Which is Better: Metal or Ceramic Bearings in Hip Replacements?

Just like families with multiple generations (great-grandparents, grandparents, parents, children), objects like hip replacements have generations. The first group of hip implants designed in the 1960s are now referred to as first-generation products. Eventually, they gave way to second generation implants in the 1970s and 80s.

Better technology and improved materials led to the switch from cobalt-chromium-molybdenum (CoCrMo) for the bearings used to create motion to cast alloy in the second generation. By the third generation of hip implants (1990s), materials changed again to high- and low-carbon alloys.

In this report, orthopedic surgeons compare the 10-year results when using metal-on-metal bearing versus ceramic-on-ceramic. They also compare the survival rates of these two types of alternative bearings with the more traditional metal-on-polyethylene (plastic) bearings. Each type of bearing has its own advantages and disadvantages.

For example, ceramic materials are at risk for fracture. Metal bearings cannot fracture but they are more likely to loosen requiring a second (revision) surgery. Metal bearings can release tiny particles of metal into the joint, which does not happen with ceramics. Well, to clarify that last point a bit, ceramic debris is possible — it’s just much less than with metal bearings. And the body does not seem to react to ceramic wear particles like it does to the less biocompatible metal debris.

Complications associated with different bearing couples were also reported on in this article. Blood clots to the lungs or in the legs (that could travel to the lungs, heart, or brain) were the biggest concern. Most of the blood clots occurred in patients receiving the metal-on-polyethylene (MoP) implant. But this may not have as much to do with the implant materials as it does with the (older) age of the patients receiving this type of implant.

Other complications were broken down into two main groups: surgical complications (e.g., nerve damage, infection, dislocation, implant fracture) and medical complications (e.g., pneumonia, heart attack, urinary tract infection). Medical complications occurred two and a half times more often than surgical complications.

The need for revision surgery was different among the three types of bearings. Loosening and dislocation were reported in the metal-on-metal group. Fracture of the implant was the main reason for revision of implants with ceramic bearings. Dislocation and infection were reported in a smaller number of patients with ceramic bearings. Metal-on-polyethylene had the least number of revisions due to loosening, infection, or bone fracture around the implant after a fall.

What are some patient recommendations that can be made from these findings? As mentioned, metal-on-metal bearings are more likely to loosen and wear out compared with bearings made of ceramic materials. Therefore metal bearings with polyethylene liners are recommended for older, less active individuals who are going to want this surgery to be their last.

The best bearing surface for younger, active patients will have to be decided on a case by case basis. The surgeon and patient should consider all the pros and cons of the different types of bearings (metal-on-metal, metal-on-polypropylene, ceramic-on-ceramic). The choice of bearings is made according to age, activity level, bone density, and relative risks and advantages of metal-on-metal versus ceramic-on-ceramic bearings. Potential complications must also be examined and every effort made to prevent any anticipated problems.

High Rate of Complications but Good Outcomes for Hip Replacement in the Young

Age 55 used to be considered “too young” for a total hip replacement. Concerns about how long the implant would last, bone loss with future surgeries, and a high rate of complications often meant patients in pain just had to tough it out and wait. Now patients as young as 14 years old are having hip replacement surgery. The authors of this article give us an inside look at the challenges and complexities of total hip replacement in the very young patient.

Most of these surgeries are being done for young adults who have severe hip damage or deformity. Such significant changes to the hip are mostly caused by osteonecrosis (bone death), osteoarthritis (usually the result of a previous injury), or juvenile rheumatoid arthritis. The goals of surgery are to relieve pain, improve motion, and restore function.

One of the reasons total hip replacements are now possible in young adults has been the switch from cemented to noncemented implant (called component) parts. Cementless cups and heads means less bone is lost when removing the implants if and when they need to be redone after 10 or 15 years. Bone loss often means leg length shortening so this feature helps reduce leg length differences, too.

A second reason results are better these days making earlier hip replacement possible is the advancement of surgical techniques. Minimally invasive approaches, muscle preservation, imaging studies to help identify structural deformities also help produce improved outcomes.

But surgeons still face many challenges when working with this group of patients. They often have had previous surgeries. This can mean plenty of scar tissue to deal with, the presence of other hardware (pins, screws, metal plates), and severe muscle and joint contractures (stiffness). Careful evaluation and pre-operative planning is advised (more than is needed for older adults who just have degenerative osteoarthritic joint changes).

The surgeon must choose the best approach and implant possible for each patient. Sometimes this decision requires special imaging studies. Magnified X-rays, MRIs, and CT scans give the surgeon a three-dimensional (3-D) understanding of the joint angles, deformities, bone condition, and bone/joint size. Special thought and care goes into removal of previously used hardware before implanting the new hip joint.

All these decisions brings the surgeons back to the need to find better ways to treat young patients with hip conditions that might require early hip replacement. Joint-preserving techniques are being developed that help improve biomechanics of the diseased or deformed hip joints.

Special surgical techniques have been developed to address problems with impingement and subtle structural problems. The authors provide readers (especially other surgeons) details of these reconstructive surgical techniques. Attention is paid to the complexities involved with children needing surgery who have not reached full skeletal growth yet. Skeletal immaturity is a complex factor to be considered that isn’t a part of hip joint replacement in older adults.

And the results? Well, all the data isn’t in yet for long-term outcomes. Smaller studies reporting a series of patient outcomes have a wide variation in results as measured by implant loosening, number of revision surgeries required, and length of time between implantation and revision surgery. Patient symptoms (pain, stiffness) and function (ability to walk without a limp) are important measures. Patient satisfaction is another way to measure and report results.

The bottom-line is that studies so far conclude that a total hip replacement is an excellent treatment option even for young (very young!) patients. It does require quite a bit of preparation and pre-planning. The procedure can be very complicated because of the presence of deformities, structural or biomechanical problems, and even the effects of systemic diseases that cause these hip problems. But with today’s more modern approaches, results are excellent. Patients can expect some bumps along the road due to the possibility of complications, which still remain high in many cases.

Hip and Spine Problems in the Elderly

It is not uncommon for adults 65 and older to develop hip and spine problems at the same time. Degenerative osteoarthritis of the hip along with degenerative lumbar spinal stenosis (DLSS) is referred to as the hip-spine syndrome. In this article surgeons from the Vanderbilt Orthopaedic Institute in Nashville, Tennessee review this condition.

Starting with the diagnostic process, the authors walk us through the history, physical exam, and diagnostic tests needed to make a differential diagnosis. Differential diagnosis means the physician considers all the possible causes of hip and spine pain presented at the same time and makes a decision about which one is the real, true cause of the problem.

For example, other conditions that can cause symptoms like hip-spine syndrome include bone fractures, neuropathy from diabetes, poor circulation, labral tears of the hip, or even cancer metastasized to the bones. X-rays, MRIs, CT scans, myelography, and electromyography are all ways to evaluate the symptoms patients are presenting with. Sometimes the surgeon must rely on diagnostic treatment such as steroid injection to help sort out what is hurting and why.

Once the source of pain has been identified, then treatment to manage those symptoms is started. For example, conservative (nonoperative) care can be provided first to obtain pain relief before considering the more invasive surgery.

The difficulty is in knowing when two or more different sources of pain are present. The processes related to both conditions could easily be inter-related and affected one another. In other words, what makes one condition worse can also make the second problem worst. Treatment is needed to address all the individual problems before patient comfort and quality of life are restored.

Even when surgery is indicated, physical therapy is recommended first. Restoring balance, alignment, and muscle flexibility is an important part of the treatment process. Studies show a poorer result if problems with posture, alignment, and flexibility are not taken care of before surgery (e.g., replacing the hip without addressing the problem of tight hip flexor muscles).

Treating one problem (hip) without treating the second area (spine) may lead to some relief of symptoms but not all. The patient is not happy nor satisfied with the results. A second surgery may be needed that could have been avoided otherwise.

Patients who have severe spinal stenosis should receive treatment for this problem first, then have a hip replacement when fully recovered. Anyone who experiences pain beyond the expected time (after the first surgery) should be encouraged to see the surgeon for follow-up. A second problem may be diagnosed.

Evidence to Support Surgery for Femoroacetabular Impingement

Surgery for femoroacetabular impingement (FAI) has been reported “successful” but results are only available for the early or short-term postoperative period. This study from Switzerland followed a group of 185 patients treated with open hip surgery for this problem. The follow-up period was at least five years. The measures of “success” included hip range-of-motion, X-ray results, patient satisfaction, and activity level. The need for further surgery (and especially conversion to a total hip replacement) was also recorded.

Femoroacetabular impingement (FAI) causes abnormal contact between the femoral neck and the acetabular (hip socket) rim. Pinching of the labrum (cartilage around the edge of the socket causes damage to the cartilage and to the bone. The result can be a stiff, painful hip with loss of motion and function.

One treatment used for this condition is surgery to alter the anatomic abnormalities that contribute to the problem. For the patients in this study, the hip was surgically dislocated, the tissue was trimmed, and the bone was reshaped to eliminate the abnormal contact that causes this type of pinching.

The goals of surgery are to return the patients to full, normal activities without pain and to prevent (or at least slow down) hip osteoarthritis. Most of the patients with FAI are young, athletes. Patient satisfaction depends on good-to-excellent long-term results. This study provides mid-term results with the intention of following these patients into the long-term.

Outcomes of activity and function were measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the SF-12 Physical and Mental Scores, and the University of California – Los Angeles (UCLA) activity scale. Before and after measurements showed improvement in hip motion and function. Eighty-three per cent (83%) of the group said their hips were normal (or near normal) in the follow-up period.

In general, surgeons say that the surgical method of dislocating the hip allows them to examine the shape and surface of the joint carefully. Surgical hip dislocation gives them an excellent opportunity to repair or detach the excess or frayed labral rim and reshape the bone itself. Restoring normal head-neck angle and position of the femoral head in the socket makes normal hip motion possible.

In summary, surgery to correct femoroacetabular impingement (FAI) has become a standard method of treatment with good results in the short-term. This study shows that this procedure also provides good-to-excellent mid-term outcomes. Defects or lesions (holes) in the cartilage that go all the way through to the bone even after surgical trimming were the most reliable predictor of patient dissatisfaction. This type of deep damage is also the main reason why hip replacement was the next step in treatment.

Long-term follow-up will be able to determine whether open surgery with surgical dislocation to correct FAI helps prevent degeneration of the joint. Slowing the formation of osteoarthritis would be an acceptable outcome as well.

Finding ways to prevent the need for hip replacement in such young, active individuals will be another focus of future studies. And finally, in this study they reported that slim, older women seemed to be most likely to experience a poor outcome. The reasons for this must be explored further with the hope of improving the results for this patient group.

Risk of Hip Impingement Developing

Athletes using hip flexion while trying to internally rotate the hip may end up with some difficulty with this motion if the femur collides with the pelvis. A painful condition called femoroacetabular impingement or FAI may develop.

Left untreated, FAI can progress to become hip arthritis. That would not be good for the young soccer player, swimmer, cyclist, or rowing athlete with the potential for FAI. The authors of this study thought perhaps it would be possible to predict, recognize, and treat early on to avoid late complications like osteoarthritis. They specifically studied individuals with the cam type of FAI.

Here’s a bit of background information to help explain cam impingement. Femoroacetabular refers to the place in the hip where the round head of the femur (thigh bone) comes in contact with the acetabulum or hip socket. Two types of impingement are known to cause pinching of the soft tissues in this area.

The cam-type impingement occurs when the round head of the femur isn’t as round as it should be. It’s more of a pistol grip shape. It’s even referred to as a pistol grip deformity. The femoral head isn’t round enough on one side (and it’s too round on the other side) to move properly inside the socket.

The result is a shearing force on the labrum and the articular cartilage, which is located next to the labrum. The labrum is a dense ring of fibrocartilage firmly attached around the acetabulum (socket). It provides depth and stability to the hip socket. The articular cartilage is the protective covering over the hip joint surface.

The rim of the cartilage hangs too far over the head. When the femur flexes (bends) and internally rotates, the cartilage gets pinched. Over time, this pinching or impingement of the labrum can cause fraying and tearing of the edges and/or osteoarthritic changes at the impingement site.

As we mentioned right at the first, every time the athlete bends the hip up fully combined with internal rotation of the hip, the femur jams into the pelvis. Besides pain, the athlete experiences decreased hip motion, and difficulty with activities like sitting, climbing stairs, squatting, changing clothes, driving, and sports participation.

Three groups of participants were examined and compared to look for risk factors that might predict the development of cam impingement. The first (control) group was completely normal with no symptoms and no evidence of impingement. The second group had a known problem with cam impingement. And the third group had obvious hip changes consistent with a diagnosis of cam impingement but no symptoms of any kind.

Hip motion was measured. CT scans and X-rays were taken. Various angles and ratios were calculated. A special three-dimensional (3-D) motion picture was taken to look for abnormal hip movement/motion patterns.

A special software program was used to help analyze and compare kinematics (joint motion) of the different patients. They also looked at shape and fit of the femoral head in the acetabulum in relationship to hip joint kinematics.

They were able to see that the control group had no risks that might predict the development of femoroacetabular impingement (FAI). Patients in the group without symptoms but obvious changes seen on X-rays were more likely to develop hip impingement compared with the control group but less likely when compared with the group who already had known FAI.

The predictive risk factors for the development of cam-type FAI included: 1) cam size (larger has worse prognosis), 2) acetabular coverage, and 3) amount of femoral rotation or twist called anteversion or retroversion (depending on which direction the hip is twisted). Up to 15 per cent of the general population has one or more of these predictive factors.

It’s clear that people without symptoms and no sign of hip problems don’t need any further treatment or intervention. At the same time, those with painful, limited hip motion and clearly documented femoroacetabular impingement (FAI) need careful management. Surgery is done to reshape the femoral head and reduce the risk of osteoarthritis.

But what should be done to best aid those individuals in the middle group? Remember, these are the folks who have some anatomic changes in the hip suggestive of FAI but no symptoms yet. The authors suggest more research is needed before suggestions and guidelines can be issued.

Questions to be answered by future studies include: 1) Is there any cartilage damage occurring in people with signs of impingement but no symptoms? 2) Should sports participation be discouraged? 3) Or is it only necessary to limit the use of certain hip positions? 4) Will the group with signs of FAI but no symptoms eventually develop a full blown case of FAI?

Running Is Possible After Hip Resurfacing But…

If you like to run but you’ve worn your hip joint out and you need a hip replacement, your running days may not be over. According to the results of this study from France, running after hip resurfacing is possible. But if this describes you, before you put those running shoes on, let’s clarify a few things.

First of all, what is hip resurfacing? Hip resurfacing arthroplasty is a type of hip replacement that replaces the arthritic surface of the joint but removes far less bone than the traditional total hip replacement. Because the hip resurfacing removes less bone, it may be preferable for younger patients. It is an attractive option for those who want to stay active.

Common sense and logic tells us that repeated movements and pounding the pavement with a hip replacement (or hip resurfacing) may not be such a good idea. It is believed that the metal-polyethylene bearings of the implant will break down with increased pressure and load that comes with activity.

But is this assumption really true? What evidence do we have that running activity after hip resurfacing is a bad idea? The first study to look at this more closely has been published. Surgeons from the Department of Sports Medicine at the University of Lille in France studied 40 of their patients who were runners and who received a hip resurfacing procedure.

By measuring the amount of time spent running, level of impact, their weekly mileage, and return to sports competition, they offer us the first look into running activity after this procedure. Symptoms such as stiffness, pain, and weakness were also evaluated. Follow-up took place over the months to years after the procedure (a minimum of two years, up to 41 months).

The younger patients (50 years old and younger) were able to maintain their same level of running after surgery as before. Some runners were even able to run competitively once again. Older patients were more likely to report a decrease in their weekly mileage. Seven of the 40 patients also commented that they felt nervous or apprehensive during sports. A few patients had pain only during activity but not intense enough to need pain medications.

The authors of this study point out that newer implants are less likely to fracture or break with weight-bearing load. Hip resurfacing gives the hip higher wear resistance. More than ever before, these new implants make it possible for patients to resume low to medium level impact sports.

The results of this study suggest that high-impact activities are also possible. Of course, this was a short-to mid-term length study. Long-term results will tell the rest of the story. Patients will be better able to make decisions about the level of physical activity they want to pursue after hip resurfacing when they know what to expect over the entire life of the implant. For now, caution is advised when counseling patients regarding activity level, intensity, and level of impact.

Getting Back Into Action After Short-Stem Hip Replacement

More than ever before, adults are seeking and receiving hip replacements at a younger age and with the intent of remaining active in recreational and sports activities. In this report, a team of surgeons describe their success using short-stem hip replacements for adults who were very active before surgery. The majority of patients in this group of patients returned to sports afterwards as well.

Short-stem implants are just as the name implies. The long part of the implant referred to as the “stem” fits down inside the femur (thigh bone). The surgeon reams out bone inside the femur in order to set the stem down inside and stabilize the implant. With a short-stem implant, less bone is removed making it possible to consider revision surgery later if it is needed.

Patients were selected carefully for this study from a group of adults less than 65 years of age and with no hip deformities. The ratio of men to women was 60 per cent men and 40 per cent women. They had to have good bone stock with no sign of osteoporosis (bone thinning or decreased bone density). They were all given the same short-stem implant with a ceramic femoral head using a modified minimally invasive surgical procedure.

The main measure used in this study to report outcomes was sports participation before and after hip replacement. Various measurements were used such as frequency of sports play (how often each week) and duration of participation (number of minutes each session). They also looked at how long it took for each patient to get back to regular and full participation in sports. And the patients rated their pain from zero (no pain) to 10 (worst pain) during the post-operative time period.

Anyone who did not return to sports was asked for their reasons. And everyone was asked about their overall satisfaction with the results. The group was asked if they experienced fear, insecurity, and/or pain during sports activities. The patients also completed surveys indicating stiffness and level of function after surgery.

Most of the people in the study were able to return to sports participation. But they tended to gravitate toward lower impact activities, which the surgeons thought was a better idea all around. High-impact activities such as running, jogging, or tennis are not advised by most surgeons.

Patients who engage in these types of activities must be warned of the increased risk of implant failure. However, this study did not support the idea that high-impact activities are necessarily detrimental to the short-stem implant. Patients who progressed slowly from low to high-impact activities and sports were very successful.

The authors suggest several factors that might account for the continued good success with short-stem hip implants. First, the surgery is performed with less invasive technique. This allows for less pain, better post-operative motion, faster healing, and a speedier recovery.

Second, improvements have been made in the implant design, which also makes the procedure easier. And third, younger patients in better physical condition before surgery are able to begin rehab sooner and recover with fewer problems or complications.

To summarize, there are more and more adults in need of hip replacement who want (and expect) to stay active. The short-stem implant used to conserve bone in younger patients was studied to see if patients can remain active without loosening or fracturing the implant. Results were excellent with a high degree of patient satisfaction based on return-to-sports at a level desired by the patients.

Review of Metallosis With Hip Resurfacing

In this article, Dr. James W. Pritchett, orthopedic surgeon from Orthopaedics International in Seattle, Washington provides us with an in-depth review of a condition known as metallosis. Metallosis following metal-on-metal hip resurfacing is the focus of this report.

Metallosis is defined as the body’s reaction to the presence of wear debris in the joint from metallic corrosion. This metallic corrosion occurs as a result of two metal surfaces rubbing against each other. In the case of hip resurfacing, there is a metal implant covering the head of the round femur (thigh bone) that sits inside the hip socket. The material is usually cobalt chromium as titanium and stainless steel are no longer used.

Symptoms of metallosis include hip pain, noises coming from the hip, joint swelling, and elevated metal levels in blood. Noise by itself is not very diagnostic. All joint implants make some noise — most of the noise is vibrational and at a frequency the human ear cannot detect. But with enough friction, the noise may become louder. Squeaking sounds are not as diagnostic of metallosis as clunking sounds that can also be felt as a clunking sensation.

Implant loosening is often a natural consequence of metallosis. When examined, the joint tissues are thickened (fibrotic) and have a grey discoloration. Soft tissue masses called pseudotumors (meaning they are like tumors but aren’t malignant or infected) often develop.

Anyone with metal-on-metal (cobalt) implants will have some increase in cobalt in their hair, blood, urine, and organs. It has even been detected in the placenta of pregnant women with this type of hip implant. The placenta is the organ that connects the developing fetus to the uterine wall. It allows nutrients in and other substances (such as metal debris) in and waste out.

To monitor for metallosis, anyone with metal-on-metal hip resurfacing implants is tested periodically to look for rising levels of cobalt in the blood. The diagnosis of metallosis is made based on patient symptoms, blood testing, and fluid taken from the joint. Early diagnosis is important in effective treatment.

Why does metallosis develop in some patients but not others? It remains a mystery why metallosis can develop in someone with a perfect surgical result but not in others who have less than satisfactory implant placement. And regardless of the implant placement, not all patients develop metallosis. So what is the key factor or factors involved?

Experts suggest there may be many different contributing factors making this a multifactorial problem. There could be specific patient characteristics, features of the implant itself, and possibly surgical technicalities at fault.

Some patients may develop hypersensitivity to the cobalt leading to the death and breakdown of bone (a process referred to as osteonecrosis). Since there is no way to test for cobalt hypersensitivity before putting the implant in place, surgeons have no way to predict or avoid the problem.

Others may have a reduced ability to absorb and excrete the cobalt through lymphatic flow, blood circulation, and kidney function. Anyone with impaired circulatory systems involving any of these systems may not be a good candidate for a metal-on-metal hip resurfacing implant.

Treatment is by surgical means. Sometimes it’s just a matter or repositioning the implant to reduce an uneven wear pattern. In other cases, it becomes necessary to replace the metal-on-metal implant to one that is metal-on-polyethylene (plastic). Advanced or progressive metallosis may only respond by replacing the entire hip joint with an entirely new joint.

For surgeons who may be interested in hip resurfacing procedures, Dr. Pritchett offers the benefit of his extensive experience with this technique. Photos, case reports, patient X-rays, and details of surgical technique are offered and discussed. Specific tips for close follow-up and assessment for complications and instability are also provided.

Fractures In and Around Joint Replacements

You finally get some pain relief from that hip or knee arthritis with a joint replacement and then the bone around the implant or the implant itself fractures. Why does this happen and what can be done about it? These are the main points covered in this review article. The focus is on fractures of the femur (thigh bone) around hip and knee joint replacements.

The medical term for a femoral fracture around the joint implant is a periprosthetic fracture. Peri means “around” and prosthetic refers to the implant itself. The series of events that lead up to this new injury start with loss of bone density called osteopenia.

Osteopenia is a natural consequence of the aging process but it leads to loosening of the implant. Combine osteopenia with loss of balance and a fall and the result can be a bone fracture. Studies from the Mayo Clinic report up to 2.5 per cent of hip replacements develop a periprosthetic fracture of the femur. The incidence is higher after a second (revision) surgery (four per cent).

The incidence of periprosthetic fractures of knee replacements is a little more difficult to calculate. But estimates place it at 1.3 per cent in Mayo Clinic patients. Other studies report anywhere from a three percent fracture rate linked with infections up to 13 per cent with knee revision surgeries.

And now there is a new group of fractures referred to as interprosthetic fractures. This type of fracture is located between the hip and knee in a patient who has both a hip replacement and a knee replacement in the same leg. This group of patients is fairly small right now but expected to rise in numbers as more and more older adults who remain active develop painful osteoarthritis in both joints.

What are the risk factors for periprosthetic fractures of the femur? Risk factors are divided into three groups: patient, medical, and surgical. Patient risk factors for periprosthetic femur fractures include being female and elderly. Medical risk factors include having inflammatory arthritis, osteoporosis (brittle bones), visual loss, and seizures. Having one of the many neuromuscular disorders such as multiple sclerosis, Parkinson’s disease, or Lou Gehrig’s disease is also a medical risk factor.

Surgical risk factors can include a previous history of femoral neck fracture, use of certain implants that don’t hold up well, any previous hip or knee surgery, and implants that have been in place four years or more. Combined together, these risk factors increase the chances of death associated with a periprosthetic fracture by three times compared with just having a single (hip or knee) replacement.

What can be done for patients with periprosthetic fractures of the femur? The goal is to restore limb alignment and stability with the hope of getting the patient back to his or her prefracture level of activity and independence.

Treatment is guided by a classification system that takes into account 1) what part of the implant is broken, 2) the quality (and quantity) of bone around the implant, 3) location of the fracture, and 4) severity of the fracture. For example, some minor fractures of the bone surface can be left alone. If treatment is needed at all, a small bone graft may be done. Nonoperative care is often reserved for patients who weren’t walking before the injury or who wouldn’t tolerate surgery due to poor health.

In some cases, the bone fracture can be held together with wires, screws, cables, or metal plates until the fracture can heal. In recent years, a special locking plate device and locking screws have been developed to help hold fractures together in fragile, brittle bones.

Sometimes treatment decisions are based on fractures of the implant itself. In the case of hip replacements, fractures have been reported affecting the tip of the stem (down inside the femur) or the stem itself. Treatment is further defined based on whether or not the broken implant is stable or in danger of shifting.

The authors of this article discuss each type of bone and implant fracture and give other surgeons notes and tips on making the decision as well as information on carrying out the procedure. Pros and cons of each fixation system for both the hip and the knee are discussed as well. Revision of the bone fracture is the first choice but if there are reasons why the implant can’t be saved, then it may be necessary to take the first implant out and replace it completely.

Best Treatment Choice for Intertrochanteric Hip Fractures

All intertrochanteric hip fractures are not alike. And because of that, each one must be evaluated and treated depending on the specific subtype of fracture present. The intertrochanteric region of the hip is just below the femoral neck. The femoral neck is the short column of bone between the main (long) shaft of the femur (thigh bone) and the round head at the top that fits into the hip socket.

About 40 per cent of all hip fractures in older adults are intertrochanteric fractures. A fall from a standing position is the most common mechanism of injury. But, of course, there are risk factors that lead to the fall — older age, fragile or thin bones from osteoporosis, poor balance, and a previous history of falls. Women seem to be at greater risk for intertrochanteric fractures compared with men.

To repeat: all hip fractures and especially all intertrochanteric hip fractures are not alike and should not be treated in the same way each time. As the author of this article points out, the location and severity of the fracture are two defining characteristics that must be considered. A fracture high up near the femoral head is different from a fracture down lower (closer to the femoral shaft).

The failure rate of surgery to repair intertrochanteric hip fractures is high — more than 50 per cent. One way to reduce this unacceptably high complication rate is to treat each and every intertrochanteric hip fracture according to its unique fracture pattern. The resulting anatomical and biomechanical changes must be reviewed and considered as well.

Stable fractures (those that are not displaced or separated and not likely to do so) can be treated with internal fixation. Fixation refers to the placement of metal plates, screws, pins, and/or wires to hold the broken pieces of bone together until they can heal. But fractures that extend up into the joint (called intracapsular) may not respond as well. Total hip replacement may be the better choice for intertrochanteric fractures labeled as severe, unstable, and/or intracapsular. Hip replacement may also be preferred when the blood supply to the hip is compromised.

The surgeon is faced with quite a challenge when making the decision as to the “best” treatment. The goal is to relieve the patient’s pain and keep him or her mobile (if they were mobile before the fracture). The first decision is whether to try and repair the fracture or replace the hip. Sometimes that decision is fairly evident. The patient’s condition, activity level, and the severity of the fracture speak for themselves.

But more often, the surgeon must weigh the odds of the hip collapsing after repair, thus causing further pain, weakness, deformity, and difficulty standing and walking. The time between the fracture and surgery will also make a difference. Studies show the best results are linked with earlier surgery (within 24 hours of the fracture).

And surgeons must keep up with current studies and data. For example, better surgical techniques and improved hardware make it possible for patients to put weight on the operated leg without fear that the screws will rip out of the bone. The author of this article also provides surgeons with an historical overview of all the ways intertrochanteric fractures have been treated in the past (from the 1700s to present time).

A description of present day fixation systems is also provided. Nails that compress allowing the fracture to sink down and stabilize itself is one of the newer approaches. Sliding devices and the use of dual screw control helps prevent neck rotation and thus reduces motion at the fracture site.

Improvements in fixation devices and plating systems are ongoing. Results of studies using various systems with different types of intertrochanteric hip fractures will continue to define and guide treatment.

Cost versus benefit and patient outcomes (function and especially return to walking for everyday activities) must be evaluated as well. There’s no point in performing expensive surgeries if the results are no better than something less complex but just as effective.

And the author’s final point? There is no “best” treatment for intertrochanteric hip fractures. They simply cannot be treated with a “one size fits all” approach. All surgeons treating patients with this type of injury are encouraged to keep up to date on research results. Likewise, surgeons in training (residents and fellows) must be given the opportunity to gain experience in the use of these devices and methods.

Guide to Acetabular Fractures in Older Adults

Many older adults sustain a hip fracture every year. Increasing age combined with certain risk factors such as osteoporosis (decreased bone density) makes it more and more likely that an older adult will end up in the hospital with an acetabular fracture.

What’s an acetabular fracture? The acetabulum is the socket side of the hip joint. It is made of cartilage over bone just like every other joint. The reason it breaks is because the person falls (and lands) in such a way that the head of the femur (thigh bone) is driven up into the hip socket (acetabulum) with enough force to break bone.

When that happens, there can be a single break or fracture line but more often the acetabular bone breaks into many tiny pieces. That type of break is called a comminuted fracture. Older men are affected more often than women by this type of damage. Their femoral bones are thicker, stronger, and transfer a greater destructive force into the acetabulum. Women tend to develop a break in the neck of the femur — long before there is any force up into the socket.

Until recently, this type of fracture was always treated conservatively (without surgery). And many times, this is still the most appropriate treatment. The presence of dementia, poor health, severe bone loss, and nonambulatory status before the fracture are reasons why surgery may not be possible.

So long as the fracture isn’t displaced (shifted), those patients who could walk before the injury are allowed to walk with the support of a walker. But only minimal weight through the hip is allowed until healing occurs.

A physical therapist helps move the hip through its motions but with some limitations to protect it. Bedrest (even for displaced fractures) with tracton was once prescribed. But this is no longer recommended due to the many complications that arise with immobility in this age group (e.g., blood clots, bed sores, pneumonia, deconditioning).

Instead (with or without surgery), patients are encouraged to get up and move as early as possible. The goals of treatment for all acetabular fractures are four-fold: 1) restore the weight-bearing surface of the socket, 2) keep good bone stock (strength and density), 3) maintain joint stability, and 4) prevent deformities.

For those patients who will have to have surgery, there are several options. A procedure called open reduction and internal fixation (ORIF) pretty much describes what happens. The surgeon makes an incision to open up the hip, lines everything back up as much as possible, and uses plates, screws, pins, and/or wires to hold it all together until it heals.

The more closely the hip is restored to its normal shape and configuration, the better the results will be. The more bone fragments and the farther apart the bone fragments separate, the poorer the prognosis. If the patient is not a good candidate for ORIF (or if the ORIF procedure fails), then a total hip replacement may be the next step.

In some cases, it’s clear that the patient should have a hip replacement right from the start. The decision is made on a case-by-case (individual) basis. The surgeon evaluates the best way to reduce blood loss, minimize operative times, and prevent complications.

Of course, going right to a joint replacement surgery usually eliminates the need for a second surgery. Even so, whenever possible, the surgeon tries to save the joint by doing an ORIF first. Delaying the joint replacement by doing an ORIF first does not put the patient at increased risk for a poor result because of the two-stage surgery (ORIF then joint replacement). But it does increase the chances for additional complications along the way (e.g., infection, poor wound healing).

By reviewing all of the options, pros and cons, and factors in treating older adults with acetabular fractures, the authors of this article show us how complex and challenging the problem can be. The surgeon must take many things into consideration when developing the patient’s plan of care.

There have been enough studies done now to help guide the surgeon by providing prognostic factors. Being able to look back and see the final results for each treatment choice has helped pinpoint who should be treated by conservative (nonoperative) means, who needs surgery, and what type of surgery is best (ORIF, ORIF with delayed hip replacement, immediate hip replacement).

Hip Fracture Threatens Independence and Mobility in the Elderly

Despite all efforts to prevent hip fractures, this injury remains a major problem among adults 65 and older. And with the aging Baby Boom population (born between 1946 and 1964) now entering Medicare, this problem isn’t expected to go away.

In fact, estimates are that there will be half a million hip fractures per year in the next 30 years. That amounts to a big chunk of change for Medicare and an even bigger inconvenience (even disability or death) for our seniors. Loss of mobility and independence are major concerns with any hip fracture in this age group.

While prevention of hip fractures in older adults remains an important step, treatment once such a break occurs is equally important. But like many other medical decisions with the elderly, there are often compounding factors that make treatment decisions and the treatment itself both complex and challenging.

There are different types of hip fractures based on location. The femur is the long thigh bone with a round bony “head” at the top. The femoral head fits inside the acetabulum or hip socket. Fractures can occur anywhere in the long shaft of the femur, the neck (between the shaft and the femoral head), and the acetabulum. There is also intertrochanteric fractures. The intertrochanteric region of the hip is just below the femoral neck.

In this article, Dr. Robert Probe, an orthopedic surgeon in Texas offers some insight into surgical treatment of femoral neck fractures. Two of the major problems that develop with femoral neck fractures are loss of blood to the femoral head and shortening of the femoral neck. Unless the patient cannot tolerate surgery for some reason, femoral fractures are best treated surgically.

But that’s where the decision becomes much more complicated. Is the fracture stable enough to pin it back together until it heals? Will it heal? Are there patient factors that might result in a nonunion? How likely is a nonunion? Should the femoral head be replaced? If the decision is made to replace the femoral head, then the surgeon must choose between a cemented or uncemented stem (the piece that fits down into the shaft of the femur).

That’s not the end of the possibilities. The femoral head is available in several different models with different options (e.g., unipolar, bipolar) for achieving movement of the femoral head. It may be necessary to perform a complete hip joint replacement (femoral head and stem along with replacing the acetabulum). Should the surgeon try and save the hip knowing the patient may end up in surgery again in order to replace a failed fixation?

Fixation refers to the use of screws, nails, pins, and metal plates to hold the broken pieces of bone together until healing can take place. This option is only available to a limited number of patients. The fracture must be stable. If displaced (separated), it must be possible to bring the pieces together and precisely match them up again.

Dr. Probe describes the technique he uses when placing screws in the hip for a stable femoral neck fracture. He also discusses the use of a fixed-angle hip compression screw fixation. The compression screw keeps the femur from further bone displacement that would change the angle of the femur as it places the femoral head in the acetabulum (hip socket).

If the surgeon sees reasons and predictive factors that point to the strong possibility of nonunion and failed fixation, then hip replacement is the treatment of choice. Older adults who are active and wish to remain active may prefer this approach as well. It bypasses the possibility of a second surgery (from fixation to replacement). Current studies show fixation failure at 25 per cent right now.

Results of total hip replacement (measured by pain, function, and revision rates) have been good-to-excellent for the “active and fit” older adults. Benefits and risks of this surgery for this age group with femoral neck fractures are still being investigated and reported.

In summary, femoral neck fractures in older adults can be complex and challenging to treat. The surgeon makes every effort to save the natural anatomy. Patient health, strength of the bone, mobility, level of community activity, and predicted life span are all taken into consideration when making a decision about fracture fixation versus hip replacement. With more and more older adults remaining active later in life, we can expect to see a higher number of total hip replacement procedures for femoral neck fractures.

Diagnosing and Treating Complications of Hip Dislocation

Hip dislocation in young adults is usually the result of a sports injury or high-speed traumatic event (e.g., car accident). This report on traumatic posterior hip dislocations in 17 adults (men and women, but mostly men) gives us an idea of the problems that can develop later.

The authors show how getting to the emergency department as soon as possible with an injury like this is very important. Waiting more than six hours to get treatment is linked with serious complications (even death of the femoral head).

Using arthroscopic examination, they were able to record the type of damage seen inside the joint and then compare that information to data collected from the patients’ charts. They looked at results compared with time between hip dislocation and treatment (closed reduction) and time between reduction and the need for arthroscopy.

Closed reduction refers to putting the hip back in place without needing an open incision to do so. Levels of hip pain, amount of joint motion, and function were the main outcome measures.

Most of the patients had a tear of the anterior labrum — that’s the fibrous rim of cartilage around the front of the hip socket. It makes sense that the anterior (front) cartilage was torn. As the hip dislocated backwards (posterior dislocation) away from the anterior labrum, there is usually enough force to pull on the labrum.

About one-third of the group also had tears of the posterior labrum — an indication that the force was enough to push the femoral head backwards far enough past the posterior labrum to tear it, too.

Everyone in the study had signs of damage to the cartilage around the head of the femur (round end of the upper thigh bone). All but one patient also had chondral (cartilage) damage on the acetabular (socket) side of the joint.

Fourteen of the 17 patients had pieces of bone or cartilage floating around inside the joint. Most likely, these fragments were causing most of the pain and loss of motion. The surgeon was able to remove the fragments during the arthroscopic procedure and repair labral tears that occurred earlier as a result of the dislocation. The result was to restore motion and function for everyone. But pain was still an issue for one patient who ended up having a total hip replacement as the final treatment.

X-rays and CT scans were used to take a closer look at the hip before and after treatment. Patients were followed for at least three years before this study was published. Everyone will continue to be followed into the future to see what other changes might occur.

The authors concluded that hip arthroscopy is a safe and effective treatment for symptomatic patients following traumatic posterior hip dislocation. Even when X-rays and CT scans are negative, a look inside the joint is still recommended when pain and loss of motion persist after hip reduction. Floating fragments of bone or cartilage can be present that don’t show up on imaging studies.

Arthroscopy may also be needed to see other damage such as tears of the ligamentum teres (the ligament holding the head of the femur in the middle of the socket). If this ligament isn’t repaired or restored, the femoral head won’t stay in the center of the socket.

Uneven wear and deformity of the hip joint from this complication can also lead to degeneration and osteoarthritic changes. Other studies show that hip osteoarthritis is more likely to develop if and when loose fragments are left in the joint after the dislocation has been reduced.

Athletes At All Levels Can Return to Sports After Surgery for Femoroacetabular Impingement

Femoroacetabular impingement, otherwise known as FAI has become a household name in the world of sports and athletics. That’s because this problem is becoming recognized as present in many more people than ever before. Is it really a new problem? Probably not — we are just getting better at identifying it when it’s there.

What exactly is femoroacetabular impingement (FAI)? And why does it affect athletes? Femoroacetabular impingement (FAI) is a pinching of the soft tissues close to, next to, or around the hip. Femoroacetabular tells us the impingement is occurring where the femur (thigh bone) meets the acetabulum (hip socket). There are several different types of impingement. They differ slightly depending on what gets pinched and where the impingement occurs.

One of the main areas affected is the labrum, a rim of fibrous cartilage around the hip socket. The labrum is designed to give the hip a bit more depth and stability. But even a small amount of asymmetry of the hip socket and/or femoral head in the hip socket can cause impingement with hip motion.

For example, a slightly oval shape instead of a perfectly round head of the femur or a slightly off-angle of the socket can result in painful pinching of the labrum or other soft tissues of the hip.

Sometimes it’s a case of a hip socket that’s deeper than normal. Over time, this pinching or impingement of the labrum can cause fraying and tearing of the edges and/or osteoarthritic changes at the impingement site.

The athlete experiences hip and/or groin pain along with decreased hip motion. The condition may look like a chronic muscle strain or groin injury but an X-ray, CT scan, or arthroscopic examination confirms femoroacetabular impingement as the true cause of the problem.

What causes FAI? Studies in children show that many of these abnormalities of hip shape, angle, or depth are present at birth. The average person would never know he or she had any of these slight anatomical changes if it weren’t for the repetitive motions of the high-level athlete. But pinch or compress those soft tissues often enough creating mini-traumas to the hip joint and a painful response will develop.

What can be done about it? Conservative (nonoperative) care with antiinflammatories and physical therapy may be recommended at first. If this approach is not helping, then surgery may be needed to restore normal hip motion. If there is a labral tear, surgery is usually done arthroscopically to repair (whenever possible) the damage. The surgeon trims the acetabular rim and then reattaches the torn labrum. This procedure is called labral refixation.

Each layer of tissue is sewn back together and reattached as closely as possible to its original position along the acetabular rim. When repair is not possible, then debridement (shaving or removing) the torn tissue or pieces of tissue may be necessary.

In a recent study from the Hospital for Special Surgery in New York City, this type of arthroscopic surgery was performed on 47 athletes with painful femoroacetabular impingement (FAI). Results were reported for 33 of those athletes at the end of one year and again two years after surgery.

More than three-fourths (79 per cent) of the group went back to their previous sport. Most of those athletes (92 per cent) participated successfully at their highest level of competition. That was the reported result one year after arthroscopic surgery. Two years after surgery, 73 per cent of the group was still going strong.

Athletes from all types (and competitive levels: high school, college, professional) of sports were included in this study. The largest number of patients were ice hockey players followed by soccer and baseball players. But swimmers, horseback equestrians, football, track, tennis, lacrosse, and crew members were also part of the treatment group.

Other studies have been done reporting the results of surgery for femoroacetabular impingement. What makes this study so special? The mixed type of sports and varied levels of participation.

The authors showed that arthroscopic surgery for femoroacetabular impingement (FAI) can be effective for all athletes at an intense level of participation regardless of sport type or level of competition (from amateur to professional). It isn’t just the highly paid, highly motivated professional athletes who can benefit from this surgery.

Athletes Who Push Beyond Their Anatomic Limits

Hip and/or groin pain in a young athlete is often a signal that something’s not quite right. And one of the most common causes of hip pain in this group is a condition known as femoroacetabular impingement or FAI. Early detection is the key to preventing serious hip problems later in life.

You might think that young athletes don’t have to worry about things like osteoarthritis. They are active and rarely overweight. They excel beyond anything the rest of us would ever dream of accomplishing. But if they push themselves beyond what their own bodies can handle, even they can break down.

Femoroacetabular impingement occurs when abnormal hip anatomy is aggravated by repetitive movements of the hip. There could be a slightly off center placement of the hip in the socket or a femoral head that isn’t perfectly round that is contributing to the problem.

Or the hip socket may be too deep for the size of the femoral head or the rim of the hip socket is too prominent. Sometimes the angle of the femoral neck is bent or twisted just a tad from normal. There could be a separate piece of bone called the os acetabulum along the front rim of the hip socket. Any of these morphologic changes can lead to impingement.

How can too much physical activity at a young age be the problem here? With impingement, the soft tissues around the joint get caught between the femur and the hip socket. There are several different types of impingement. They differ slightly depending on what gets pinched and where the impingement occurs.

The labrum, a fibrous rim of cartilage around the hip socket is the most likely area to get pinched. Add repetitive motion and you get repetitive pinching or compression until the labrum starts to fray and tear.

How can this problem be treated? That’s a good question and along with that question is this one: does it need to be treated at all? The reason that second question even comes up is because some high level athletes with abnormal hip joints never develop problems. Who does develop femoroacetabular impingement and how to predict if/when it should be treated are areas where further study is needed.

In the meantime, arthroscopic surgery may be the most effective way to handle the problem. When pain interferes with participation in sports, athletes are eager to find ways to get back in the game. Conservative (nonoperative) care may be tried first. But if that fails to yield the desired results (elimination of pain and restoration of motion and function), then it may be time to take a look inside the joint and see what can be done.

With an arthroscope, the surgeon can enter the joint without making a large incision. A tiny TV camera on the end of the instrument projects a picture on a screen for the surgeon to see. Any areas of damage to the labrum can be smoothed down and repaired. The rim of the acetabulum and even the head of the femur can be reshaped if necessary. Reshaping the area where the femoral head and neck meet takes quite a bit more skill but may be helpful, too.

In a recent study of 200 athletes who had arthroscopic surgery for femoroacetabular impingement, 92 per cent were able to return to full participation in the sport of their choice. Whenever possible, the surgeon repaired the labrum instead of removing or shaving it off. This approach may account for the good results.

Runners, football players, soccer players, and basketball players made up the bulk of the patients. But there were also wrestlers, ice hockey players, weight lifters, swimmers, dancers, golfers, and even two bull riders in the group who had this arthroscopic treatment of femoroacetabular impingement.

The results weren’t perfect as there were some complications (e.g., temporary nerve damage, bone formation within the hip capsule). One athlete ended up getting a total hip replacement and four others had to have a second surgery because of continued problems with hip pain.

The surgeon who conducted the study commented that by the time the athlete comes in for surgery, there is often some damage to the joint that simply can’t be reversed. He advocates for earlier diagnosis in order to help prevent some of the unavoidable consequences of this problem in active, young athletes.

Surgeons Take a Closer Look at a Hip Replacement Implant

Hip replacement surgery has been around long enough now that there are numerous implants to choose from. Size, design, type of material, and cemented versus cementless are some of the key features that differ from one system to another.

In this study, the CementLess Spotorno System (CLS) was investigated for long-term (10 year or more) results. Like all other hip implant systems, the CLS has two basic components: the acetabular cup (socket) and the femoral head and stem. The cup and stem are made of titanium. The femoral head is ceramic.

There is a polyethylene (plastic) liner that goes inside the socket. The head of the femur fits into the liner. The liner or insert helps absorb impact on the implant so it must be as durable as possible.

Extensive wear of the liner or insert can result in failure of the entire implant, the release of debris into the joint, and osteolysis (bone loss). Too much wear of the liner or insert can result in the need for a revision surgery to remove the worn liner or insert and to replace it with a new liner or insert.

Both pieces (femoral and acetabular component parts) are press-fit into the bone. The stem fits down inside the center of the femoral shaft. The surface of the implant is coated with hydroxypatite, a compound that gives the surface a rough finish to which bone will adhere or stick.

The first hip replacements were all cemented in place. But over time, surgeons found that a cementless fixation had many advantages over a cemented implant. There are fewer cases of implant loosening with cementless implants.

If a reoperation to revise or remove and replace the implant ever becomes necessary, the cementless type is easier to work with. Best of all, the bone is less likely to be disrupted with a cementless hip implant like the CementLess Spotorno System (CLS).

Most of the patients in this study had osteoarthritis of the hip but there were a few with rheumatoid arthritis (RA) or osteonecrosis (bone death from loss of blood supply to the bone). Everyone was 66 years old or younger.

Long-term results were measured by looking at hip motion, pain, walking ability, and X-rays to look at wear and tear on the implant and any underlying bone loss. Surgeons also use type and number of complications, number of revisions, and overall survival of the implant as outcome measures.

In the final evaluation, there were 14 of the 102 patients who had a second surgery to revise the implant. Most had a loose cup without infection. Like other types of hip implant systems, the CementLess Spotorno System (CLS) had some problems with wearing of the polyethylene liner.

Analysis of the data showed that risk factors for implant failure (especially liner wear) in this group of patients included younger age at the time of surgery (more active), larger femoral head component part, smaller socket size, larger body-mass index (BMI), and male sex.

All implants did quite well during the first 10-years (first decade). Problems didn’t start to develop until the second decade (years 11 through 20). The number of CLS hip implants that were still intact and working fine after the first ten years was 92 per cent. That’s called the survival rate. Survival rate after 15 years was 78.4 per cent (good but not as good as the first decade). Survival rates past 15 years are not available yet.

The overall complication rate was 20 per cent. The most common complications included heterotopic ossification (HO) (formation of bone in the muscles and soft tissues around the joint), hip dislocations, bone fractures around the implant, infections, and deep vein thrombosis (DVTs or blood clots).

How does the CementLess Spotorno System (CLS) stack up against other similar hip implant systems? The authors say, “very favorably.” Survival rates, complication rates, and improvements in pain, motion, and function were all in the same ranges.

The biggest problem remains loosening of the cementless cup during the second decade of use. Knowing what some of the risk factors might be may help shape future patient selection and management approaches. More long-term studies following patients a full 20 years are also needed.

Is Hip Bursitis Still Around?

Pain along the side of the hip is still a common spot for bursitis (also known as greater trochanter pain syndrome. A large tendon passes over the bony bump on the side of the hip called the greater trochanter.

Inflammation in the bursa (a protective gel sac) between the tendon and the greater trochanter is called trochanteric bursitis or lateral hip bursitis. You can see there are many names for this problem.

Hip bursitis is common in older individuals. Women seem affected more often than men. It may also occur in younger patients who are extremely active in exercises such as walking, running, or biking.

Pain associated with this problem is often made worse by lying directly on the hip, walking, or going up stairs or steep inclines. It may not be possible to walk without a limp because of the pain. Hip motion and strength are not affected at first. But left uncorrected over time, the patient changes the way he or she moves. Then impairment of muscle function may develop.

Treatment early on can prevent this painful condition from becoming a chronic problem that might require surgery. Short-term use of nonsteroidal anti-inflammatory medications along with physical therapy may be all the person needs.

The physical therapist will correct any postural components, muscle imbalances, and help restore normal function of the affected hip muscles. The muscles involved most often include the gluteus minimus and the gluteus medius, the so-called rotator cuff muscles of the hip.

The effectiveness of conservative (nonoperative) care depends on a correct diagnosis and assessment of the severity of the underlying tendon injury. There are three types of hip rotator cuff tears that can cause lateral hip bursitis: 1) degenerative or traumatic tears seen most often in older adults, 2) nonpainful tears associated hip fractures or hip osteoarthritis, and 3) tendon avulsion (tendon is not just torn but pulled completely away from the bone).

Other causes of lateral hip pain can be hip osteoarthritis, an undetected hip fracture, nerve injury, or problem in the lumbar spine (low back) such as stenosis or spondylosis. The surgeon uses certain clinical tests (e.g., hip range-of-motion, straight leg raise) and imaging studies (e.g., X-rays, MRIs) to sort out what’s really going on in the hip.

MRIs are especially helpful in seeing the condition of the tendons and muscles and identifying partial tears from full-thickness tears and avulsion injuries of the gluteal muscles. Individuals who have had a previous total hip replacement may develop lateral hip pain from tendon avulsion, which will show up on an MRI.

What can be done about this problem? We already mentioned physical therapy and antiinflammatories. If conservative care doesn’t yield the results the patient is looking for, the surgeon may inject the area with cortisone. But if the MRI reveals a full-thickness tear or avulsion of the tendon, then surgery to repair the damage may be needed.

Studies show good results of surgical repair even after years of pain from the tendon tear. Of course, the earlier the repair, the better the results with fewer complications or problems. Unrepaired, damaged tendons often fill in with fat or scar tissue making repair more challenging.

Sometimes the surgeon comes across a gluteus muscle tear and trochanteric bursa filled with fluid at the time of a hip fracture repair or surgery to replace an arthritic hip joint. The tear will be repaired and any osteophytes (bone spurs) that have formed will be removed.

Various repair and reconstruction techniques have been used by different surgeons. Severe damage to the gluteal tendons and muscles may require more extensive surgery with transfer of a muscle flap from the largest gluteus (buttock) muscle, the gluteus maximus.

In all cases of chronic, painful lateral hip bursitis, the goals are to reduce pain, improve walking, and even allow the patient to get rid of any walking aids (cane, crutches, walker).

In summary, tears of the gluteal tendons of the hip leading to hip pain are fairly uncommon. But the surgeon evaluating older women with hip pain along the side must consider lateral hip bursitis as a possible diagnosis. Early diagnosis (confirmed by MRI) and treatment (whether conservative or surgical) gives the best results. Patients can expect improvement in their pain but may not regain full strength.

Hip Instability Possible Without Trauma

Just because you’ve never knowingly injured your hip doesn’t mean you don’t have a hip problem. That’s one conclusion from this review article on the topic of hip instability.

Hip instability can include subluxation (partial dislocation), complete dislocation, and microinstability. The last classification (microinstability) is just what it sounds like — too much looseness in the joint but without a big enough shift in hip position to cause a subluxation.

Many people with hip instability have a known etiology (cause). It could be from a stretching of the ligamentous joint capsule that helps hold the hip in the socket. Or a tear in the labrum (fibrous cartilage around the rim of the hip socket). If there’s no known history of injury, then the condition is referred to as atraumatic (without trauma) instability.

With atraumatic hip instability, there may not be a specific injury but there is still usually a reason the problem develops. There could be an underlying systemic disease affecting the soft tissues (e.g., Ehlers-Danlos, Marfan, or Down syndrome). Abnormal anatomy of the bones or soft tissues could also contribute to the problem.

The diagnosis of traumatic or atraumatic hip instability can be difficult. Patients complain of vague hip pain, often with reports of clicking, locking, catching, or “giving way” (leg gives out underneath them). Athletes engaged in sports such as football, rugby, bicycling, skiing, golfing, dancing, and hockey seem to be at increased risk for hip instability from injury or repetitive motion.

After taking a careful patient history, the surgeon will perform specific tests as well as order appropriate imaging tests to confirm the diagnosis. It may take special MRIs with dye injected into the joint and/or arthroscopic examination to make the final diagnosis.

Those two tests along with X-rays help the surgeon inspect the hip anatomy to look for any deformities, tears, or other structural changes that might lead to instability. CT scans show any loose fragments of bone or cartilage inside the joint. Fractures of the acetabulum (hip socket) also show up on CT scans. Of course, a patient who can actively pop the hip in and out of the socket has a clear case of hip instability.

Once the diagnosis has been made, forming a plan of care is next. Treatment depends on the extent of injury or damage as well as the degree of instability. Mild instability may be treated successfully without surgery.

Physical therapy, activity modification, and protected weight-bearing are tried first. Even with hip capsular laxity (looseness), physical therapy to improve core (trunk and abdominal) strength can be helpful. The surgeon may also inject a numbing agent into the hip to stop the pain. Sometimes just putting an end to the pain cycle is enough to ensure that conservative (nonoperative) care will work.

Surgery is more likely for the patient who has persistent pain and subluxation or dislocation. The type of surgery done depends on what’s wrong. If the joint capsule (soft tissue) is too lax or loose, there are ways to surgically nip and tuck it closer together (called plication). Radiofrequency to generate heat can also help shrink the capsule and make it tighter.

If the joint is dislocated, reduction is necessary. To reduce a joint means to put the head of the femur (thigh bone) back in the socket. Sometimes reduction can be done with traction and without an open incision. In some cases, there are multiple problems to address at once — the capsule is stretched, the labrum is torn, and the hip is dislocated.

The authors provide a diagnostic and treatment algorithm or path to help surgeons decide what’s best for each patient. This is a flow chart that shows what choices or options are available from beginning to end. The treatment algorithm has three main pathways with multiple choices along each one.

For example, the authors note that if there is a dislocation, then a reduction is needed right away. Whether that is a closed or open reduction depends on the CT or MRI results. And the algorithm branches off for decisions under each of those headings.

Or if the hip is in place but there is a fracture of the socket, then get a stress X-ray may be needed. The next step will depend on the imaging findings but could include nonsurgical treatment, further testing, or open reduction with internal fixation (ORIF). Fixation refers to the use of pins, wires, plates, and/or screws to hold everything together until healing takes place.

In summary, evaluating and treating hip instability from trauma or other (sometimes unknown) causes can be a very challenging task for the surgeon. This review covers factors to consider including anatomy, biomechanics, history, physical examination, and imaging.

The information gathered from each of those areas is then used to create a management plan based on cause (traumatic versus atraumatic instability). This approach is not as scientific or evidence-based as it could be.

There is a need for future research to find better ways to evaluate, diagnose, and treat hip instability. The wide range of differences seen in the bony and soft tissues may account for the varied outcomes. But even that idea is just theoretical and needs to be studied further.

Comparing Antiinflammatory Drugs After Total Hip Replacement

Antiinflammatory medications are used after a total hip replacement to prevent a complication called heterotopic ossification (HO). HO is the formation of bone in the soft tissues around the joint. This postoperative problem causes pain and stiffness — the very symptoms a joint replacement is supposed to eliminate!

No one knows for sure why some patients (quite a few actually) end up with heterotopic ossification after a hip replacement. Some experts think that trauma to the muscles or bone sets up a response that results in new bone formation in these tissues.

Studies show that one fourth (25 per cent) up to almost half of all patients develop heterotopic ossification (HO). That raises the question of if so many people develop HO, why doesn’t everyone?

It seems that patients with certain risk factors are the most likely to develop HO. Those risk factors include male sex and age older than 60 years. A past history of another bone condition called ankylosing spondylitis or a past history of HO in either hip also increases the risk.

Until we know for sure what triggers this response and how to avoid it, there are two preventive techniques that seem to help. One is to radiate the tissues but that might increase the risk of cancer. So the use of nonsteroidal antiinflammatory drugs (NSAIDs) is the front runner prophylactic (preventive) treatment.

But antiinflammatory medications don’t come without their own unique set of potential problems. Standard nonsteroidal antiinflammatory drugs (NSAIDs) are known to cause gastrointestinal side effects (e.g., nausea, vomiting, bleeding). A newer line of NSAIDs called COX-2 inhibitors have fewer side effects but how effective are they in preventing heterotopic ossification?

A review of the recent studies suggests that standard NSAIDs and the newer COX-2 inhibitors are equally effective in preventing heterotopic ossification. Bleeding is not as likely with COX-2 inhibitors as it is with standard NSAIDs. However, the risk of high blood pressure is greater with COX-2s.

In the case of heterotopic ossification prophylaxis after hip replacement, the short amount of time COX-2s are used may keep patients from experiencing adverse effects from the drug.

Only a small number of studies are available to judge the use of NSAIDs versus COX-2 inhibitors for the prevention of heterotopic ossification. More studies with larger numbers of patients are needed to answer the question of which is better. Ultimately, determining the cause of heterotopic ossification and preventing it without the use of radiation or medications with their potential negative side effects is the goal.

Hip Replacement in Adults Who Had Perthes Disease As a Child

Hip replacement in adults who had Perthes disease as a child is technically challenging and difficult but entirely possible and with good results. That’s the report from Italian orthopedic surgeons on 32 hip replacements.

Legg-Calvé-Perthes disease (Perthes) is a rare disease that most often affects boys between the ages of 2 and 12. Girls can have LPD. The hips are the main problem. Sometimes both hips are involved, but usually only one side is affected.

With Perthes, blood flow to the ball of the hip is stopped and bone death (necrosis occurs. As necrosis spreads, the ball develops a fracture of the supporting bone. This fracture signals the beginning of bone reabsorption by the body. As bone is slowly absorbed, the body tries to replace it with new tissue and bone.

Degenerative osteoarthritis can occur with age in adults with Perthes. It seems to depend on two things. If the ball reshapes itself and fits into the socket, arthritis is usually not a concern. If the ball does not reshape well, but the socket’s shape still conforms to the ball, mild arthritis occurs in later adulthood. A flattened ball and shallow socket create the most significant problems later.

These patients may need a joint replacement before the age of 50. In this study, the average age at the time of the hip replacement was 37.8 years. Patients included were as young as 19 up to 65 years old.

Total hip replacement is a challenge for these patients because of the odd shape of the hip and leg length differences. The surgeon must work around multiple different deformities affecting the femoral head and hip socket.

Changes in the bone and soft tissues around the hip as a result of previous surgeries can also be a problem. Disruption of bone growth often results in a short femoral neck. Scar tissue can pose some technical pitfalls.

Muscle and tendon surgical releases and bone osteotomies (pelvic or femoral) performed during childhood further alter hip alignment. An osteotomy is the removal of a wedge- or pie-shaped piece of bone in order to shift the position or angle of the bone. It helps in the short-term but can make hip replacement later more difficult and sometimes impossible.

Previous studies comparing adults with hip osteoarthritis but without a childhood history of Perthes to patients with hip osteoarthritis and a positive history of Perthes have been done. Results show that the final outcomes are better in patients without a history of Perthes.

But that has not kept surgeons from trying to improve the procedure for patients with Pethes who develop secondary hip osteoarthritis. With some creative modifications (aligning femoral stems and placing cups on the socket side at just the right angle), it is possible to restore good hip biomechanics.

The authors share their tips and techniques for getting just the right type and size of implant and using special surgical techniques. They point out special considerations the surgeon should watch for (e.g., excess bone that needs trimming, bony overhang after cup placement).

Their success rate is impressive with 96.9 per cent implant survival after 15 years and an overall complication rate of 12.5 per cent. Test scores for hip function were much improved from before to after surgery.

Most of the complications occurred as a result of the procedure itself. There were two patients who developed permanent sciatic nerve palsy when the involved limb was lengthened surgically. One patient had a hematoma (pocket of blood) that had to be drained surgically. And the femur (thigh bone) fractured in one other patient as the implant stem was being placed down inside the bone.

The authors conclude that hip replacement in adults who had Perthes disease as a child is possible. That’s good news for those who develop severe, disabling hip arthritis in their early adult years.

As this study shows, it requires experience and expertise on the part of the surgeon to perform this procedure under these circumstances. Much preoperative planning goes into a procedure like this. Careful examination of the patient and evaluation of imaging studies (X-rays and CT scans) is required. Patients face some risks of complications but if the people in this study are any indication, most will be satisfied with the reduced hip pain and improved hip function.