News Category: Hip

Hip replacements come in different types, shapes, and sizes. Most people have a total hip replacement (THR) where both sides of the hip are removed and replaced by an artificial part. The socket, head of the femur (thigh bone), and stem down into the femur are all brand new.

But sometimes only one side (either the socket side or the femoral head side) needs replacing. In such cases, a hemiarthroplasty is done. Sometimes only the surface of the femoral head needs replacing. This is called hip resurfacing arthroplasty (HRA).

HRA has actually been around since the 1930s when the femoral head was capped with ivory, glass, or stainless steel. But there were problems and HRA fell out of use until the 1970s. Femoral resurfacing started up again then but bone loss and loosening occurred too often.

Advances today have allowed resurfacing again with new metal-on-metal implants. Just resurfacing the worn side of the joint saves bone and preserves normal bone stresses needed for normal joint function. Some experts say the resurfacing also saves more of the joint proprioception. Proprioception is the joint’s sense of position.

There are a few problems with HRA. The surgeon can’t adjust the patient’s leg length when using an HRA. This type of adjustment is made for patients who have lost bone from fracture or osteoporosis. Fracture of the femoral neck is more common with HRA. This is more likely to happen if the surgeon is just learning how to do this operation.

Long-term studies of HRA with today’s materials aren’t available yet. Short-term results from a dozen studies show the best outcomes using metal-on-metal resurfacing in young patients (less than 60 years old). Women seem to have more problems than men after HRA. Overall the risk of dislocation is less compared with standard THRs. If the HRA fails for any reason, the patient can always get a THR instead.

Developmental hip dysplasia (DDH) affects five to 13 percent of Caucasian adults. DDH is a shallow hip socket with increased risk for dislocation and arthritis. In this study, CT scans are used to find out how often both hips are affected. The anatomy of dysplastic hips was compared to normal, healthy hips.

Patients were included in the study before they had any corrective surgery. There was no sign of arthritis on X-rays or CT scans. Patients with unilateral hip pain (pain on one side) were examined and put into one of four groups. The groups included patients with DDH in the right hip, the left hip, and both hips. The fourth group of patients had borderline DDH in both hips. Patients in this last group were left out of the study.

The results of CT scans were compared based on gender (male versus female) and differences in hip anatomy. Rotation of the femur (thigh bone) and the angle of the femoral neck called anteversion were compared from the DDH groups to the normal (control) group.

They found a greater amount of anteversion (tilt or angle) in the normal group. Many of the DDH hips were already subluxed (partially dislocated) in the DDH group. The 3-D hip anatomy seen on CT scans helped show that increased rotation of the femur is linked with subluxation. There were no major differences between men and women.

The authors conclude that adults with hip pain and DDH on one side often have DDH on both sides. Subtle changes in hips previously thought to be “normal” are common in adults with unilateral DDH. Transverse pelvic CT scan is a good tool to find hidden DDH on the contralateral (opposite) side.

Long-term studies are needed to see if the abnormal stresses from DDH lead to arthritic changes on both sides in adults with known hip dysplasia on one side.

Sweden has a National Hip Arthroplasty Register. All orthopedic surgeons report information about hip replacement patients to the register. The results of this study come from the data on hip fracture after total hip replacement (THR) that was reported to the Register.

At the time of this study, the register had a record of 242,393 primary (first-time) THRs. An additional 28,000 reoperations and nearly 23,000 revisions were also included. The goal of the study was to find out how many THR patients have a hip fracture after hip replacement. Identifying risk factors might help prevent these fractures.

The authors report dislocations, implant loosening, and fracture were the three top reasons for reoperation after THR. A total of 321 periprosthetic femoral fractures were reported. This type of fracture occurs at the top of the femur (thighbone) near the implant. Minor trauma was reported as the most common event leading to fracture.

X-rays showed a common cause of fracture was a loose implant. A loose stem was reported in two-thirds of the primary THRs and over half of the revision group. Most of these patients knew the implant was loose. They were on a waiting list for revision surgery.

Analysis of data from the Swedish National Hip Arthroplasty Register shows a rise in the number of periprosthetic femoral fractures. This is an uncommon but serious complication. The authors suspect implant design may be a key risk factor. Fractures were more common in patients who had straight, short implant stems. Surgeons must select the implant carefully when choosing the right replacement for each patient.

Hip problems can be intraarticular (inside the joint) or extraarticular (outside the joint). Arthroscopy can be used to diagnose intraarticular conditions. Arthroscopy is done with the patient under anesthesia. The surgeon inserts a long, thin needle into the joint. A tiny TV camera on the end of the sope shows what’s inside the joint.

Changes in the tissues, damage to the bone, or loose pieces of cartilage or bone can be seen. In this review article, surgeons identify who can benefit most from a hip arthroscopy.

First, patients with hip pain that persists despite treatment are considered good candidates. Second, signs and symptoms of an intraarticular problem supports the need for arthroscopy. This can include groin pain or upper thigh pain that goes down the leg. Locking, popping, and/or loss of motion are symptoms of an intraarticular hip problem.

The doctor’s diagnosis and decision to do arthroscopy are based on a physical exam, X-rays, CT scan, or MRI. X-rays only show the true cause of hip pain in about 25 percent of the cases. CT is used to look for bone fragments after trauma or injury.

MRI shows the soft tissues and condition of the bone. Injecting a dye into the hip and viewing the joint with special imaging called fluoroscopy is sensitive for labral (cartilage) tears.

When none of these tests leads to a diagnosis, then hip arthroscopy may be the next step. Older patients with severe arhtritis are not likely candidates for hip arthroscopy. Younger patients with fairly recent hip pain and who are not obese have the best results and the fastest recovery time.

There’s a band of tissue along the outside of the thigh called the iliotibial band or ITB. In a small number of people (usually women) a thickening of the posterior edge of the ITB can cause a condition called the external snapping hip syndrome. When the patient bends or flexes the leg up, the ITB slides over the hipbone and “snaps.” Pain occurs with the snapping if the bursa (protective pad) between the ITB and the bone gets inflamed.

In this study, surgeons use an endoscope in a closed operation to cut the ITB. Results were compared to the open cut method of operation. Ten patients were included. Nine were women; one woman had both hips done.

The authors carefully describe the surgical method. Patient position, use of supports, and draping are described. Saline (liquid) is injected between the bone and the ITB to develop a space under the ITB.

After a small opening is made, an arthroscope is inserted. A special needle (endoscope) is used through the arthroscope to cut a diamond-shaped portion of the ITB and release the tension. The bursa is taken out. The patient is tested for any snapping left over. When the snapping is all gone, the saline is removed and the incision is closed.

Results were 100% for pain relief. One patient still had snapping but no pain. The authors conclude that endoscopic release of the ITB for snapping hip syndrome works well. It offers a minimally invasive way to surgically treat this problem when nothing else works. Studies with more patients and longer follow-up are still needed to confirm the use of this operation.

Total hip replacements (THRs) aren’t always successful. Sometimes infection, fracture, or loosening of the implant means the patient needs another operation. In this study 16 patients who had previous hip operations now had major bone loss in the femur (thigh bone).

Treatment of a failed THR with a large piece of bone missing is a challenge. Surgeons at the Allegheny Hospital in Pittsburgh, Pennsylvania used a custom-made femoral replacements. Each implant had to be special ordered. The first three implants used were customized further in the hospital’s machine shop by the senior surgeon.

The old implants were taken out. The femoral implant (a long rod-shaped device) was put in the canal of what was left of the patient’s femur. Cross-locking screws were used to hold the rods in place wherever there wasn’t enough bone.

All but one patient had a good result. No one had an infection or hip dislocation. X-rays showed the bone was starting to thicken and fill in around the rod and screws. The authors conclude this method of reconstruction for severe femoral bone deficiency works well. There is a wait of six to eight weeks for the custom-made rod. There’s also a risk of bone fracture when holes are drilled into the bone.

Patients in this study will be followed long-term to see what the final outcome is for deficient bones treated this way.

In this article, orthopedic surgeons review the use and cost of surgical treatment options for a displaced femoral neck fracture. This type of break occurs near the top of the femur (thigh bone) just below the femoral head (round ball) that fits into the hip socket. A displaced fracture means the two ends of bone have shifted and no longer line up on either side of the break.

Hip fractures are a common problem in the aging population. And the number of people over age 65 is going to explode as the baby boomers reach this milestone. More cases of osteoporosis and hip fracture are expected as the human life span keeps increasing.

Surgeons must be prepared to treat these patients. They must choose between repairing the fracture or replacing the hip. There are two main choices in hip implants: partial or complete replacement. The surgeon will have to decide which one is best for each patient.

Repairing the fracture with a plate and screws is called internal fixation. It’s a good idea to save the bone whenever possible but many times the fracture doesn’t heal in older adults. They end up having a second surgery to replace the joint. Internal fixation is used for patients younger than 65 who have good bone quality.

If the surgeon decides to replace the femoral head, there are three options to choose from: unipolar hemiarthroplasty, bipolar hemiarthroplasty, and total arthroplasty. Unipolar hemiarthroplasty is a partial replacement. For this type of fracture, only the femoral head is replaced.

Bipolar hemiarthroplasty is a partial replacement of the femoral head but it comes in two parts. The natural acetabulum (hip socket) stays but a metal cup lined with polyethylene fits inside the socket. This allows for motion in two places: the new femoral head rotates inside the plastic cup and the cup rotates inside the acetabulum. This type of replacement is not advised for the elderly. The less expensive unipolar hemiarthroplasty works just as well in less active patients who have fewer years to live.

The authors say that a total hip replacement (THR) is the best treatment option for older adults with a displaced femoral neck fracture. It’s more durable and gives better function. The cost is less than having a failed internal fixation operation.

When making the final treatment decision, the surgeon may have to rely on the patient’s mental status and level of independence and activity. Other factors to consider include the condition of the joint and surrounding bone. Family support and living arrangements are also important factors.

Patients with painful, loose hip replacements are usually advised to have surgery to repair or replace the implant. In this study, researchers look for factors that predict the outcome.

Level of pain and physical function are used as the main measures of success. In particular, how long the patient waited to have the surgery and problems after the operation are evaluated as predictive factors. Patients were followed for up to two years.

The authors report that time waited for revision surgery didn’t affect the results. It turns out that older men had more problems lasting two years or more after the revision operation.

The greater their pain before the second operation, the worse their final results were. Also patients with other health problems were at greater risk for more pain and less function after the revision surgery. Most patients got the maximum gain in the first six months after surgery.

The authors suggest revision surgery for any reason should be done as soon as possible. This approach gives patients pain relief sooner than later. It also decreases the chances that function and pain will get worse while the patient is waiting.

Some patients are put on a waiting list such as in Canada where this study was done. If this is the case, they should be rechecked often. Change in pain (increase) or function (decrease) should bump the patient up higher in the list.

Many older adults are faced with the problem of hip fracture. Which is better? To repair or replace the hip? Elderly patients in good physical and mental health who could still walk before the fracture are advised to choose the total hip replacement (THR).

Long-term studies in Sweden report fewer problems after THR compared to patients with a screw (internal fixation) holding the hip together. Patients with THR had less pain and could walk farther. Hips with internal fixation had 42 percent complications compared to four percent for the THR group.

There were also fewer reoperations after THR (four percent) compared to hip repair (47 percent). Most of the fractures repaired with screws had to be converted to a THR later.

Quality of life (QOL) was also measured in both groups. There was a decline in QOL for all patients. But the decline was minor in the THR group. Complications and reoperations for the internal fixation group resulted in major decreases in reported QOL.

National health care statistics help doctors, hospitals, and policy makers plan patient care and make decisions about medical treatment. A national organization called Healthcare Care and Utilization Project (HCUPnet) collects and reports the data. Here’s what they recently reported about hip fractures.

About 300,000 Americans are hospitalized every year with hip fractures. Most are admitted through the emergency room. About one-third have a partial or total hip replacement. The rest have surgery to repair the fracture. Three-fourths are women over the age of 65.

Hospital stay and cost is about the same for hip fracture repair versus replacement. The average adult stays six and a half days at a cost of $30,000 to $35,000. Most older adults with hip fracture go to a nursing home or rehab facility after they leave the hospital.

Mortality (death rate) from hip fracture is about two percent. This compares to three percent for hip replacement patients who die while in the hospital. Death rate for older adults who die while getting other kinds of treatment is about the same (two percent).

Data from HCUPnet shows us that billions of dollars are spent each year in the U.S. for hip fracture care. This kind of information helps bring to light the need to prevent hip fractures and reduce overall medical costs.

Getting up from a chair, on and off the toilet, and putting on shoes and socks may seem like simple tasks. But for someone recovering from a hip fracture, these are important daily skills that can be slow to return. In this study researchers develop and test a new way to measure function after hip fracture. It’s called the Lower Extremity Gain Scale or LEGS.

In the past, recovery of function was assessed using self-report measures. Nurses and doctors asked the patient (or family member) what activities he or she could (or couldn’t) do.

There are problems with this type of testing. For one thing, patients and their family members or caregivers overestimate the patient’s ability. The family wants to encourage independence. The patient wants to avoid dependence. Typical questions asked don’t always reflect small, but important, changes. Focus on walking doesn’t give the whole picture. The patient may be able to walk, but can’t pick up a sock from the floor.

LEGS gives normal values for function in adults 65 years old or older after hip fracture. Results can be used to gauge recovery. Nine activities such as walking, dressing, and toileting are included. Length of time it takes to complete an activity with or without assistance is taken into consideration. A patient whose scores fall outside the normal values may need more rehab or closer monitoring at home.

The authors report LEGS is easy to give, takes a small amount of time, and tracks patient recovery of day-to-day function. It is a reliable tool to use for adults 65 and older up to one year after hip fracture.

Back in the 1970s blood clots after total hip replacement (THR) were a major problem. Up to eight percent of the patients operated on were affected. Today, thanks to prevention measures, this figure has dropped to less than one percent.

In this study researchers looked at prevention measures used before and during the operation instead of after. Patients were taken off any kind of drug that could cause blood to clot. Patients donated their own blood ahead of time. Changes were made in how the surgery was performed to minimize the risk of clotting.

After surgery patients were given special elastic stockings and a machine to compress the legs. Exercises to keep the feet and lower legs moving were added. Everyone was up and walking on postoperative day 1. Patients were started on blood thinners after the THR. All of these actions taken together are called multimodal prophylaxis.

The results were excellent. The rate of dangerous clots was decreased. In fact the rate was the lowest ever reported. There was a cost savings from not using anticoagulation (drug) therapy. And there were fewer problems without the routine use of anticoagulants.

The authors concluded that multimodal prophylaxis before, during, and after THR can safely replace drugs that increase the risk of bleeding.

Adults are living longer and with that means more hip fractures. Surgery and rehab are the most common treatments for hip fracture. Results aren’t always so good. In this study researchers try to find factors affecting outcome. The goal is to target these factors early for a better outcome later.

The authors report eight things that can make a difference in a patient’s function after treatment for hip fracture. Four of those can be changed or modified. These modifiable factors are 1) shortness of breath, 2) decreased vision, 3) level of albumin in the blood, and 4) decreased folic acid level. Albumin and folic acid are related to diet and nutrition.

Four nonmodifiable factors included 1) function before the fracture, 2) mental status, 3) age, and 4) previous stroke with motor problems. Even though these can’t be changed they can still be used to predict outcome. For example patients at increased risk because of age, mental status, or poor motor function can be monitored early and often. Preventing falls and other problems related to these factors may make a difference.

The authors suggest taking these eight factors into consideration when planning rehab for patients after surgery for hip fracture. Outcomes can be improved with changes in clinical and nutritional factors. Prevention can also be part of the plan.

Medical errors are a fact of life. Doctors do everything they can to reduce errors whenever possible. In the world of orthopedics leg length discrepancy after total hip replacement (THR) is one of the more common types of error. Dr. Clark and his associates from the University of Iowa Hospitals report on this problem.

Patients who are unhappy with the results of their THR often have a leg length discrepancy. This is an unexpected and uncomfortable result. Sometimes there is pain involved because of nerve damage. Problems can occur with walking and balance. Severe neurologic symptoms are possible.

What can be done to prevent this from happening? Dr. Clark advises orthopedic surgeons to do three things. First assess the patient for leg differences carefully before surgery. Ask the patient if the legs feel equal. Do they use a shoe lift? Ask about the history of any conditions that can have an effect on leg length.

Second, check for muscle tightness and measure for length differences. These two steps must be done before and during the operation. Ways to accurately measure leg length are described. X-rays should be examined for any sign of leg length differences. This baseline will be used during and after the operation for comparison. Assess for spine curvature called scoliosis.

Third, the surgeon must warn the patient that equal leg length is not guaranteed after a THR. Tissue scarring and muscle shortening can make the leg shorter. If the longer leg is being operated on, adding the various parts of the hip implant can make it even longer.

Finally the authors discuss ways the surgeon can treat a leg length difference. Time is the first treatment. Soft tissue relaxation and changes can occur during the first six months after THR. In other words the problem may go away on its own. A shoe lift works for some. Others benefit from physical therapy. In the future improved implants, operative technique, and technology will likely do away with this problem altogether.

Adhesive capsulitis also known as “frozen” shoulder is a common problem, especially among middle-aged women. According to this study it looks like a “frozen hip” or adhesive capsulitis of the hip is also a problem in this group.

Nine cases of hip adhesive capsulitis were identified. Patients were followed for more than a year after treatment. Eight were women who had a good result. The one male had degenerative hip changes and no improvement with treatment. Treatment was with hip manipulation under anesthesia followed by arthroscopic exam.

Manipulation is done by placing the patient’s foot on the opposite knee in a figure-4 position. The patient is lying down on his or her back with the affected hip and knee bent. Gentle pressure is applied until the adhesions are broken. Too much pressure can cause a hip fracture. Gentle stretching of the hip and leg is done while the patient is still anesthetized.

The author reports seeing typical findings of adhesive capsulitis during arthroscopic exam. Besides fibrous debris in the joint, there were tears in the cartilage. In some cases there were also tears of the rim called the labrum. One patient had a torn ligamentum teres. This is the ligament that holds the femur (thigh bone) in the hip socket.

This is the first report of hip adhesive capsulitis. The authors suggest it’s more common than once thought. Early identification of the problem may allow more conservative treatment with physical therapy. Surgery may be needed in more advanced cases.

Pain control during and after hip surgery is the topic of this article. Doctors from the Department of Anesthesiology at Duke University write about current trends in pain management. Their focus is major hip surgery. They also predict what will come in the future to help patients recover faster after hip surgery.

Epidural or spinal anesthesia has replaced general anesthesia for hip operations like total hip replacement (THR). Today doctors have even better tools for pain control and pain management.

They can block nerves now and control a specific area like an arm or a leg instead of putting the entire patient to sleep. This is called regional anesthesia. With a regional there is less blood loss and fewer blood clots in the leg(s).

Severe pain after an operation can keep a patient in the hospital longer. This means a higher cost and lower patient satisfaction. Doctors are working to find ways to use continuous nerve blocks for a few days after the operation.

Patients may even be able to go home with this type of pain control. Effects of the drugs given in the hospital might last up to 96 hours at home. Research for a time-released drug is already underway. Safety remains a concern.

Problems can occur after any operation. Nerve palsy after total hip replacement (THR) is one of the worst. Doctors at the Mayo Clinic reviewed 27,000 cases of THR to find out how often this happens. They also wanted to know what the risk factors are to help avoid the problem in the future.

Nerve damage resulting in nerve palsy can leave patients in pain and with weakness that affects their function. Motor nerve palsy doesn’t happen very often. Studies report a range from 0.3 to 3.7 percent. In this study only 0.17 percent of the 27,000 patients had partial or complete nerve paralysis.

Patient chart were reviewed to find out what caused the problem. They looked at type of anesthesia, patient diagnosis, and type of implant used. They compared diagnosis and nerve function before the operation. The type of nerve palsy was recorded (which nerve was affected). They measured the severity of the nerve damage after the operation.

The results showed that half the motor nerve palsies were present within the first 24 hours after surgery. The other half was diagnosed in the first two to 74 days. They found a variety of reasons for the problem. In some patients bleeding put pressure on the nerve.

In a few cases the nerve was accidentally cut during the operation. Patients who had hip dysplasia or arthritis after an injury had a greater chance of nerve palsy. Other risk factors included a posterior incision, cementless implant, and making the leg too long.

Most of the patients didn’t recover. Only about one-third had full recovery. The rest had only partial or no recovery. A large study of this type may help prevent complications of this type in the future.

In this study doctors from the School of Medicine at UCLA take a look at the results of hip fracture treatment in over 1,000 elderly patients. By looking at death rates, type of implants used, and steps to prevention, they hope to improve overall treatment results. Data was taken from 49 California hospitals to give an idea of results across different hospitals.

The authors gave a detailed report of many factors:

Two orthopedic surgeons offer a different way to do double hip joint replacements. They do the two operations five to seven days apart. The patient doesn’t leave the hospital until after both surgeries. Usually both hips are replaced during the same surgery. Sometimes after the first hip replacement, the patient leaves the hospital and comes back six weeks later for the second operation.

Over 32 years, 112 patients had bilateral total hip replacements (THRs) with this unique timing. Most patients had severe osteoarthritis in both hips.

All THRs were done using the same method, though a variety of different implants were used. Over the years the average number of days in the hospital decreased from 25.8 (1972) to 11.8 (2000). Patients were followed for one to 23 years, but on average patients were tracked for about 6.3 years.

The authors report their results compare favorably with other studies of bilateral THRs. Failure rates for patients in this study weren’t any higher than in other similar studies. Patients reported excellent recovery and a high level of satisfaction.

The biggest advantage of using this type of timing occurs during rehab. Both hips do well because rehab is not held back by a stiff or painful hip on the nonoperative side. There is also a cost savings with fewer days in the hospital. The greatest cost savings occurs when both hips are done at the same time.

A small number of patients develop thigh pain after a total hip replacement (THR). Doctors at the University of Miami School of Medicine did this study to find out how thigh pain affects their quality of life (QOL) and activity level.

Two groups of patients were compared. One group had thigh pain after THR; the other group did not. All patients had a cementless THR with the same implant. X-rays were used to check the alignment and fit. Everyone filled out two surveys to measure pain level, QOL, and activity.

The results of this study show that QOL is not affected severely after surgery in patients with thigh pain after THR. Their functional activities are impacted by pain.

Other studies have shown that patients who had thigh pain after the operation often had poor function before surgery. The authors suggest that patient who wait too long to have a THR deteriorate too far and can’t recuperate as fast as other patients.