News Category: Hip

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.

Doctors agree that patients having a total hip replacement (THR) are at risk for blood clots. But what’s the best way to prevent blood clots from forming? Should a blood thinner be given before the operation? During or after the operation?

In this study two groups of total hip patients were compared. All patients were at high risk for blood clots. Risk factors included age (over 65 years), obesity, heart disease, and previous history of a blood clot. Another word for ‘clot’ is thrombus (one blood clot) or thrombi (more than one clot).

One group got a single dose of heparin, a blood thinner used to prevent blood clots. The drug was given by IV about halfway through the operation but before the hip was replaced. A second group of total hip patients received a single dose of saline (salt) solution in the same way at the same time.

After the operation patients in both groups took aspirin (325 mg) twice a day for one month. Everyone was up and walking the day after the surgery. A special imaging test called magnetic resonance venography (MRV) was used to look for signs of blood clots.

They did not find any clots in the lower part of the leg that was operated on in the heparin group. They did find clots higher up in the pelvic area. This suggests pelvic clots may form at a different time during the surgery. Overall the heparin group didn’t have fewer blood clots. In fact there were slightly more blood clots in this group compared to the control (saline) group.

The authors report this study was actually stopped early. Another study showed the use of pneumatic compression was better than intraoperative heparin in reducing blood clots. Foot and ankle motion are also used along with early walking. Heparin can still be used to prevent thrombi in the lower leg.

Orthopedic surgeons from Wales report on a case of prolonged bleeding after hip replacement surgery caused by ginkgo biloba. A 77-year old woman had a routine total hip replacement (THR). There were no problems during the surgery.

After the operation there was blood and clear fluid coming from the wound. The incision wasn’t infected. The discharge lasted three weeks. She had to go back into the hospital for tests to find the problem.

Blood clotting tests were normal. The doctors took a close look at the wound site. There weren’t any open blood vessels causing the “oozing.” The patient’s use of drugs was reviewed but no clues were found there.

Finally a relative told the doctor the patient was taking gingko biloba (an herbal remedy) to improve her mental alertness. Ginkgo biloba does have an anticoagulant effect. This means it keeps the blood from clotting. The result is bleeding and oozing.

The supplement was stopped and within 10 days the wound was dry. This case report shows how important it is for patients to let their doctors know everything they are taking over-the-counter. Combining ginkgo biloba taken with other anticoagulants like aspirin can be dangerous. Anyone having surgery is advised to stop taking anticoagulants because of the risk of bleeding.

After a total hip replacement (THR) patients are restricted in what they can and can’t do. The idea is to prevent early hip dislocation. But do these restrictions really make a difference? That’s the focus of this study.

Two groups of patients with a THR were included. Care before, during, and after surgery was the same for all patients. Both groups were asked to avoid bending the hip more than 90 degrees. Rotating the hip too far in one direction or the other was also limited.

One group (restricted group) had some extra guidelines. They had to use a special abduction pillow between the legs right after the surgery while still in the operating room. Pillows were used in bed to keep the legs apart. Raised chairs and toilet seats were also used. Patients in the restricted group were told not to sleep on their sides. They weren’t allowed to drive or even ride in a car for six weeks.

After six months there was only one hip dislocation. It occurred in the restricted group when the patient was moved from the operating table to the bed. The abduction pillow was in place at the time.

Results of other measures showed greater patient satisfaction in the unrestricted group. They returned to their normal daily activities sooner. This included side sleeping at three weeks after surgery compared to almost six weeks in the restricted group. Driving or riding in a car occurred sooner and more often in the first six weeks for the unrestricted group. In the final measure of outcomes, patients in the unrestricted group went back to work three weeks sooner than the other patients.

The purpose of this study was to find out if extra hip precautions are really needed after a THR. The authors conclude that only range of motion restrictions are needed for six weeks after THR. Use of pillows and added restriction for sleeping, sitting, and driving are not necessary.

Does a smaller incision for total hip replacement (THR) mean less blood loss? Shorter surgery time? Shorter hospital stay? Less need for pain relievers? According to this study from Canada, the answer to all these questions is “no.”

Sixty patients were included in this study. Thirty had a THR using a minimally invasive (MI) incision. MI means the length of the cut along the skin was less than 10 cm or 2 1/2 inches long. An equal number of patients had the standard length incision (up to 22 cm or six inches long).

Patients in both groups were very similar in terms of number of men and women, age, body size, and type of joint problem. All patients had osteoarthritis of the hip. The operation was the same for both groups, except for the length of the incision. The results of the two groups were compared. The authors report no differences between the groups.

The use of a small incision for THR is not new. Many studies using this approach have been reported. The authors of this report point out the use of the term “minimally invasive” is not the correct term to use if nothing else is different in the way the operation is done.

If the muscles and tendons are cut, it’s not minimally invasive. There’s no advantage to a small incision when the soft tissue is disrupted. The scar may look better but the patient’s recovery time is the same.

The authors conclude cosmetic reasons for a small incision should not replace concern for safety and good results. Minimally invasive should not be confused with minimally disruptive.

Imagine having your hip replaced and walking on that leg the same day as surgery. Now imagine going home the same day! That’s the subject of this study. Doctors at Rush Medical College tracked the results of 100 patients who had a total hip replacement (THR).

All operations were done using a minimally invasive approach. This means only two small incisions are made. No muscles or tendons were cut. The hip joint was removed in segments, rather than all in one piece. The joint capsule is cut open but not taken out. A special X-ray called fluoroscopy is used to see what size and shape implant should be used.

Everyone was seen for up to three months after the operation. A rapid rehab program was followed. Results were measured by how soon patients left the hospital, stopped using crutches, and started driving again. Other measures included use of pain medication, number of days to return to work, and how soon they could walk 1/2 mile.

All patients left the hospital within 23 hours of the operation. Physical therapy was started on the day of surgery except for a few patients with nausea. Everyone went home and continued physical therapy. Most patients got rid of their crutches within six days. Patients with jobs went back to work on average in eight days. Not everyone could or wanted to walk 1/2 mile. Those who did (87 percent) could do so by day 16.

During the three months follow-up, no one had to go back into the hospital. There were no infections, dislocations, or second operations. Recovery was rapid with the advanced rehab program.

The authors report that recovery was much faster than ever before at their clinic. They conclude minimally invasive THR is safe. Combined with a rapid rehab program, patients recover much faster.

Zimmer, the makers of total hip implants, has a training program for surgeons. More than 500 surgeons have gone to the Zimmer Learning Institute to learn how to do a two-incision total hip replacement (THR). This new operation is part of a move toward what’s called minimally invasive (MI) surgery.

With MI a much smaller opening is made in the skin. Special tools are used to insert the implant. A special X-ray called fluoroscopy lets the surgeon to see inside the joint and helps guide the operation.

As part of the training the surgeons were asked to report the results of the first 10 operations they did using the two-incision method. This study presents the findings of 159 surgeons who did 851 THRs this way. Zimmer cementless implants were used in all cases.

Data collected included patient age, gender, weight, and diagnosis. All patients had osteoarthritis or arthritis from trauma or injury. Other measures included incision length, operative time, blood loss, and problems after the surgery. The number of fractures, nerve injuries, dislocations, and infections was recorded.

The authors report four key findings:

Doctors know displaced fractures of the femoral neck must be operated on. But what’s the best method of treatment? Should the bones get reset and pinned together with screws? Is it better to remove the top part of the broken bone and replace it with a partial joint replacement? Maybe a complete hip joint replacement works best.

These are the comparisons made in this study from the Department of Orthopedic Surgery at the Lahey Clinic Medical Center (Burlington, Massachusetts). Doctors there compared two groups of patients. The first group had 120 patients who were treated for displaced hip fracture with internal fixation. The second group had 66 patients treated with partial or full joint replacement.

A displaced hip fracture means the bone is broken and separated. Internal fixation is a way to line up the two pieces of bone and hold them together with screws until healing takes place.

Partial hip replacement is called hemiarthroplasty. Usually the head, neck, and upper part of the thigh bone (femur) are replaced in a hemiarthroplasty. A total replacement also includes putting in a new cup or socket.

Doctors compared the results of these two groups. They used number of reoperations, deaths, function, living status, and cost as the measures of success. The authors report no difference in rates of reoperation or death between the groups. The arthroplasty did give patients much more time before either of these events occurred.

Arthroplasty also gave each patient more function. They could live alone longer. Patients treated with internal fixation needed nursing home care sooner and more often. The arthroplasty also cost less than internal fixation.

All in all, the authors conclude that a complete joint replacement was the best treatment for displaced femoral fractures in older adults.

Imaging technology continues to improve doctors’ ability to find out what’s wrong with painful joints. Early treatment can help prevent other problems from developing. In this article, Dr. McCarthy reviews the kinds of joint damage found using arthroscopy. He reports on conditions that doctors didn’t know even existed 10 years ago.

Patients with painful hip symptoms often have normal X-rays and MRIs. Bone scans don’t show anything either. Conservative treatment often doesn’t work. Tears of the cartilage inside the joint and tears of the labrum (rim of cartilage around the socket) can occur. These kinds of problems as well as damage to the cartilage over the bone are called intraarticular lesions. They can be seen using an arthroscope.

The scope is a long needle inserted into the joint. A tiny TV camera on the end of this tool gives the physician a clear view inside the joint. Patients with intraarticular tears often have a telltale catching, locking, or buckling of the hip joint. They also have severe, disabling pain.

The authors conclude that arthroscopy has made it possible to treat a list of hip conditions previously untreatable. The list continues to grow as the use of arthroscopy for painful hips increases. Arthroscopy not only shows what’s wrong, it gives the surgeon a way to correct the problem at the same time.

This study measured hip muscle strength and walking speeds before and after a home exercise program for patients with a total hip replacement (THR). All patients had the THR at least one and a half years. They found that patients who exercised at least three times a week for 12 weeks improved in strength and walking ability significantly.

Two groups of patients with THR were included. The first group did a 12-week exercise program. Hip muscles were strengthened. Everyone was instructed to walk 30-minutes every day. The second (control) group did not get any training.

The training group kept a daily record of how often they did the exercises. The training group fell into two sections: those who exercised 50 percent or more of the time and those who exercised less than 50 percent of the time. These two groups were labeled exercise-high and exercise-low.

The researchers show in this study that the type of exercise done after THR is important but so is compliance. Patients in the exercise-high group made big improvements in strength and function after THR compared to both the exercise-low and control groups. Both the hip with the THR and the other hip showed improved strength. Only the exercise-high group improved in walking speed.

Previous studies have shown that hip muscle strength decreases one to two years after THR. This study reports patients can prevent future hip problems by exercising regularly. A program of walking and specific exercises seems to work the best.

Doctors at the Mayo Clinic report the long-term results of a total hip replacement (THR) after a hip fracture didn’t heal. They followed 99 patients with this problem between two and 15 years after surgery. All patients received the same kind of total hip implant (a cemented Charnley).

Almost all of the hip fractures had been treated first with a metal plate and screws to hold the break together. The bone didn’t heal, and the hips were converted to a THR. Patients were followed on a regular basis at two months, one year, two years, and five years after the operation. Everyone was still seen or contacted at five-year intervals after that.

Results were measured using X-rays, pain levels, and ability to walk without help. Twelve hips needed a second operation. Most were redone because the implant came loose or dislocated. In a few cases, there was a hip infection.

The authors report that the hip implant lasted longer in older men who were not overweight. The implant was less durable in younger patients. In general, the implant didn’t last as long in patients with hip fractures compared to patients without a hip fracture. This may be because fractures repaired first with plates and screws have holes in them. This makes the bone weaker, so the implant doesn’t hold up as well. The high dislocation rate suggests that doctors must choose the implant type and method of surgery carefully in patients with a previous hip fracture that doesn’t heal.

This is the first study to report the long-term results of total knee replacement (TKR) in obese patients after more than 10 years. Other studies have followed patients for shorter periods of time. Researchers compared two groups of patients with TKR. One group had a body mass index greater than 30, which means they were obese. The control group had the same TKR, but these patients were not overweight.

A special computer program was used to match patients from each group. The patients were paired based on gender, age at the time of surgery, type of arthritis, and length of follow-up after surgery. Level of activity after TKR was also measured for each patient.

The researchers reported the following findings:

Does a delay in treatment for hip fracture increase the death rate in older adults? This is the question doctors answer in this report. The answer to this question isn’t easy. Most patients who have delays until surgery are sicker. Death may be linked more with their poor health than with the delay in the timing of treatment.

Records were studied for more than 18,000 Medicare patients. All were over age 65 and had a closed hip fracture. (A closed fracture means the broken bone didn’t break through the skin.) According to this study, delays are more common for patients who break their hips over the weekend. Patients admitted to the hospital on Saturday, Sunday, or Monday have a delay of 1.22 days. This delay is only 1.13 days for patients who come to the hospital Tuesday through Thursday. A delay of two days or more increases the risk of death by 15 percent in the first 30 days after fracture.

Delay in treatment for hip fracture does increase the risk of death in adults over age 65. The results of this study raise more questions. Should patients have surgery immediately after admission? Should surgeons and operating room staff be kept on standby alert over the weekend? It’s not yet clear that the extra cost is worth it. More studies are needed before changing hospital policy.

Most surgeons agree that sexual activity can be resumed safely after total hip replacement (THR). The patient usually must wait one to three months after the operation. Certain positions are safe to use. But according to this study, doctors rarely talk about sexual activity with their patients.

Doctors who are members of the American Association of Hip and Knee Surgeons took a survey on the topic. They were asked how often patients ask questions about sex after THR. They were also asked how often they bring the topic up.

Data on hip dislocation during sexual activity was collected. The surgeons also looked at sketches of 12 common positions used during sexual activity. They were asked to tell which positions are okay and which ones should be avoided after THR.

Eighty percent of the surgeons surveyed don’t talk about sex with their patients. Those who do a lot of hip replacements are more likely to bring it up. Any discussion of sex takes up less than five minutes of the office visit. Twenty percent of the doctors reported at least one case of hip dislocation during sexual activity.

The authors conclude that waiting to return to sexual activity after THR is advised. Wound and muscle healing improves comfort. It also decreases the chances of a hip dislocation. Most hip dislocations happen in the first three months after the surgery.

The purpose of this study was to compare the cost of a total hip replacement (THR) in Canada and the United States. Hospital costs for THRs were collected from three Canadian hospitals and three teaching hospitals in the United States. Patients were very close in age, health, and background.

The authors report that the total cost of THR in the United States is double the cost for the same operation in Canada. Patients stay in the hospital longer in Canada but still have lower costs. The difference seems to be in the cost of the implant.

The cost of joint implants has increased by 212 percent in the United States over the past few years. The same implant from a single source can cost as much as 700 percent more in one hospital than in another. In this study, the researchers found that hip implants cost four times more in American hospitals than in Canadian hospitals.

Overhead costs are also higher in American hospitals. The authors say this is caused by the United States multipayer insurance system. The government-run health care system in Canada has fewer administrative costs.

In summary, the results of this study suggest that Canadian centers try to reduce the length of hospital stay for THRs. At the same time, hospitals in the United States must control the costs of implants.

For the past 25 years, patients with hip arthritis who are too young for a total hip replacement have had an osteotomy instead. In this joint-saving operation, a wedge-shaped piece of bone is removed from the neck of the femur (the thighbone). A metal plate and screws hold the bone together until it heals.

Taking a piece of bone out changes the way the head of the femur rests inside the hip socket. It gives the joint better contact and improves the joint space. The surgeon may even use the removed bone to make a deeper hip socket. This is done by taking the wedge of bone and attaching it to the outer edge of the hip socket. It forms a little shelf or roof over the bone in the socket.

Long-term results of this operation are unknown. In this study, researchers followed patients for up to 25 years after an osteotomy. They found that although the X-rays looked good, the patient didn’t always have a better outcome.

The authors report that patients younger than 50 who have just one hip osteotomy have the best results. Patients over age 50 or who have bilateral osteotomies have a worse result. Pain, range of motion, walking ability, and daily activities were the measures used to rate the outcomes.

Osteotomy is still a good option for severe hip arthritis. Best results occur when the patient is too young for a total hip replacement and only needs an osteotomy on one side. Forming a deeper socket by building a shelf may not be needed.

One thousand in one year. That’s how many total hip replacements (THRs) were done at one hospital in Philadelphia, Pennsylvania. This study reports the results of those 1000 THRs. The hope is to find ways to prevent complications after the operation. The researchers also wanted to know if the complication rate goes down as the number of THRs a hospital does goes up.

All patients were getting either their first total hip replacement or a revision of an implant already in place. All operations were done by one of three senior surgeons. The authors report a complication rate of 7.9 percent for first-time THRs. There was a much higher (16.5 percent) rate in hips that were revised.

There were a total of five deaths in both groups. The exact cause of death was unknown in each case. From the patients’ records, it didn’t look like any deaths were directly linked to the THR. Other data was collected and reported. This included length of hospital stay, complications, and number of patients readmitted to the hospital.

The authors conclude that the number of problems after THR (including death) goes down when the number of operations (volume) goes up. There is a point at which complications plateau. In other words, the rate doesn’t keep going down to zero no matter how high the volume.

X-rays often show changes in the hip joint associated with osteoarthritis (OA). But arthritis may not show up until more severe damage is done. Physical therapists are studying ways to test for mild OA that don’t depend on X-rays. This study is a report on one patient who was diagnosed with OA of the hip based on hip pain and range of motion.

A 43-year-old woman was treated for right hip pain off and on for five years before seeing a physical therapist (PT). The PT gave her a special set of questions to measure pain, stiffness, and function. Follow-up tests included range of motion, strength, and leg length. Her pattern of walking was also reviewed.

The patient had decreased right hip flexion and right hip inward rotation. Trunk and knee motion were normal. Testing showed decreased strength in three groups of hip muscles on the right side. A special test for hip arthritis called Patrick’s test was positive on the right.

Studies show that decreased hip internal motion and reduced hip flexion are linked to OA. This patient’s X-ray confirmed the presence of joint changes from arthritis. Treatment was begun to restore normal hip motion and strength. Reducing hip pain and improving the patient’s gait pattern were also goals of treatment. A program of gentle stretching and proper sitting postures was started. Strengthening exercises were also added.

As the patient’s pain decreased, her motion and function improved. The authors conclude it’s possible to use decreased hip motion as an early sign of OA. This is especially true when more than one plane of motion is affected. Other signs and symptoms of arthritis will likely be present to guide the diagnosis.

Physical therapists often help patients increase muscle flexibility. There are different ways to stretch the same muscle. Which is better: passive or active stretching? This is the focus of a study from physical therapists in the military.

Two groups of soldiers were tested. One group used only passive stretching exercises. The second group did active stretching exercises. All soldiers in the study had low back pain and leg injuries. All had reduced hip extension caused by tight hip flexor muscles.

The soldiers did two hip stretching exercises each. All stretches were held 30 seconds if possible. Each stretch was done 10 times. There was a 30 second rest between stretches. Hip range of motion (ROM) was measured before the stretching program began. ROM was rechecked after three and six weeks of stretching.

The authors report that both groups had improved ROM over time. There were no real differences between the groups. It seems that active or passive stretching work equally well. The authors aren’t sure this is true for older adults, since the soldiers in this study were all young. More studies are needed to compare groups of different ages.

Not all hip fractures are alike. How you fare after a hip fracture depends on the type of fracture you have. Your health before the break is even more important. These are the results of a recent study of 537 patients.

Four different kinds of hip fractures were studied. All patients were older than 50 and had a fracture of the femur (the thighbone). The break was either in the femoral neck or at the intertrochanteric line.

The femoral neck is a bridge of bone between the end of the bone and the round ball off to the side that fits into the hip socket. The intertrochanteric line is at the base of the neck and sits between two bony bumps on the femur.

The fractures were both stable and unstable. An unstable fracture is more likely to collapse or break further. Some fractures were impacted, meaning that the two ends of the bone were pushed into each other. All patients in the study had surgery to repair or replace the hip. Some had screws put in to hold the bones together. Other patients got a new hip joint.

Before and after treatment each patient answered questions to measure function. The authors reported in detail common patient characteristics linked to each type of hip fracture. Blood loss, time in the operating room, and complications were also compared. Death occurred at an equal rate, regardless of the type of fracture.

The researchers in this study set out to describe differences in function and number of deaths after hip fracture. As expected, they found that death was linked to poor health and low function before the fracture. Patients with unstable fractures had the worst trouble with mobility six months later.

Knowing what happens to patients after each type of fracture may help doctors plan the best treatment for each patient. The best outcome still depends on patients’ preinjury health and activity level.