Walking It Off: Early Walking Predicts Short-Term Results from Hip Surgery

The cost of health care has gone steadily up in the last 10 years. Hospitals must do their best to provide good treatment in as little time as possible. This often means sending a patient home soon after surgery. Going home after surgery requires that the patient is medically stable. The patient must also be able to walk and move without help.

Often hospital staff are already planning the patient’s discharge before surgery even begins. How is this possible? Do they have a crystal ball to show how well someone will do? No, they use a set of “predictors.” In the case of hip fracture, age, mental state, and the ability to get around before fracture predict how well someone will do in the early days after surgery.

Many studies have identified factors that don’t predict how well someone will do after surgery. These factors include type of surgery, type of anesthesia, side of fracture, education level, and country of origin. Researchers keep trying to find new factors that will help with discharge planning. A recently identified factor is the ability to move around the first few days after surgery.

Researchers in Australia found that mobility two days after surgery is a very reliable measure of short-term ability. Patients who could get up and walk by day two were able to go home at the end of their hospital stays. Patients who were not able to walk by day two had to consider other options such as discharge to a rehab clinic or nursing home.

When an older adult has a hip fracture, it is very helpful to know how to plan for his or her recovery from surgery. How well the patient can walk in the first two days after surgery is a good predictor of short-term results. This kind of information helps hospital staff and other caregivers plan for the patient’s release from the hospital. Sometimes it’s necessary to arrange for extra care at home or a middle step before returning home. Knowing who will need this extra care can help caregivers plan for the best possible recovery.

Hips Snap Back into Shape

You’ve heard of snapping turtles, but how about snapping tendons? A snapping hip happens when the hip tendon of the iliopsoas muscle rubs over the hip bone. This medical problem isn’t very common and mostly affects teenagers and young adults. Most of the adolescents with this problem are either dancers or runners (sprinters or long-distance runners).

The problem of snapping iliopsoas is not dangerous or life threatening. However, it can be quite painful. The snap of the tendon over the bone can be felt and heard when the leg moves forward and back. Pain and aching occur in the groin area, making movement difficult.

This problem can be treated with or without surgery. Treatment without surgery means medication, rest from activities that cause snapping, and stretching. Stretching the iliopsoas tendon must take place over a minimum of three months. This combination of treatment works for about one-third of the people affected. The other two-thirds say they feel better, but the symptoms continue.

Surgery can be done to lengthen the tendon. However, hip weakness after surgery has been a problem. To change this, a group of doctors tried a different surgical method. They cut all the tendon fibers at the connection where the muscle ends and the tendon begins. The results were very positive. No one had a measurable loss of hip strength. All of the patients said they would have the operation again if they had to do it over.

Adolescents with painful snapping of the iliopsoas tendon that does not improve with rest and stretching can benefit from surgery. Lengthening the iliopsoas tendon where it meets the muscle is a safe and effective surgery for young patients.

Need a Hip Replacement? Who Ya Gonna Call?

Should you travel to a big hospital for your hip replacement surgery? Or is it just as good to go to the smaller hospital near your home? Studies have shown that patients having some surgical procedures fare better when treated in hospitals that perform a lot of similar procedures. Patients also do better when the surgeon routinely performs that type of procedure. Is the number of surgeries done by the hospital and/or surgeon important to hip replacement surgery?

These authors studied the results of Medicare patients who had total hip replacement or additional surgery on a new hip (“revision” surgery). About 59,000 patients had total hip replacements. About 13,000 had revisions. The average age of the patients was 74. Patients were mostly female and white. Most had arthritis. None had hip fractures.

Many of the patients were treated by hospitals and surgeons that didn’t do a lot of hip surgeries. About ten percent of the hip replacements and half of the revisions were done in “low load” hospitals, in which less than ten of these surgeries were done a year. Half of the hip replacements and three-quarters of the revisions were done by “low load” surgeons, who did less than ten a year.

Patients who had hip replacements in “high load” hospitals (more than 100 procedures a year) had lower rates of death and hip dislocation than those in “low load” hospitals (fewer than ten procedures a year). Patients in “high load” hospitals were also somewhat less likely to have infections.

Patients whose hip replacements were done by “high load” surgeons (more than 50 procedures a year) had fewer dislocations than those operated on by “low load” surgeons. They were also a little less likely to have other complications.

The results for revisions were basically the same. One difference was that the number of procedures done by the surgeon (instead of by the hospital) was related to patient death.

There was no magic number of procedures that changed patients’ outcomes from better to worse. Patients’ results declined steadily as the number of procedures went down. The number of procedures per surgeon made the most difference in hospitals with less than 100 hip surgeries a year. In hospitals that did more hip surgeries, the number done by each surgeon didn’t matter.

The authors feel that there might be fewer deaths and complications from hip surgery if more patients went to hospitals and surgeons that treated a lot of these cases. Still, the authors can’t say what it is about high volume that improves patients’ outcomes. The authors also don’t know whether high volume means better pain control and function for patients. Clearly, more studies are needed.

Arthritic Hips Out of Rhythm: New Rhyme for the Reason

A basic idea in science says that for every action there’s an equal and opposite reaction. If someone gets pushed, the usual reaction is to shove back. The same thing happens when we walk. The foot and the ground each exert a certain amount of force on each other. What if someone has hip pain from arthritis? The natural response is to change how fast and how hard the foot hits the ground. However, the force of the ground meeting the foot doesn’t change. Where does the rest of that energy go?

Interesting question! When it is necessary to change the way we walk, the body compensates by moving differently. The force goes to a different section of the body. Suddenly, the foot isn’t striking the ground on the painful side of the body as hard as it is on the other. The force or action is shifted away from the hip to the pelvis and the knee.

How do scientists know that? Advances in camera technology have made it possible to study how people walk. Specialized cameras can capture movement during walking from all angles. A special plate on the floor measures foot force without the person even knowing it is there. Computer software takes the measurements and does the math. Here’s what researchers have discovered.

People in early stages of osteoarthritis start to walk with shorter steps and slower speeds. They use fewer steps per minute, a measure of cadence or rhythm. Posture changes as they lean forward. This causes a flatter low back with less of an arch or curve. The force through the hip is less because the pelvis (bones between the hips) tilts down to take some of the force instead.

Not only does the pelvis adjust for the change in force through the foot, so does the knee! The knee changes the way it moves when the hip cannot absorb the full force of the ground. As the arthritis gets worse, these changes increase. Over time, these compensatory changes can cause even more problems because the back and the knee have to take more force than normal.

New technology has allowed scientists to show how (and how much) the muscles and joints compensate for early arthritic hip pain. The body has amazing strategies for handling this type of pain. Knowing these kinds of changes begin early in arthritis can help doctors and therapists develop ways to prevent future problems.

Primary Osteoarthritis: What Is It?

What are your chances of getting arthritis of the hip? In the United States, three to six of every 100 Caucasians have a form of hip arthritis called osteoarthritis (OA).

This type of arthritis occurs when the lining of the joints wears away. When this happens, the bones have no cushion and rub together. This damages the joint surfaces even more. The hip and the knee are most commonly affected.

Sometimes people get OA because of another condition that’s already present. A hip condition present at birth called hip dysplasia (shallow hip socket), rheumatoid arthritis in childhood, or any other infection or injury can lead to OA. The term secondary OA is used to describe OA from one of these conditions. When OA is present without a known cause, it is called primary OA.

Researchers are keeping track of how many people develop primary OA. By studying these people, it may be possible to tell who is more likely to have primary OA. Family studies from Sweden, Britain, and the United States show higher rates of hip OA in first-degree relatives (parents or siblings). Very few Black, Asian, or Hispanic people have hip OA. People from Japan and Hong Kong have almost no primary OA of the hip, but they do have more OA of the knee.

People who develop primary OA probably have genetic (inherited) factors present. If you are white and have a mother, father, sister, or brother with primary OA, your chances of getting primary OA are increased.

Goochy, Goochy, Goo: It’s a Brand New Baby–and Hip Joint, Too!

It used to be that women who had hip joint replacements were older and no longer likely to get pregnant. However, young women today with arthritis or hip defects from birth can also have hip joint replacements.

Can women who have this surgery have a successful pregnancy and delivery without damaging the new hip? Yes! With new technology and materials, younger women can have hip joint replacements and still have babies without harm to the hip.

Only a small number of younger women have had hip replacements. In the United States, 138,000 total hip replacements were done in 1996. Three thousand of these were done in women under 45 years of age. It is not known how many women become pregnant after hip replacement. Limited information collected on five women of childbearing age with total hip replacements is available. Women in this group were compared to another group of women in the same age range who had not had babies. A special type of hip joint that does not require cement was used for both groups.

Using the doctor’s examination and X-rays, each woman in the first group was followed through one or more pregnancies. It seems that successful pregnancy with a normal birth can occur safely after a total hip replacement. In these women, the new hip was not affected by any of the pregnancies observed. In fact, there was no difference in results between women who had babies after the hip joint replacement and those who did not.

Leg-Length Difference in the Elderly: How Much Is a Problem?

After an artificial hip replacement, patients sometimes notice a slight but annoying difference between the length of their legs. This difference in length can change the way a person walks. It can also make walking more difficult, requiring more effort. However, the amount of difference that begins to cause problems in an elderly person hasn’t been firmly established. Researchers recently set out to find the answer.

They tested 44 men and women who ranged from age 55 to 86. Participants who were selected for the study had less than 1 cm of difference between the length of their legs. None of them had significant neurological, orthopedic, pulmonary, or cardiac problems.

The researchers added crepe shoe lifts to the participants’ shoes to mimic the effect of different leg lengths. Then the participants were monitored while walking on a treadmill. The researchers randomly varied the height of the shoe lifts for each participant at 0, 2, 3, and 4 cm. At each height, participants were checked for heart rate, muscle activity, the amount of oxygen they used, and the how much air they exchanged. They were also asked to rate the amount of effort they felt they were exerting.

The researchers found that 2 cm of leg-length difference had a considerable effect on how much oxygen was consumed and how much effort participants felt they were exerting. Between 2 and 3 cm of difference in leg length made a big difference in most of the factors that were tested. This led researchers to conclude that elderly patients with significant cardiac, pulmonary, or musculoskeletal problems might have trouble walking with even 2 cm of difference in leg length.

Cha-Ching! The Total Cost for a Hip Fracture Is …

Hip fractures are costly accidents–both to society and to individuals. This Belgian study set out to put a number to that cost. Researchers located 159 women with a mean age of 79 who had suffered their first hip fracture. Researchers then recorded the women’s medical history and medical costs for the hip fracture and over the following year. This data was compared to the same information from a control group of 159 elderly women who were about the same age and lived in the same neighborhoods or nursing homes as the women with hip fractures.

Let’s crunch the numbers. The average cost of hospitalization for the hip fracture was–cha-ching–about $9500 in U.S. money. Medical costs for hip fracture patients was almost $13,500 in the first year after leaving the hospital. This compares to $6170 for a year of medical care in the control group–a difference of about $7300. Much of the difference could be traced to stays in nursing homes (31%) and rehab centers (31%). The rest of the increase was from hospitalizations (16%) and home physical therapy services (14%). Two-fifths of the extra costs were accrued during the three months after leaving the hospital. These amounts compare fairly well to costs in the U.S. and to two other studies that have been done on the economic costs of hip fractures. Whew!

What do all those numbers mean? Older women who have a hip fracture will have about three times the health care costs of older women who don’t have hip fractures. Obviously, the best way to decrease these costs is to avoid hip fractures in the first place. And medical professionals need to refocus their efforts on controlling costs. The authors say that most efforts so far have gone into decreasing the length of the hospital stay. This may help reduce hospital costs, but it may simply shift more of the total cost to the nursing homes. The authors suggest that new efforts should focus on reducing the time spent in nursing homes or rehab centers.

Cost is not simply measured in dollars. It’s also a measurement of life and death. Of the hip fracture patients, 13% died within the year after hospitalization. Only 3% of the control group died. The control group may have been a healthier bunch than the hip fracture patients to begin with, which would skew the numbers a little bit. Still, the higher death rate is a good reminder that hip fractures are serious business–that carry a serious cost in both dollars and in health.

Take Heart, Seniors–You Can Recover from Leg Fractures

Fractures to the legs and hips are one of the main reasons that people over 65 end up in the hospital. But not much is known about how these patients recover. This study followed 30 seniors who had leg fractures in accidents such as car crashes.

Researchers did physical tests of strength and range of motion and asked the subjects questions about their health, activities, and mental state. The subjects were tested an average of almost three years after their injuries.

The results showed that almost all of the patients had recovered very well. Their physical tests showed that the injured legs and uninjured legs functioned at about the same level. The subjects reported a low level of pain. And they even compared well to a control group of seniors who had never broken a bone in their legs.

One surprising difference between the subjects and the healthy control group was the results of the scores on mental state. Even though the subjects had returned to good function and low pain, they showed a much lower mental state. The authors don’t know how to explain this. They note that the lowest scores came from people who had spent a long time in the hospital, and that two subjects were diagnosed with depression. Their responses may have caused a lower overall average score.

These results are somewhat different than other similar studies. The researchers suggest that it could be because their study limited subjects to people who had relatively simple fractures, without other major injuries. The good results could also be because the long follow-up time gave the patients a better chance to recover.

Whatever the case, it’s good news for seniors who suffer a fracture. The results of this study suggest that patients fitting this description will likely get back to the activities they enjoy.

Doctor, Can I Play Tennis after My Hip Replacement Surgery?

Most doctors agree that patients who have had a total hip replacement should avoid playing high-impact sports such as tennis. In this recent study, over half of the doctors told their patients not to play tennis. A third recommended only doubles tennis. Only 14% said it would be okay for their patients to play singles tennis after the surgery.

The danger of overdoing it after hip replacement surgery is that the new implant could loosen up, requiring another surgery to revise the hip joint. Also, there are concerns that the surfaces of the new joint might wear out sooner because of the heavy and repeated strains placed on it.

The authors polled members of the United States Tennis Association from three states. Fifty men and eight women who had total hip replacement filled out and returned the questionnaire. On average, these players returned to the court about seven months after their surgery. Even though they weren’t as quick on their feet, they all reported better performance on the court than when they were feeling symptoms before surgery. By eight years after surgery, only 16% reported pain or stiffness on the court. The authors reported a 4% failure rate, meaning that three hips eventually had to be revised.

Readers must keep in mind, however, that this study compared highly competitive tennis players who were members of the United States Tennis Association. The authors acknowledge that this can lead to “selection bias,” since patients who had stopped playing or who were unable to play after hip replacement surgery would likely have discontinued their membership. As a result, these patients would not have been part of the study.

Therefore, the conclusions of this study must be viewed cautiously and should not be used to say that anyone who has had a total hip replacement would be safe to play tennis, that their game would improve, and that they probably wouldn’t end up needing a revision.

The authors insist that doctors not use this research as a basis to advise people on continuing to play tennis after having a total hip replacement. They also say that doctors should “advise caution in tennis activities.” Further, the authors recommend that doctors who allow their patients to play tennis should follow these patients on a yearly basis to make sure the joint and surrounding bone are holding steady.

Elderly People Are Hip, Except When They Fall

It’s one thing to design prevention programs to help elderly people avoid a serious fall. It’s another to figure out why some folks have have a greater risk of having such a fall. Knowing the root of the problem could help refine treatments and reduce the cost and suffering associated with falls.

Researchers used three-dimensional technology to see if hip tightness could be related to fall risk in the elderly. Healthy elderly people were compared to a group of peers who’d fallen at least twice in the previous year. The measurements were also compared to the scores of a group of healthy young people.

All subjects were analyzed while they walked at a comfortable pace. The two elderly groups were also scored as they walked quickly. Calculations were taken of how far the hip, knee, and ankle joints moved. Researchers saw the most difference in extension of the hip joint. (While walking, the hip extends when the leg is back.)

Hip extension angles stayed the same in the elderly subjects, even when they walked faster. This is significant, because it means their hips didn’t extend nearly as far as younger subjects. Another major discovery was that hip extension was most limited in the elderly people who’d fallen in the past. Could this be a factor in why some elderly people are at risk falling? If it is, a stretching program to improve hip extension might lower the chances of an elderly person having a fall.

The authors suggest that future studies need to test whether a stretching program to help improve hip extension could help elderly people walk better and keep them from falling.