avoid surgery too early in the disease process.

Fortunately, a new way of treating disabling hip arthritis in younger (less than 65 years of age) patients is now available. This procedure is called a surface replacement arthroplasty (SRA). SRA is a type of hip replacement that replaces the arthritic surface of the joint. But it removes far less bone than the traditional total hip replacement.

The surgeon shapes the bone of the femoral head and then fits a metal cap snugly on top of the bone like a tooth capped by the dentist. The cap is held in place with a small peg that fits down into the bone. The patient must have enough healthy bone to support the cap. The hip socket may remain unchanged but is usually replaced with a thin metal cup.

No one is sure yet how long the SRA will last. Studies so far report excellent results in the first five years. That buys the patient some time before converting to a total hip replacement. It’s a nice stopgap measure for patients like you who are too young for a total hip replacement but too disabled to wait years and years for the help they need now.

That’s a very good question. It might be helpful to think about your father’s level of activity before the hip fracture. This will help you identify what he could do before the injury and set that as the end-goal or at least the focus of your/his direction.

Some simple things you can use to measure activity level might be how far he walks in a day. Purchasing a simple pedometer that counts footsteps will give you a fairly accurate estimation of footsteps. Have your father wear this for a three to five days just to see what his daily distance might be and perhaps get an average over that period of time.

The goal might be to increase the number of steps taken each day by 10 or 20 or 50 paces — whatever seems reasonable and do-able. Don’t set the goal so high that he gets discouraged and gives up. Start with trying to maintain a base level (taking the same number of steps on most days) and build from there. Expect some ups and downs based on level of fatigue, general health, and motivation.

Your father will most likely have been given an exercise program to carry out each day. Here you can set the timer and record the number of minutes it takes him to complete the exercises. Once he knows the program well, he can work to complete all the exercises in less time. When the average time it takes seems steady (i.e., he can’t get them done any faster without losing the benefit of doing them correctly), then start to increase the amount of time he exercises by one or two minutes each day. That will help improve overall physical endurance.

Those are just a few suggestions to get you started. If you see there’s a problem even getting this simple program going, you may need the expertise of a physical therapist to help get him started and keep on target. The rest can be done at home under your watchful eye.

You may be referring to the recently published Clinical Practice Guidelines for physical therapists treating patients with primary or posttraumatic hip osteoarthritis. Although these were written for physical therapists, there’s nothing wrong with you taking these to your therapist and asking if you have covered everything in treatment that’s appropriate for your situation.

The guidelines are based on evidence from published studies compiled, reviewed, and summarized by a panel of experts. The authors say the guideline will be reviewed again in five years (2013) or sooner if new evidence comes to light. Here’s a brief summary of the main points and recommendations given for physical therapists evaluating and treating patients with hip osteoarthritis:

Surprisingly, even with today’s high-speed technology and ultra-fast communications, not everyone has the same information or ideas about treatment. And that’s true even for common problems like hip osteoarthritis.

However, there is a move in the medical world to help health care professionals get on the same page. That means if you have a health problem, condition, illness, disease, or injury — no matter where you live, you should get the same top quality treatment based on the best evidence currently available.

Toward that end, physicians and physical therapists are putting together something called clinical practice guidelines. As the name suggests, these guidelines are meant to help guide current practice. Most recently, a set of clinical practice guidelines has been published for hip osteoarthritis.

The set of suggestions is based on a review of high-quality studies published between 1967 and 2008. It includes information about the pathology behind hip arthritis, the risk factors, and how the condition is diagnosed or classified.

Other categories reviewed include examination measures and treatment used by physical therapists called interventions. Specific treatment interventions summarized include patient education, gait (walking) and balance training, manual therapy, and exercise. The hope is that therapists everywhere will read and use these clinical practice guidelines when evaluating patients with hip osteoarthritis and when establishing a plan of care.

Though the specifics of exercises might vary somewhat, folks like your parents would benefit from the expertise of two different therapists. They could take whatever written instructions they are given and share it between therapists to ensure a smooth transition between places. It should work out quite well for them.

Hip replacements are made from a variety of materials such as ceramic, polyethylene (plastic) and metals such as titanium, high-carbide cobalt, and chrome. A popular implant has a metal-on-metal (MOM) design. It gives the hip smooth action. But with repeated motions, flecks of metal ions are released into the joint and into the blood stream.

Metal ion release may be a factor in implant loosening. Some patients are hypersensitive to these particles and develop hip pain as a result. And there’s been some question about the possibility of an immune system response to the foreign debris being linked with cancer.

Particles of both cobalt and chromium have been found in urine, blood, and organs of the immune system (e.g., spleen, lymph nodes) and in red blood cells and the liver. There are no reported cases of cancer linked with debris from hip replacements. For now, it’s just a theoretical possibility. This will bear warching in future studies.

Here are a few facts to consider. A quarter of a million people in the United States will fracture their hips this year. One-fourth of those adults die within the first 12 months after that fracture. And only half of those who survive will be able to return home and resume a normal life. Those are very sobering statistics.

Studies show that if this happens to you or to a loved one, motivation level can be a key factor in success. Patients who are highly motivated to participate in their rehab program are more likely to have a positive outcome and successful rehab. But how can we measure motivation? And what can we do to increase motivational levels to ensure better results?

Physical and occupational therapists are looking for ways to answer these questions. Now that patients go home so much faster after hospitalization, it’s even more important than ever that therapists quickly determine what level of participation they can expect from each patient. And it’s equally important that patients fully participate in their own recovery process whenever possible.

In a study conducted at the University of Pittsburgh, patient activity levels, participation/motivation, and function were measured in patients who had a hip fracture without complications. Patient with higher activity counts also had excellent participation scores. The more active patients were, the better their function, too. And these results were consistent when reviewed at the end of three and six months.

Therapists are interested in helping patients post-fracture avoid a decline in function, speed up recovery of function, and foster physical activity to improve function. Looking at activity levels and how these match up to final outcomes is useful information.

Finding ways to encourage patients to increase their activity and participation levels is a key focus of the rehab program. Most of this has to come from within the patient but the staff’s attitude and the family’s encouragement can go a long way in getting older adults to progress past the need for skilled nursing or assisted living and get home once again.