News Category: Hip

There is a concern in the medical world that men and women with broken hips aren’t being checked or treated for osteoporosis. Osteoporosis is a common disease among aging adults. Osteoporosis involves a decrease in bone mass. The result is an increased number of fractures. The bones in the spine, wrist, and hip are affected most often.

When people come to the hospital with a hip fracture, they aren’t always going home with the right care. Anyone over age 55 who has broken a bone should be tested for osteoporosis. Anyone with signs of osteoporosis must be given calcium and some new drugs to fight the disease.

Women after menopause and adults over 55 who have a broken bone are at risk for another fracture. Their current calcium and medication use should be reviewed. Just taking calcium is not enough. They also need enough vitamin D and, when needed, the right drugs to prevent further bone loss.
 
More and more people know about osteoporosis. New drugs to stop osteoporosis are making a difference in the effects of this problem. Both doctors and patients still need more education about this disease.

For example, not all doctors are checking for osteoporosis. Patients with a hip fracture sometimes go home from the hospital without receiving treatment for osteoporosis. Likewise, it isn’t clear if patients who are given the drugs actually take them once they get home. More research is needed to answer this question.

Coaches, trainers, and athletes are always looking for ways to prevent injuries. Hockey players are no different. Strains of the inner thigh muscles are among the most common problems in ice hockey. These muscles are called the hip adductors.

The best way to prevent injuries is to find out how often the injury occurs, and what the risk factors are for that injury. Then researchers can look for ways to reduce the risks and the number of injuries. Preseason testing of muscle length and strength is important in this process.

This study measured the muscle strength of the hip muscles on the inside and outside of the hip. The adductor muscles should be at least 80 percent as strong as the muscles along the outside of the hip, the hip abductors. If the ratio is not 80 percent, an exercise program is advised.

Active training programs can be used to prevent adductor muscle strains in hockey players. This prevents injury and results in a less severe strain when it does occur. Because of this program, injured players don’t miss as much playing time. Preseason hip strengthening is advised for some hockey players, namely those whose hip adductors have much less strength than their hip abductors.

Hip fracture is a bad break in more than one way. It requires surgery and often leads to a loss of function. The patient who gets up and moving in the first few days after surgery does the best. This is easier than it sounds when pain, loss of strength, and the effects of the injury hold us back.

There’s a lot we don’t know yet about treatment after surgery for a hip fracture. What works fastest to get people back on their feet and moving? What’s best over the long term? Do some things work better earlier or later in recovery? Electrical current to the muscles is a good option early on. This is called neuromuscular stimulation. It can be applied while still in the hospital and used at home, too.

Neuromuscular stimulation works well after knee surgery. Now, it’s been tried after surgery for hip fracture. Small patches called electrodes are applied to the large muscle in front of the thigh (the quadriceps). Electrical current is passed through the electrodes for three hours a day, starting one week after surgery. It’s continued for six weeks.

Three-fourths of the patients who have the stimulation walk sooner compared to those who don’t. They are able to walk without a walker, cane, or crutches earlier than those without the neuromuscular stimulation.

Stimulating the quadriceps muscle of the leg with a hip fracture works to help patients regain strength. This allows them to walk sooner. It also helps them get rid of walking aids and walk faster.

Even though hip joint replacements are available, doctors sometimes fuse the joint instead. This is often the case with young patients who have severe hip damage on one side. Most of the time, the damage is related to some form of arthritis. Sometimes an accident or injury leads to infection and destruction of the hip joint. Tuberculosis that affects the bones is another cause of hip joint problems.

Doctors try to fuse the joint in a way that still allows the patient to change or convert to a new joint later on. Most hip fusions last at least 25 years before conversion to a new joint. When the patient has back, hip, or knee pain that gets in the way of everyday life, it may be time to convert the fusion.

The conversion from a fused joint to a new hip joint is difficult. An experienced surgeon is needed. Even then, problems after the operation can occur. Complications after conversion include nerve damage, infection, loosening of the implant, and hip dislocation. Rarely, a bone may fracture.

Records kept over the years by doctors who have done this surgery are helpful. Several studies report that converting a fused hip to a total hip replacement has a good outcome. There are some possible problems, but these are limited with a good surgeon.

If you are under 50 years of age with severe hip problems, you know that a total hip replacement often isn’t possible. The reason for this is that joint replacements don’t last forever. The average replacement is revised 15 to 20 years later. For a young person, this means an operation and new joint two or three times. There are too many risks with so many operations.

For teenagers or young adults with disease in one hip, there may be another choice. Hip fusion, called arthrodesis, saves the bone and gives pain relief for a long time. If the hip is fused in the right position, the other joints can be spared added stress. A good joint position also saves muscle bulk and strength.

Hip arthrodesis in the young patient has another advantage. It still allows the hip to be replaced with a new joint years later. This process is called conversion. The fusion is usually converted to a joint replacement when there is chronic back or knee pain.

There are other reasons to consider a conversion. Poor hip position from fusion may also result in loss of function. The patient has trouble getting shoes and socks on or using the toilet. Sexual activities may be difficult because of the loss of hip motion. If the leg is turned inward too much, the patient may actually trip over the turned-in foot.

Hip fusion is not the best way to treat severe hip problems in a young patient. However, it is an option that may buy some time while keeping the patient active and free from pain.

There are many different kinds of artificial hip joints. Some require a special type of cement to hold them firmly in place. Some newer types use no cement. “Cementless” designs are made so that the nearby bone grows into pores within the joint, holding the joint in place. Both types of artificial hip joints seem to work well. But does one type work better?

This study tested two types of artificial hip joints. One type used cement, and the other did not. Both were made of a titanium alloy. Doctors put the joint with cement in 124 patients and the one without cement in 126 patients. All the patients had osteoarthritis (OA) in the one hip joint.

Doctors followed the patients for an average of six years. Both groups had improved function and quality of life getting a new hip joint. But there was a definite difference in performance between the two types of new joints. Over 10 percent of the cemented joints failed and needed to be fixed. This compares to only about five percent of the cementless joints. The authors call the 10 percent rate “unacceptable.” Clearly, for the type of artificial hip joint studied here, no cement appears to have been the best choice.

Osteoporosis, a condition of low bone mass, is the most common cause of hip fractures in adults over age 65. Bone becomes thin and weak with fewer bone cells. Osteoporosis can cause fractures in any bone, but fractures in the spine, wrist, and hip are the most common.

Hip fractures can lead to death in 10 to 30 percent of those affected. The good news is that more and more patients are having successful hip fracture repairs. Doctors are now shifting their attention to better function after surgery.

Bone mineral density (BMD) is a test that can measure for osteoporosis. When measured at the femur (top of the thigh bone), it gives a rating for the risk of hip fracture. It can also help predict recovery after fracture. Muscle strength is another measure of recovery after hip fracture.

Doctors aren’t sure yet if muscle strength, BMD, and recovery are linked after hip fracture. They do know that femur BMD after hip fracture can’t predict how patients will do after undergoing rehabilitation. Change in function doesn’t seem to be linked to BMD.

Using BMD measures to prevent fractures from osteoporosis is an important goal in health care. Finding out who may be at high risk of fracture and treating those patients is one step. Preventing disability after fracture is also important. BMD may predict the result after fracture, but not functional recovery after rehab.

Did you know that hip bursitis can mimic back pain? Even though doctors know this, 20 percent of the LBP cases caused by hip bursitis aren’t properly diagnosed. There are many possible reasons for this.

Hip bursitis is a painful irritation on the side of the upper part of the hip. A jelly-like sac called the bursa sits between the hipbone and a tendon. It’s designed to offer a cushion for the tendon as it slides over the bone. Hip bursitis is part of a larger group of problems called greater trochanteric pain syndrome (GTPS). GTPS is most common in middle age–just about when many vague aches and pains begin.

At first, the symptoms of GTPS may be too hard to pinpoint. This prevents a correct diagnosis. The painful symptoms may move down the thigh to the knee with numbness and tingling present. These symptoms are just like another problem called lumbar radiculopathy. Radiculopathy occurs when pressure from a spinal disc, tumor, or bone spur causes shooting pain and numbness down the leg.

An MRI doesn’t always show a problem with the hip bursa. This can work against the patient who really does have a local irritation of the bursa. There are two ways doctors can confirm the presence of GTPS as a cause of LBP. The first is called the “jump” sign. The doctor puts thumb pressure along the bursa on the outside edge of the hip. When GTPS is the cause of painful symptoms, the tendon visibly “twitches” when pressed. This is called a “jump” sign.

Second, the doctor can inject the bursa with a steroid medicine and a numbing agent. At least half of the time, the injection reduces or takes away the pain. This actually confirms the diagnosis of GTPS. Early diagnosis of GTPS can save patients costly and painful treatment, including unneeded operations.

The ability to keep walking as we get older is vital. This is especially true for adults over age 90 who fracture a hip. Immobility or bed rest can lead to a decline in mental function. Lung and urinary tract infections increase when older adults are on bed rest. These complications can be life-threatening.

For these reasons, aging adults with a hip fracture are treated ASAP (as soon as possible)! But how successful is this approach? Doctors in Japan tracked 60 patients with hip fractures who had surgery. They followed the patients’ progress for at least one year and as long as four years.

They found that being able to walk is a very important factor in success of the operation. Patients who could walk after the operation lived longer. In other words, patients who are unable to walk after surgery for a hip fracture have a greater chance of dying.

Patients with dementia are also at risk. It’s not that they forget how to walk. The authors of the study report that patients with severe dementia just don’t respond to rehab afterwards. Patients without dementia regain the ability to walk more often than those with severe dementia.

Adults 90 years and older with hip fracture are helped by surgery. It should be done as soon as possible after the injury to avoid complications. Getting patients back up on their feet and walking is a key factor in the success of this operation.

Epidemiologists study the big picture of disease. They look at data to find out how a disease affects the population as a whole. Epidemiology doesn’t just produce facts about disease. It also gives information about how the health care system works.

This article is about the Epidemiology of total hip replacement (THR) in the United States. The authors analyzed data from Medicare records of people 65 or older over the course of one year. They focused on patients who had THR or revision THR surgery, but not because of hip fractures, hip infections, or cancer. The authors discovered some interesting facts about THR.

An “enigma” is something that’s hard to understand, something puzzling. Thigh pain after a surgery for a new hip joint is one of such puzzle. This enigmatic pain can occur when a cementless implant is used. Doctors report several possible causes.

Sometimes the implant is too stiff for the bone. It doesn’t “bend” enough so that stress builds up between the bone and the implant. The shape and size of the implant are also important. There is a greater chance of thigh pain with a larger implant.

The quality of the patient’s bone is also important. Poor bone structure from osteoporosis results in a “less stiff” bone. The zone between the implant and weaker bone may be mismatched. Thigh pain can be the result.

This pain is usually described as a dull ache. There is no fever and no history of trauma or illness. The patient often points to the spot where the tip of the implant is located. Some patients report only mild discomfort. Others walk with a limp and need to use a cane or walker. The pain can be severe enough to limit activity. The patient may even need pain medication.

Doctors are working with companies that make joint implants to find a better joint replacement. The goal is to design one that is firm enough, but not too stiff. In general, a joint replacement done without cement is less likely to come loose than one held in place with cement. The right size and shape to match each patient is also important in preventing thigh pain.

Hip fractures at any age are serious business. These are most common in adults over 65 years of age. However, younger adults can break their hips, too. Breaks in younger people are most often caused by a serious fall, car accidents, or an activity such as water skiing.

One serious hip fracture occurs at the top of the long thighbone (femur) in an area called the femoral neck. The neck connects the femur to the ball at the top of the hip. The ball is sometimes called the femoral head. A fracture of this type separates the femur from its head. It’s called a subcapital hip fracture. If left untreated for too long, loss of blood can occur with death of bone tissue.

The usual treatment for younger adults is surgery to repair the break. Screws are used to hold the bone in place while it heals. Older adults are more likely to have the hip joint replaced.

Doctors want to prevent serious problems like avascular necrosis. This is a loss of blood flowing from the femur through the neck to the head. The head of the femur will collapse and die without enough blood. If the surgery can be done within 12 hours, there is much less chance of blood loss. The longer the surgery is delayed, the greater the risk for avascular necrosis.

Hip fractures in any adult of any age are an emergency. Surgery is usually needed as soon as possible. This will help prevent problems like blood loss to the head of the fumur and resultant death of bone tissue. This is especially true after a subcapital fracture of the femoral neck. In fact, delay in surgery is the number one risk factor for these problems.

Smaller may be better in joint replacement surgery–smaller incisions, that is. The trend in most joint replacement surgeries is to use the smallest incision possible. The thinking is that smaller cuts do less damage to the surrounding tissues. This can mean fewer complications and quicker recovery.

This study looked at the possible benefits of a type of hip replacement surgery that uses very small incisions. Researchers compared it to a more common type of hip replacement surgery. Both groups got good results from their surgeries. They had about the same rate of complications after surgery and got out of the hospital in about the same amount of time.

But the “mini-incision” group had shorter surgeries. They also had less blood loss and needed fewer blood transfusions during surgery. The mini-incision group walked sooner after surgery and needed less help with moving around. Patients in this group were also less likely to need high levels of nursing care after leaving the hospital.

Researchers tested to see if mini-incision hip replacement worked for obese patients. It seemed to have the same benefits for them. However, the incisions did need to be somewhat larger, and obese patients had more blood less than thinner patients.

The authors emphasize that surgeons need to practice the techniques of mini-incision hip surgery. But clearly, this specific type of mini-incision hip replacement surgery can maximize benefits in the operating room and right after surgery. The senior author now uses mini-incision surgery for all his hip replacements.

Coxa saltans . . . sounds like a new snack cracker, but it really means “snapping hip syndrome.” As the hip is moved forward, a snapping or popping occurs. This can be felt and heard.

This is caused by a tendon snapping over the pelvic bone. Usually, the iliopsoas tendon is the problem. This tendon and its attached muscle bring the hip forward into flexion. If the tendon is tight as it passes over the rim of the bone, painful snapping occurs when the leg is flexed. This is present over the front of the hip close to the groin area. It often happens during or after exercise.

The initial treatment for coxa saltans is antiinflammatory medications and physical therapy. The therapist uses deep heat, massage, and stretching to treat this problem. Manual hip traction and exercise are also part of the program. This treatment works well for two thirds of the cases. The rest may need surgery to lengthen the muscle. In all cases, the problem is solved with either physical therapy or surgery.

A new method of releasing this tendon has been reported. Doctors use the crease of the groin to make an incision. The tendon is cut right where it enters the belly of the muscle. This allows the tendon to slide and gain length right over the rim of the bone. Doing it this way prevents muscle weakness afterwards and the scar can’t be seen.

Persistent snapping hip can be treated successfully. Most cases respond well to physical therapy. When this isn’t helpful, surgery to lengthen the iliopsoas muscle is done. The final results are usually favorable with complete relief from painful snapping. Rarely, a second operation is needed to shave a ridge of bone under the tendon.

Hip dislocation can happen after hip replacement surgery. The highest risk of dislocation is in the months right after surgery. However, dislocations sometimes happen even after many years. Hip dislocations that occur five years or more after surgery are called late dislocations.

Not much is known about late hip dislocations. These doctors went back through the records of more than 19,000 hip replacement surgeries over 25 years. They found that a total of 2.6 percent of these patients had a hip dislocation. About a third of that number was late dislocations.

Late dislocations happened between five and 25 years after surgery. The total number of late dislocations was small–less than one percent of the total patients who’d gotten a new hip. Still, late dislocation was more common than most doctors would have expected.

The authors compared patients with dislocations within five years with those who had late dislocations. They found that patients with a late dislocation were more likely to be women and to have had their surgeries at a younger age. Other conditions like Parkinson’s or Alzheimer’s disease may have contributed to the hip dislocation in some cases. In others, the new hip joint may have been poorly positioned in the initial surgery, making the joint more likely to dislocate at some point.

In large medical centers, doctors are able to replace joints two at a time now. When arthritis destroys the hip joint, it often affects both hips, not just one. Surgery to replace the joint can be done one at a time or both at the same time. If both hip joints are replaced in one surgery, it is called a single-stage bilateral operation.

Replacing both hip joints together reduces the cost of two separate operations. There is less exposure to anesthesia for the patient. The hospital stay is shorter, and the time away from work is less.

Safety is the biggest factor in deciding whether to replace the hip joints separately or both at the same time. When both are done at the same time, there is an increased risk of dangerous blood clots. And the risk of infection is greater because it can occur in two separate wounds. When safety is a concern, the savings is second in importance.

Only certain patients are able to have a single-stage bilateral hip joint replacement. Good health is required. They must be free of any other diseases such as diabetes or heart or lung disease. Any previous history of blood clots prevents a single-staged operation.

Hip joint replacement is the most common bone surgery in the United States. About 170,000 hip replacements are done every year in the U.S. The most common reasons for having this surgery are hip pain and loss of function. These symptoms occur most often because of arthritis or hip fracture. Sometimes bone tumors or trauma cause joint damage that leads to a hip replacement.

Most patients with a hip joint replacement are treated after surgery by a physical therapist. Then they are sent home with an exercise program and self-care instructions. No further therapy is provided. Therapists wonder what happens to these patients. Do they have their full motion and strength a year later? Are the exercises given in the hospital enough for the entire recovery time?

A group of physical therapists have been studying these and other questions. They found that 12 months after a total hip replacement, most adults have gained back their full motion. Pain is not usually present, but feeling unsteady on the leg is a problem. This is called joint instability.

No one is quite sure what it takes to make a joint stable. It likely includes motion, strength, and a sense of joint position called proprioception. Even a small loss in hip muscle strength affects joint stability. Joint stability is needed to prevent falls and injury.

Exercise programs used after a hip joint replacement are not enough. These help patients regain motion and care for themselves, but they do not give joint stability when checked a year later. The first set of exercises should be followed four months after surgery. Then, a follow-up visit with the therapist is advised. Strength, motion, and stability will be measured. An updated and advanced set of exercises should be prescribed. It seems clear that full recovery from hip replacement requires a two-phase exercise program.

Runners are taught to stretch muscles and warm up for a long run to avoid injuries. One of the stretches often included in the exercise program is for the iliotibial band (ITB). This is a thick band of tissue that runs along the outside of the thigh from hip to knee. Other muscles of the hip attach to this band.

When this band gets tight and rubs against other muscles or bone, it can cause ITB syndrome. The friction can lead to pain and severe burning along the outside of the knee. It is the most common cause of knee pain in long distance runners.

There are several ways to stretch the ITB in the standing position. In all three stretches, the leg to be stretched is crossed behind and the person leans away from the side to be stretched. In one stretch, the arms remain down at the side as the upper body bends to the side. In another stretch, the arms reach up overhead as the upper body bends to the side. A third stretch is with the upper body bent forward and the arms stretched across and down toward the floor.

Researchers in a high-tech laboratory measured the effects of all three stretches. Each stretch lengthened the ITB, but the second stretch worked the best. Teaching runners this simple standing stretch may help prevent the ITB syndrome.

Every year, thousands of Americans have their hips replaced with artificial joints. Sometimes these replacements dislocate. This means the ball-shaped bone at the top of the leg comes out of the hip socket. When this happens, another operation may be needed. This is called revision total hip arthroplasty.

Prevention starts with the selection of patients for hip replacement. Certain patients are better candidates than others. Patients with hip muscle weakness and poor mental abilities are more likely to dislocate the new joint. So are patients with drug or alcohol problems.

Proper matching of patients with replacement joints helps prevent dislocation, but this isn’t always easy. Doctors sometimes have problems fitting new joints in place during surgery. If patients have more bone loss than expected, the new joint may not be stable.

If patients can’t or won’t follow directions after surgery, the joint can dislocate. For example, patients are told to avoid certain movements of the hip for at least six weeks after hip replacement surgery. When the surgery is done from the back of the hip (called a posterior approach), patients are not to move the affected leg across the middle of the body or bend it more than 90 degrees. The hip must not be turned in (rotated) at all.

Special care must be taken before, during, and after total hip joint replacement to prevent dislocation. Doctors decide what kind of surgery and replacement joints to use. These depend on patients’ health and mental status, muscle strength, and bone structure.

Total hip replacement is a serious surgery. It is the last stage of treatment when hip pain or disability has finally become unmanageable. Deciding when to have hip replacement surgery is difficult. Each patient makes the decision depending on his or her own health, lifestyle, and fears. It would be helpful if doctors had a clear set of data to help patients understand the risks and benefits of hip surgery at different stages–but they don’t.

These authors tried to fill in some of the gaps in the data. They surveyed 1120 Medicare patients in 12 states who had hip replacement surgery because of osteoarthritis. Patients were asked about their activities and pain level before surgery and during the year after surgery. The idea was to see if patients’ status before surgery could predict outcomes a year after surgery.

The results were mixed. People who had the most pain and the poorest function before hip surgery still had the most pain and disability a year later. This was especially true for the people who had needed help with walking, housework, or shopping before surgery. Most of them still needed help with those activities.

The authors weren’t sure why this was true. Maybe the condition of these patients had gotten so bad that surgery couldn’t help them very much. It is also possible that they had gotten used to the help and found it hard to go back to doing things on their own. But not all the news was bad for the group with the poorest function before surgery. They showed the greatest reductions in pain and disability levels after surgery.

So how can this information help patients decide when to have surgery? It doesn’t give a clear forecast. But it does suggest that waiting until patients need help with daily tasks is not a good idea, even if these patients can still benefit from hip replacement surgery.