News Category: Hip

It makes sense that less invasive surgery for total hip replacement (THR) means less pain and faster recovery. But it doesn’t always work out that way. Surgeons from the Mayo Clinic report on a group of patients who had a less invasive two-incision THR instead of the standard posterior approach.

The goal of the study was to see how hard the new method of operating was. They also looked at safety issues and results. Length of time for the surgery was used as one measure.

Complications after surgery were also charted along with return to activity. Activities measured included time to stop using crutches, walker, and cane. Use of pain meds and getting up and down stairs were reported. Return to driving, work, and walking were also included.

Results of the two-incision group were compared to the results for the group who had a posterior approach. All patients in both groups got the same kind of implant. Age, sex, and weight were the same for both groups. All operations were done on as inpatients at a hospital.

The authors say the two-incision approach is technically more difficult and takes longer. It’s also not as safe as the traditional posterior approach. Patients had more problems after the two-incision THR. Obese women were at greatest risk for fracture and dislocation requiring a second operation.

Dr. Swanson from the Desert Orthopaedic Center in Nevada has completed 1500 total hip replacements (THRs). He reports on the first 1000 operations.

All patients had a posterior, single-incision, minimally invasive (MI) operation. The MI method avoids cutting the muscles and soft tissues around the hip. New technology allows for smaller incisions and gentle pulling on the hip structures.

The author describes the surgery in detail. He reports results were satisfactory for 95 percent of the patients. Problems after the MI surgery weren’t any more or less when compared with the standard method of operation.

A review of other studies along with this one concludes that MI THR has better early results than the operation with a full-incision. There’s less bleeding, shorter operations, and fewer days in the hospital.

Most patients are able to get back to their normal activities about one month after the THR. Long-term results seem about the same between the two operative techniques.

The editors of the Clinical Orthopaedics and Related Research journal offer a statement on the use of a newer method of doing hip and knee replacements. It’s called minimally invasive or small-incision joint replacement surgery.

A group of surgeons formed a taskforce to study the results of this new approach. This report reviews what they found from articles, meetings, and talking to surgeons who use this method on a regular basis.

Since incisions have gotten smaller over time even with the standard operation, the authors offer some definitions of a less-invasive operation. It involves an incision half as long as the standard cut. New ways of getting to the soft tissues under the skin are also used. There is less muscle cutting.

Patient selection, advantages, and disadvantages are reviewed. A wide range of opinions is offered on these three topics. The authors point out the need for more research. It’s important to get the same results using the same surgical methods and implants on the same kinds of patients. Only then can the new method be given a “thumbs up.”

The final point of this article is to say there isn’t much proof to support the use of a minimally invasive approach. Patients don’t necessarily get better long-term results with small-incision surgery.

One orthopedic surgeon at the University of Missouri School of Medicine compared two ways of doing total hip replacements (THRs). The first group of 96 patients was operated on using a single mini-incision. With the second group (89 patients) the surgeon used a two-incision approach. All THRs were guided by a special imaging X-ray called fluoroscopy.

The goal of the study was to find out if the results were any different for the two groups. The surgeon went into the study thinking there would not be any more problems with the two-incision method compared to the one mini-incision operation.

The results were quite different from what was expected. There were a very high number of problems after the two-incision operation. Fractures, dislocations, and sinking or loosening of the implant occurred. There were problems with wound healing. One-fourth of the patients had nerve damage.

In this study the rate of complications with the two-incision method of THR decreased as the surgeon did more operations. Many studies say that THR with two-incisions is complex and technically demanding. This is true even with the help of fluoroscopy.

The author suggested if an experienced surgeon who only does joint replacements has such a high rate of complications, it’s likely to be even higher for a surgeon with less practice doing joint replacement surgeries.

The risk of hip fractures and problems that go along with fractures increases with age. It isn’t always easy to get back to normal function and quality of life after a hip fracture. Physical therapists in Taiwan studied the use of an extended rehab program to regain function after hip fracture.

They compared two groups of older adults with hip fractures. The first group had home-based physical therapy. The therapist went to the patient’s home eight times over a period of 12 weeks. Exercises included muscle strengthening and range of motion. Balance training and improving function were also part of the program.

The second (control) group went home from the hospital with exercises given at the time of discharge. All patients in both groups were examined four times after discharge up until six months later.

Researchers doing this study report the home-based group did improve significantly. They had better psychologic and physical function than the control group. Their recovery was faster and occurred between one and three months. The control group gained recovery between three and six months.

They concluded that a home-based physical therapy program gives earlier recovery and function after hip fracture. These findings should be looked at carefully by patients’ families, health care providers, and insurance companies.

Some people just don’t do as well as others after a total hip replacement (THR). There is some thought that obesity puts patients at increased risk for problems after surgery. Doctors may even refuse to operate on patients who are overweight. This study reports that body mass index (BMI) is no reason to withhold THR.

Doctors at the Queen Margaret Hospital in England followed 800 patients for 18 months after having their first THR. They measured pain, range of motion, and activity.

They also looked at the number of dislocations, reoperations, and deaths. Problems such as blood loss, infection, and blood clots were factored in as well.

The researchers report no evidence that obesity is linked to problems after THR or failure of the implant. In fact the more obese patients were less active. Less activity means less load on the new joint.

The authors think it’s more likely a group of factors puts patients at risk for failure after a THR. It may be that a two or three medical problems such as smoking, diabetes, and heart disease puts the patient at risk for problems. These conditions are linked with obesity.

More study is needed to sort out all the factors before patients are denied treatment. These patients will continue to be followed to assess medium-and long-term effects of body mass.

Debate continues over a new way of doing total hip replacements (THRs). Minimally invasive THR uses two small incisions instead of one long cut. Previous studies report the pros and cons of this method. This report is a case study of one patient who developed heterotopic ossification (HO) after a mini-incision was used to replace her hip.

HO is the name given when bone grows outside of its usual location. In this case the bone grew in the muscles around the hip joint. The woman lost full hip motion and developed pain. An X-ray was used to make the diagnosis.

The patient didn’t have any of the usual risk factors for HO. The authors of this case report say there may be more trauma linked with the minimally invasive operation than previously thought. The development of HO may be the first sign of a new complication with minimally invasive THR.

In this study doctors from the Mayo Clinic report on five cases of joint replacement in patients with osteopetrosis. Osteopetrosis also known as Albers-Schonberg disease is a bone disorder of varying severity. The bones are very dense but also break easily. The cavity for bone marrow doesn’t form.

Arthritis and fractures cause joint problems. Joint replacement may be an acceptable form of treatment. The hard, brittle bone without a normal cavity may make it difficult to put a joint implant in place. Long-term results are unknown.

In these five cases patients either had a total hip or a total knee joint done. Patients were followed from one to 20 years. Everyone had a good result with few problems related to the joint replacement.

The surgeons report surgery time was longer than usual for patients with osteopetrosis. Hard bone and lack of a normal canal for the implant stem increase the normal operative time.

Long-term results in these five cases were good. None of the implants loosened. No one had a bone fracture around the implant. The general conclusion is that patients with osteopetrosis can benefit from joint replacement.

Total hip replacement has become a very popular and successful operation. But some patients are unhappy with the results. The goal of this study was to see if rehab advice before surgery can help patients recover after surgery is done.

Two groups of patients were studied. All had the same type of cemented total hip replacement. One group got the standard care. The other group was given a hip exercise class two to four weeks before the operation. In the class they learned how to do the exercises that would be given after the operation. They also learned how to use a walker or cane and got a special booklet. The booklet gave information about the surgery and answered frequently asked questions.

Results were measured in both groups using pain, function, patient satisfaction, and quality of life. A special test was also used to measure positive and negative mood. This showed the researchers if the patient was positive or negative about life in general.

The authors report that the group with advice before surgery had higher levels of satisfaction at discharge and three months later. Everyone in both groups had better function. The biggest difference between the two groups was length of hospital stay. The advice group left the hospital three days sooner and needed less occupational therapy. The cost savings per patient was about 800 dollars. The cost of the class was 20 dollars per patient.

This study supports the use of advice given before hip joint replacement. Information on what to expect and how to do the rehab exercises before the operation saves money afterwards. Patients have better function and seem happier with the overall results.

This case report reviews the progress of a 68-year old woman three months after a hip fracture. When she finished her first session of physical therapy she wasn’t happy with the final results. She still couldn’t walk long distances. She was unable to go shopping because of leg and body fatigue. She also couldn’t get up off the floor.

A special eight-week program of exercise was designed based on her goals and physical abilities. Exercises to overload the muscles were used. The idea of overload is to exercise a muscle at an intensity level higher than normal. A training response occurs as more and more nerves and muscles respond.

Exercise specificity was added. Exercising the muscles in a particular direction and movement pattern did this. Then the patient was progressed to aerobic training. Riding the stationary bike helped the patient increase her endurance when walking. She was also measured for a shoe lift since the fractured leg was shorter than the other side.

The patient’s strength, walking endurance, and balance improved greatly. She was able to sit down on the floor and play with her grandchildren and then stand up again. She wasn’t able to get back to her level of function before the fracture. This may have been because her extreme fear of falling limited her activity. Or perhaps a longer period of exercise(more than eight weeks) was needed to get better results.

This case shows that hip fracture patients can go beyond the basic physical therapy program after hip fracture. Exercise must be specific and give enough overload to make a difference. Each patient must be examined and the best program for each one determined by a physical therapist.

What factors affect recovery from hip fracture in adults aged 90 and older? Is it age, gender, or spinal fractures? Or perhaps type of surgery or number of days in the hospital makes a difference?

This study looks at the long-term results of 74 elderly patients with hip fracture. All had surgery to repair the fracture. Some had pins put in place. Others had a partial hip replacement.

Spinal X-rays and bone density were measured in all patients to look for osteoporosis. Everyone had some amount of osteoporosis. Ninety percent had one or more spinal (vertebral) fractures.

Walking ability did not improve with surgery. Those who walked well before the fracture had the best results. Many patients ended up either using a walker or wheelchair. Some went from using a wheelchair to being bedridden.

The number of vertebral fractures and the degree of dementia before and after surgery had the biggest impact on recovery. Walking ability was directly linked to these two factors. Other factors didn’t affect walking ability but did predict long-term survival.

The authors conclude that when it comes to prolonging life, preventing vertebral fractures is more important than improving bone density.

Is it reasonable to switch to the newer, minimally invasive (MI) method of total hip replacement (THR)? That’s the question asked by the authors of this article.

Sure it’s nice to have a smaller incision. But it’s not worth taking the risk of a poor result just for a smaller scar. The authors suggest taking a common sense approach to MI joint replacements.

Most important is the reduced tissue trauma with this surgery. The muscles around the joint are protected. The patient has much less pain. Recovery is faster when pain is controlled after surgery.

On the other hand the authors point out that tissues can be less traumatized without a MI approach. Local injection of a numbing agent can be used. Better pain control after surgery is advised.

The results of this study involving 35 patients showed that MI THR isn’t advised for most patients. Instead reduced tissue trauma THR is recommended. Patients get the same high-quality joint replacement that will last a long time.

Yoga has been shown to have many mental and physical benefits. It can be done by very elderly, ill, or disabled people. In this study yoga is used to improve hip motion and stride length when walking. The goal is to reduce falls in older adults caused by age-related changes.

The authors showed that a gentle eight-week program of yoga increased lower-body strength and flexibility. The final result was increased hip extension and increased stride length.

All the people in the study were 62 years old or older. None had any previous experience with yoga. Everyone came to a 90-minute yoga class for four weeks. They also did 20 minutes of yoga at home five times each week. The yoga exercises were for beginner, older adults.

Walking speed and stride length were measured before and after the yoga program. Pelvis and lower extremity motion were also measured. All measures showed a major improvement after eight weeks of yoga.

The study also showed that the more often people did yoga and for longer periods of time, the more improvement they had. The authors conclude a gentle yoga practice can benefit gait function in older adults.

Total knee and total hip implants have a limited life. Most doctors tell their patients to expect the implant to last 10 to 15 years. How long they last really depends on use, not time. Researchers are studying how active patients are and how this affects the implant.

The question asked in this study was how many days of study are needed to measure activity. They compared number of steps taken (walking) on four days and compared it to a sampling over seven days.

They found the level of activity recorded over four days is just as good as counting the number of steps taken over seven days. Researchers will be able to use this information to set up future studies of joint implants. Changes in activity from season to season and year to year will be studied next.

Hip dislocations after trauma can cause knee injuries too. There’s a 93 percent rate of knee problems in patients with hip dislocation after traumatic injury. Most were involved in a car accident. Doctors in Pittsburgh, Pennsylvania, used MRIs, X-rays, and exam under anesthesia to find this out.

Hitting the knee against the dashboard is one common cause of bone bruises around the knee. Bone fractures, ligament injuries, and meniscal tears were also seen with MRI.

After traumatic hip dislocation and surgery, patients in this study were unable to walk for three months. Any injury to the knee went unnoticed until months later. Finding these injuries early can lead to treatment sooner. Early treatment can mean better results for the patient.

The authors of this study advise the liberal use of MRI to find these extra injuries. Not all knee injuries after hip dislocation are obvious. X-rays and physical exam while the patient is under anesthesia will show some knee injuries. MRIs will help show the rest.

Surgeons are under pressure to reduce the cost of total hip replacements (THRs). One way to do this is to shorten the hospital stay. In this study one orthopedic surgeon compared the costs of inpatient versus outpatient THR.

Ten patients were in each group. The outpatient THR patients were admitted and discharged within 12 hours. This was possible using a minimally invasive operation (MIO). One surgeon did all 20 operations. Only a small incision is made for the MIO. There is very little blood loss and less postoperative pain than with the open incision approach.

The author reports the total charges for outpatient THR were $4,000 less than for inpatient surgery. Most of the added costs were linked with drugs, lab tests, room charges, nursing, and physical therapy care.

If only one-third of today’s THR could be done on an outpatient basis, more than $300 million would be saved each year. There may be other factors to think about. Results of the surgery and patient satisfaction are important. More studies are needed to show that the cost savings go along with a safe and effective outcome.

This large study of two groups of patients compares single total hip replacement (THR) with bilateral THR (both hips are done at the same time). Simultaneous bilateral THR decreases time in the hospital and time off work. Only one operation means only one anesthesia. It might be easier to keep everything even (symmetrical) from side to side if both are done at once.

The researchers matched patients in both groups based on the type of implant used. This was important because different implants have different failure rates. Patients were followed for up to 27 years or until death.

The death rate between the two groups in the first year after the operation was about the same. Patients who died within the first year after THR were much older than those who survived.

Differences occurred in post-operative problems. The bilateral group had more lung problems (blood clots) after surgery. Long-term survival, implant survival, and function were the same between the two groups.

The authors conclude that bilateral THRs work well in younger, healthy adults. Information from long-term studies like this can help doctors counsel patients. They may also be able to avoid problems after surgery.

Smaller incisions for total hip surgery are the latest trend in orthopedics. This is called minimally invasive arthroplasty (MIA). But some doctors are concerned that there isn’t enough proof to support the safety of this method. There’s even a question whether MIA is of greater benefit to the patient or marketing boon for the surgeon.

In this study patients with a MIA were compared to patients having the standard surgery for hip replacement. Measures included how long the operation took, length of hospital stay, and amount of blood loss. These are the main measures because the belief is that there is less tissue trauma and bleeding with smaller incisions.

The results of this study confirmed less blood loss in the MIA group. There were also fewer patients in this group who limped at six weeks. There were no other differences noted. Everyone was the same by the end of one year. This last finding is the same as the results after one year in other studies.

This study shows that the minimally invasive method of total hip replacement is safe. Long-term results are not sacrificed for short-term gains with MIA.

In this study 208 patients were followed for two years after spinal fusion. Each one donated bone from the pelvis for the graft. Patients were asked about pain and appearance of the donor site. Pain was measured by intensity and by how long it lasted.

The researchers found that one-third of the patients still had pain two years after the operation. Most of the patients (84 percent) thought the graft site looked “good” at the end of two years. About 16 percent said it looked “fair” or “poor.”

Other studies have reported this problem of graft site pain lasting for months to years. Many of those studies are done by reading the patients’ charts (called a retrospective study). This study was different in that the patients were contacted directly at six weeks, three, six, 12, and 24 months.

The authors report it doesn’t seem to matter which side (right or left) the graft comes from. Whether the graft is removed from the front of the body or from the side doesn’t seem to make any difference either. In all cases, pain occurs lasting weeks to months to years.

This study doesn’t report if pain changed patients’ daily activities. The amount of bone taken for the graft wasn’t measured. A future study might be able to see if there’s a link between amount of bone removed and pain levels afterwards.

Orthopedic surgeons at a specialized hip and knee surgery center review three cases of total hip replacement (THR) that had catastrophic results. All three patients were given the THR by a surgeon outside their center. The patients were sent to the hip and knee center by the first surgeon when serious problems developed.

In all three cases the THR was done with a small incision. This method is called minimally invasive. It’s a fairly new technique that is still being studied. The goal behind this smaller opening is to reduce blood loss and speed up recovery time. So far studies have not supported these claims.

Each of three cases is reviewed in this report. The authors describe what went wrong and what they did to fix it. In one case the patient died before leaving the recovery room. In a second case the damage couldn’t be repaired and the patient had a permanent limp and unstable hip. Only one patient had a successful revision surgery.

These case reports show the need for further study of the minimally invasive THR. This method must be proven safe before it’s used with everyone. The authors say problems like this point out the need for surgeons to get special training before trying a new way of operating.