How Am I Doing After My Hip Replacement?

It’s no surprise that a hip replacement reduces pain, increases hip motion, and restores movement and function. After all, that’s why people have the procedure done. The real question now is how long does it take to recover? More than ever, today’s active seniors are asking this question long before they even get the new hip.

After surgery, the most common question patients have is: “How am I doing compared to everyone else?” With information from a new study on recovery following a total hip replacement, the physical therapist or surgeon can now answer with some ball park figures.

Of course, there is always variability among groups of seniors following any surgery. In the case of recovery following total hip replacement, it appears there are two phases. The first occurs 12 to 15 weeks after the procedure. Rapid change occurs in the first three months and then starts to slow between 15 and 20 weeks.

By the end of four months, most patients have been discharged from treatment. They are well on their way to resuming all physical activities and exercise they are interested in. More physical therapy with a supervised rehab program may still be needed if you have not experienced good improvement or the results you expected.

Thirty (30) weeks (seven and a half months) later, patients experience another leveling out as they are now able to walk again at a normal pace. Physical function involving the legs continues to improve though at a much slower pace than early on. Balance and postural stability seem to take longer to recover.

If you continue to follow the exercise program prescribed by your physical therapist, then by the end of 12 months (one full year), you should be fully recovered. Hip muscle strength, joint motion, and leg function should test within normal limits for your age. Patients who quit doing their exercises too soon often have muscle weakness and report falls two years after hip replacement.

You can use these known guidelines to establish your own goals and check your recovery against the average. Setting too high of expectations can discourage you — especially in those early weeks of recovery. Adopt a “can do” attitude, follow your therapist’s and surgeon’s advice, and give yourself some time to recover.

The therapist will use several tools to measure how you are doing. A popular (valid and reliable) test of physical activity is the six minute walk test. In this test, how far you can walk (and how fast) in six-minutes is measured and compared.

For both men and women after a total hip replacement, the peak distance walked occurs around that 30-week postoperative timeframe. Women don’t walk as far as men and their early recovery time is a little slower but in the end (a year later), walking ability evens out between the sexes.

Other measures may include whether or not you still need a walking aid (e.g., walking sticks or cane), your pain level, and how much medication you are still taking for pain. How well you can go up and down stairs is a functional skill of importance. Your ability to carry out daily activities may also be examined closely.

Don’t be afraid to ask your team how they think you are doing as you evaluate your recovery. If it seems (to you or to them) that you have fallen behind, it may be time to reevaluate or reassess your progress and perhaps alter the rehab program. Limping, loss of balance, and falls are three clear signals that you may need additional therapy to fully recover.

Long-Term Results of Cementless Hip Replacement

Hip joint replacement has entered a new age: the completely cementless implant. Fifteen years ago, surgeons were combining the use of a cemented stem (down into the femur or thigh bone) and cementless cup. That combination has gradually been replaced with all cementless implants. In fact, up to 90 per cent of today’s hip replacements are cementless.

In this report, surgeons from a large joint replacement center (Center for Joint Preservation and Replacement at The Rubin Institute for Advanced Orthopedics, Sinai Hospital in Baltimore, Maryland) review the long-term results of six different cementless hip joint implants.

The implants are compared based on their surfaces and coating, geometric designs, and technique of preparation. Other factors that affect implant fixation and stability such as the patient’s bone quality, age, activity level, and any deformities present at the time of the replacement procedure.

In order to study and compare the various types of cementless implants available, six separate groups or classifications have been established. By name, these include: 1) single wedge, 2) double wedge, 3) tapered, 4) cylindrical, 5) modular, and 6) anatomic. The tapered implant has three separate types: round, cone, or rectangle (referring to the top of the stem that fits into the round ball that replaces the head of the femur).

Each of the unique design features of these six types has important characteristics and purposes. The surgeon chooses the implant design that is best for each patient on a case-by-case basis. The different shapes allow for different areas of bone-to-implant fixation needed for a stable unit.

The shape of the stem (whether tapered, round, curved, or straight) also influences bone-to-implant fixation by changing the contact points between these two surfaces. For example, tapered stems are wider at the top and narrower at the bottom. Bone fixation is greater at the top where there is more surface to latch onto.

Problems may develop in the future as newer, different designs are developed that don’t necessarily fit into one of the current six implant types. The classification scheme may have to be changed over time as newer materials and designs become available.

For now, let’s look at what the authors can tell us about the long-term (10 to 15 years or longer) results for these six groups. The overall goal of all implants (no matter what their design) is to make contact with the bone and stabilize the joint.

As it turns out, all six types have equally good rates of survival and success. The average patient will respond well to any of these implants. When there are deformities and/or problems with the bone, then the surgeon may need to select a specific implant based on its design.

For the general population, materials and fixation aren’t as important as the geometric design. For example, type one (single wedge) is flat and thin with less surface space for contact with bone. Type three (tapered) can be fluted at the end with multiple slots and edges to make greater contact with bone. Type four (cylindrical) is a fully coated porous surface (bumpy, not smooth) that touches the bone along the entire length of the stem.

The outcomes for these implants also depends on the preparation required before inserting the stem down into the shaft of the femur. The femur has to be reamed out to make a channel for the stem to fit.

The surgeon must understand how the implant geometrical design and stem shape determine surgical preparation of the femur. Preserving as much bone as possible is a key feature of each procedure. For surgeons interested in reviewing the six types of stems, the authors provide an in-depth discussion and comparison of each one to the others.

The bottom-line is patients want a hip replacement that is sturdy, strong, and holds up for many years. Both surgeon and patient want to avoid implant loosening, sinking down into the bone, or breaking. Often, the first sign that something is wrong is thigh pain.

The authors conclude by saying that future studies will need to pay more attention to the bone type of patients when selecting the an implant that will give the best results. Long-term studies are needed to show outcomes based on bone quality (e.g., thick versus thin, osteoporotic versus normal).

Cause of Rare Implant Fracture After Revision Surgery

It doesn’t happen very often but sometimes patients who have a total hip replacement end up having a second or revision surgery because of a failed implant. Even more rare is the occasional revision surgery that fails. In this series of six cases, the stem of the femoral implant broke in half. The implant fractures occurred early on (within the first six years). The surgeons in charge of the cases wanted to know why this happened in hopes of preventing such problems in the future.

Previous studies have shown that certain risk factors are linked with stem fracture. The most common of these factors are being overweight, high levels of physical activity, and malposition of the first implant. Implants have improved in design to help counter these problems but there are still a few now and then. And any number of failures (no matter how few) are unacceptable to the surgeon as well as to the patient.

One of the features of the new implant designs is a concept called modularity. These implants are somewhat adustable to offset leg length differences from bone loss. This feature allows for improved joint movement that mimics normal motion more closely than previous less adjustable implants.

The modular units (like a modular home) come with interchangeable parts that can be assembled and adjusted at the time of the surgery. A prosthetic femoral stem component is made up of a body, a neck, and a stem.

The height of the neck is adjustable (high or low) and the stem can be made longer or shorter according to what the patient needs.For patients with bone loss, the newer revision implants don’t require cement to hold them in place. Instead, the surgeon can use hardware or fixation devices such as pins, wires, and screws to secure them.

The separate pieces of the modular implant are held together with a modular connection and that connector has a taper junction and an engaged-fit junction. Femoral stem fractures are a problem at these modular junctions. Implant manufacturers have worked with surgeons to find a design strong enough to withstand the forces at the intersection between two component parts.

At the same time, studies like this one attempt to identify all the risk factors for stem fractures. With this information, they may be able to incorporate features in the new designs that will prevent such problems. In order to accomplish this, the surgeons involved in this study took a very close look at fractured stem implants after they were removed.

First they made note of the location of the breaks. Then they used high-powered microscopes to examine the surface of the implants very carefully. They found that the fractures occurred most often just above the body-stem junction (hidden under the main body of the stem). They realized that a force strong enough to bend the stem at that point was contributing to the fractures.

Chemical analysis of the implants was also studied. Tests of “hardness” were conducted near the site of the fractures and compared with similar measurements far away from the fracture site. The strength of the implant material was not a cause of the fractures. Tensile strength was maintained at the fracture site and there was no sign of corrosion or softening of the metal.

It turns out that the biggest risk factor for stem fractures was the patient’s body weight. All of the patients in the study who experienced failure of their revision implant were either overweight or obese. The second risk factor was poor bone structure that could not support the junction area of the stem. There was also visible evidence of wear and tear on the implant stem near the junction.

As a separate point of interest, analysis of the data showed that age was not a risk factor. Patients ranged in ages from 37 to 88. A recent history of trauma to account for the fractures was not present either. Many of the patients reported thigh pain as the first symptom of a problem. X-rays, of course, showed the fractures.

Given the results of this study, the authors make several suggestions for ways to prevent the problem in the future. They suggest surgeons who assemble the modular unit before putting it in the patient make sure the component parts fit perfectly. Where the body and stem fit together must be tight without even the smallest of motion between them. It may be necessary to fill in the crack at the junction. Other specific surgical techniques of interest to the surgeon are outlined.

Patients getting a total hip replacement and who suffer more than one implant failure don’t have to fear losing hip motion and function. There are always options. New implant designs developed as a result of research results from studies like this one will help prevent future cases of implant failure.

Ninety-day and Ten Year Risks Associated with Hip Replacement

Did you know that two-thirds of all adults who have a total hip replacement also have high blood pressure? And many patients getting a hip replacement have what’s called multiple comorbidities — in other words, lots of other medical problems.

Besides hypertension, heart disease, high levels of cholesterol, and a past bout with cancer head the list of comorbidities. And the list goes on: heart arrhythmias, lung disease, urinary tract infection, diabetes, obesity, anemia, rheumatoid arthritis, depression, dementia, and many more.

According to a recent study, the presence of these risk factors increases the chances of periprosthetic infection (around the implant) and even death. In the first 90-days after surgery, up to one per cent of patients die as a result of complications. A slightly higher percentage (up to two per cent) of patients develops an infection in or around the implant during the first 10 years after surgery.

Surgeons would like to erase those problems but how? This study provides the first step: identify the risks. Then look for a way to reduce or eliminate them. If the surgeon doesn’t even know there’s a link between some of these comorbidities and infection (or worse yet: death), then he or she won’t necessarily be looking out for them as major risk factors.

This study not only identified the risk factors, it also quantified them. To quantify something means to give it a number that helps put the risk into perspective. So for example, patients with rheumatoid arthritis having a hip replacement were 1.7 times more likely to develop a periprosthetic infection. Obesity and blood clots had a similar hazard ratio.

Two tables were included in the article. One listed the risk factors for prosthetic joint infection (and their hazard ratios). The other presented hazard ratios for comorbid conditions linked with death in the first 90-days postoperatively. Those hazard ratios ranged from 1.3 for heart arrhythmias up to 1.7 for rheumatologic diseases.

Risk factors studied in association with death in the first three months following hip replacement were as low as 0.62 for high cholesterol levels. That actually places high cholesterol as a condition that decreases the risk of mortality (death). But dementia (2.04), metastatic cancer (3.14), and congestive heart failure (2.11) were much higher. And many patients had more than one health concern. The risk of combined medical conditions on infection and/or mortality was not calculated.

The surgeons involved in this study agree that the numbers of patients who die in the first 90-days or who develop a hip joint infection in the first 10 years are small but important. If you ever become a patient in the one to two per cent who develops these serious problems, it becomes a matter of great importance. Surgeons’ attention to these matters is appreciated by all patients undergoing hip replacement.

Cement or Cementless Hip Replacements?

In Finland, almost all patients who receive a total hip replacement are enrolled in a data registry called the Finnish Arthroplasty Registry. Information on the patient’s age, sex (male or female), diagnosis, type of implant, and surgical approach is entered into a computer database.

The information is confidential as to the individual patient names. Having this type of information makes it possible for researchers to examine trends in treatment over time. Changes in surgical techniques, implant designs, and technology have the potential to also change results or outcomes. Keeping track of those changes and trends helps guide continued improvements in patient care.

In this particular study, the first ever effort was made to look at long-term results for patients with rheumatoid arthritis getting a total hip replacement. A specific focus of the data analysis was to see how well cemented versus cementless hip implants survive in patients 55 years old (or older) who have rheumatoid arthritis (RA).

The 4,019 hips included were broken down into three groups: one group who had cementless implants and two groups with cemented joint replacements. The majority of implants for this group were cemented in a 3:1 ratio (three cemented implants for every one cementless implant). The two cemented patient groups had implants with different stem designs.

The stem is the part of the femoral component that fits down inside the bone and supports the head of the femur as it fits into the hip socket. One cemented stem is called the loaded-taper stem. This type of stem settles down inside the bone as the patient puts weight on the leg. The second stem type is the composite-beam stem. This stem is truly cemented in and shouldn’t budge or shift.

The results showed that out of the 4,019 implants, 371 failed for some reason and had to be revised. Any time the implant was removed or exchanged (old parts removed, new parts installed), it was considered a revision procedure. The reasons implants fail were due to infection, malposition, fracture, or loosening of any of the component parts.

Revisions were most common in the cemented composite-beam stem implants. The long-term results (after 15 years) were better for cementless and cemented loaded-taper stems compared with the composite-beam design. In general, the cementless implants held up better for this particular group of patients.

Patients with rheumatoid arthritis who have a hip replacement have some unusual factors that can affect outcomes. Pain, inactivity, bone loss, and the long-term use of medications with side effects may contribute to problems even after hip replacement designed to reduce pain and improve motion, activity, and function.

Other changes in hip joint replacements that might influence results include the development of a plastic liner inside the cup (socket) part of the implant, new and improved cement and cementing techniques, and new drugs to treat rheumatoid arthritis.

The authors concluded that cementless hip implants work well for older patients with rheumatoid arthritis who are having a hip replacement. If anything, the liners were really the cause of many problems, not the issue of cement vs. cementless stems and cups. The poor results associated with composite-beam stems bears further study. The increased use of cementless cups will also be reviewed more closely.

An Update on Osteonecrosis of the Hip

In this update on osteonecrosis of the hip, two orthopedic surgeons on opposite sides of the globe team up to review diagnosis, causes, and treatment. Dr. G. C. Babis from the University of Athens and Dr. J. Parvizi from Thomas Jefferson University in Philadelphia explore this condition as it affects the head of the femur (thigh bone). They remind us of the many classifications and treatment options (nonoperative as well as surgical).

Osteonecrosis of the femoral head refers to death of the round ball of bone at the top of the femur that fits into the hip socket. Another term used for osteonecrosis is avascular or ischemic necrosis. Avascular and ischemic both mean a loss of blood supply to the area is the cause of the problem.

But what turns off the flow of blood to that area? That’s the real cause or etiology. The authors provide a table of more than a dozen potential causes or etiological factors. From a broad perspective, the etiology of femoral osteonecrosis is the result of genetics, risk factors, and specific events. This is considered a multifactorial etiology.

Let’s take a closer look at some of the more common causes and risk factors first. Number one is trauma: a hip fracture or hip dislocation with damage to the blood vessels supplying the femoral head is the most commonly reported cause. Most of the time, older adults are the prime group at risk.

Number two is the use of corticosteroids — medications such as prednisone used to reduce inflammation and the immune system. Adults with arthritis, anyone who has had an organ transplantation, and cancer patients in treatment are just a few of the types of people taking corticosteroids. Usually long-term use of corticosteroids is the trigger but there have been reports of patients developing osteonecrosis within a month of starting these drugs.

Number three: lifestyle factors. Smoking and alcohol abuse compound the problem and increase the risk of femoral head osteonecrosis. Even occasional drinking (once a week) increases the risk of developing avascular femoral necrosis. But the odds are much higher for those who drink daily and especially if they drink more than one alcoholic beverage in a 24-hour period.

Then there is a long list of other diseases and conditions that are associated with increased incidence of femoral head osteonecrosis. These are referred to as nontraumatic causes. For example, there is a link between osteonecrosis and more commonly known problems like leukemia, sickle cell diseases, and HIV infection and less well-known diseases such as Gaucher disease, hyperuricemia, and Caisson’s disease.

The etiology and risk factors for osteonecrosis of the hip are just one side of the coin. The other side (and the remainder of this article) is devoted to understanding classification and staging as part of the diagnosis and finally, treatment. The plan of care really depends on an understanding of the severity of the condition.

Through X-rays and MRIs, the physician is able to “stage” the condition. This classification process helps pinpoint the problems and identify the solutions. But there isn’t one method of describing osteonecrosis that includes all the important variables to consider. Instead, there are at least six classification systems on record for osteonecrosis.

Even saying that imaging studies are used to stage the disease doesn’t really describe the process and why so many systems are out there. That’s because there are many, many different elements that can be examined using X-rays for example. The same can be said when using MRIs to determine exactly what’s going on around and inside the hip joint.

All kinds of efforts have been made to treat femoral head osteonecrosis nonoperatively. But despite protecting the joint from weight, using various medications, and attempting electromagnetic stimulation and shock-wave therapy, the results have been poor.

That’s why surgeons have turned to operative procedures to treat this problem. But even within the realm of surgical care, there many different options to choose from: decompression, osteotomy, and reconstruction head the list. And, of course, there are an equal number of ways to perform each of those procedures. For surgeons involved in treating patients with avascular femoral necrosis, the authors discuss in detail specific surgical techniques, grafts, fixation devices, and choices among joint resurfacing and hip replacements.

How does the surgeon decide what to do? Two tools are at their disposal. First, there is what’s referred to as a treatment algorithm. That’s a step-by-step process where each factor is examined and considered carefully when planning the treatment. Age and life expectancy, patient’s goals and activity level, and general health and presence of other health problems are a big part of that equation.

Second, the surgeon knows the benefits and drawbacks of each surgical procedure available. Matching up the specific patient characteristics with the surgical options becomes the final step of the algorithm. For patients with poor health or a limited lifespan, more temporary measures may be advised.

For young, active adults, the more invasive but permanent reconstructive techniques may be selected. Severity of disease, length of time from diagnosis to treatment, and intensity of symptoms are also taken into consideration when planning treatment. You can see how this can range from minimal intervention for mild disease in patients with no symptoms to total hip replacement for those with bone death and deformity of the entire joint.

In summary, this review article examines many aspects of osteonecrosis of the femoral head. In the first half, the problem is defined, the causes and risk factors are outlined, and an understanding of the various classification systems is provided. In the second half, treatment is discussed — both the specifics of what treatment to use and how to decide the best plan of care. Anyone with an interest in the topic of osteonecrosis of the femoral head will find this information useful.

Problems With Hip Replacements

It is often the case that research results as they are published are far behind actual knowledge in medicine. And changes in medical (clinical) practice by the majorityof health care professionals is delayed even more. To combat this, many orthopedic surgeons rely on annual meetings to keep them as up-to-date as possible.

In this specialty update, current information on total hip arthroplasty (THA, otherwise known as a total hip replacement) is summarized. The ideas presented were first offered at the 2009-2010 meetings of the American Academy of Orthopaedic Surgeons, the Orthopaedic Research Society, the Hip Society, and the American Association of hip and Knee Surgeons.

Surgeons agree there are still many problems to overcome when it comes to hip replacement surgery. Two of the biggest dilemmas faced right now are the increasing number of older adults who need joint replacements and fewer surgeons specializing in this procedure. Some surgeons are shying away from hip replacement surgeries because of the high costs. There have been problems with the implants holding up. Product liability is a huge factor in this issue.

It seems like the outcomes of hip replacement are less predictable and worse now than ever before. One of the reasons for this may be the fact that so many surgical techniques are available now. Which method works best for each individual patient problem has not been determined. Problems such as bone deficiency, infection, and hip dislocation add to the many challenges faced by patient and surgeon.

There are also many more implant designs and materials to choose from. For example, more porous materials like titanium foam, cobalt-chromium foam, and tantalum foam are available. These materials make it easier for bone to fill in and around the implant to help hold it in place. The surgeon can also use cement and/or bone grafting to help seal the implant in place. All of these efforts are geared toward one thing: preventing loosening of the implant — the most common complication of hip replacement.

Research has focused on ways to prevent implant loosening. Some surgeons have advised their patients to limit physical activities the first 12 months after receiving a hip replacement. Others have suggested low-impact sports over high-demand activities. Some studies have concluded that patient selection is really the key factor here. By looking at who ends up requiring revision surgery, it’s possible to make some observations that might help.

For example, the revision rate is higher for women than men and in patients who receive smaller-sized implants. Hip resurfacing has higher revision rates than total joint replacement, especially for older patients. Getting the cup part of the hip replacement seated in the right place with the correct angle seems to be a key ingredient to success.

One of the new tools in the pipeline for surgeons to use is a special computer software that would improve patient selection and predict which hips are at risk for failure. This same software will have the ability to measure (and thereby improve) the best place for cup position. Advances have been made just from the fact that when failed implants are removed, the surgeon can examine them for changes that might help explain those failures.

For example, wear patterns and fatigue fractures of cup liners have led to improved materials that hold up better with greater wear resistance. And metal debris found in the removed implants suspected as the cause of inflammation has resulted in the increased use of polyethylene (plastic) and ceramic components.

Several recent studies have also suggested surgeons reconsider when thinking about using a metal-on-metal implant for women young enough to have children. There is evidence that ions associated with metal can cross from the mother to the developing child in utero (inside the womb).

Besides the many concerns and factors just related to the surgical technique and implants, surgeons must also pay attention to pain management, post operative complications, and rehab protocols. The cost of these operations hasn’t escaped examination either. Hospital managers agree that economics and cost containment are important if joint replacement surgeries are going to continue to be affordable. And that doesn’t even touch the issue of the uninsured Americans who need joint replacements.

In summary, this update on hip replacements focused on five major areas of concern. Results referred to as outcomes are at the top of the list. Implant types, designs, and surface take up the bulk of the discussion. Complications following surgery and even resulting in implant failure are discussed. And finally, economic and management issues are presented. Anyone who wants to keep up with the latest concerns and directions regarding total hip replacements will find this update helpful.

Clinical Practice Guidelines for Periprosthetic Joint Infections

The 13 co-authors of this article sat on a committee together to come up with Clinical Practice Guidelines (CPGs) for the diagnosis of infections in joint replacements. The proposed guidelines were approved by the American Academy of Orthopaedic Surgeons (AAOS) in June of 2010 and published here for all to see.

Clinical Practice Guidelines (CPGs) are an important tool in helping physicians keep up-to-date with what the evidence says about treatment of various problems and conditions. The goal is to improve treatment based on high-quality evidence.

CPGs are especially helpful when care for musculoskeletal problems is provided by a wide variety of health care professionals. This could include emergency medical staff, primary care physicians, physical therapists, physician assistants, chiropractors, orthopedic surgeons, athletic trainers, and others.

The 15 recommendations contained in these Clinical Practice Guidelines for the diagnosis of infections of joint replacement implants are based on a systematic review of all available research results in this area.

Ten of the 15 are based on high-quality evidence. A full viewing of all 15 is available on-line at Here’s a quick review of the most reliable points.

  • Anyone suspected of a periprosthetic joint infection (PJI) should be screened using two tests: erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).
  • Patients with higher lab values indicating inflammation (e.g., ESR and CRP tests) are more likely to have an infection. Further testing is required. This is based on a probability and statistics model.
  • One other lab test (i.e., gram stain) should not be used to say there is no joint infection. In other words, the gram stain test is not a good rule-out test.
  • Whenever ESR and CRP tests are abnormal, fluid should be aspirated (drawn) from the joint and sent for testing to confirm infection and type of pathogen (bacteria).
  • Aspiration is not necessary when there are normal ESR and CRP levels. Hip aspiration can be painful and difficult to do without actually injecting the joint with more bacteria. Therefore hip aspiration is not done routinely (unless there are abnormal screening tests) and especially not when surgery isn’t going to be done.
  • Positive ESR and CRP tests in patients who are NOT having surgery should be retested in three months.
  • Repeat joint aspiration tests for the knee follow similar guidelines as for the hip but the need for repeated testing is much less for the knee. Joint infections of knee implants are easier to diagnose and confirm compared with hip infections.
  • Taking fluid from the joint to test it for the specific bacteria present should be done before any antibiotics are given. Sometimes this doesn’t happen and the patient is put on antibiotics immediately regardless of what kind of pathogen is present.
  • If antibiotics have been prescribed, then joint culture by aspiration must wait until two weeks after the patient stops taking the drugs. Discontinuing the medication is important because taking antibiotics limits the number of bacteria present and prevents accurate testing.
  • The need for diagnostic imaging (PET scans, bone imaging, CT scans, MRIs) is unclear. Patients who are not going to have surgery probably don’t need the added testing.
  • When surgery is done, fluid should be taken from the joint and retested. In fact, more than one sample should be drawn and tested. More than one positive test increases the certainty that there is a joint infection.
  • The bad effects of implant infection suggest the need for antibiotics before the first joint replacement surgery is done. Prophylactic (preventive) antibiotics preoperatively to prevent infection.are advised even for low risk patients.

    For those who are interested in these clinical practice guidelines, the authors advise remembering two additional factors that can affect decisions. First, each patient is unique and must be evaluated based on his or her situation. These guidelines are exactly that: guidelines, not a standard of practice that should be applied in a cookie-cutter fashion.

    Second, health care professionals should not assume the clinical practice guidelines outlined here are set in stone or indefinite. As new studies are published, these guidelines may become outdated.

    The guidelines help level the playing field, so-to-speak (everyone uses the same guidelines to direct treatment decisions). Even so, it will be necessary to update the guidelines every five years and possibly even remove them if they are outdated.

  • Source of Blood Supply to the Hip Labrum

    There are plenty of studies and reports on the soft tissue structure known as the hip labrum. This may be the first published on the blood supply to the labrum. Several other studies have reported on the location of blood vessels inside and around the labrum. Now we have clear photos of the precise pattern of those blood vessels.

    The labrum is a thick rim of fibrous cartilage around the edge of the hip acetabulum (socket). It is there to increase the depth of the hip socket. The labrum also provides a seal to help protect the hip articular (joint surface) cartilage.

    The average person on the street isn’t going to think much about the blood supply to the hip labrum. That’s okay so long as the surgeon operating on that person’s labrum sits up and takes notice. Understanding the labral blood supply is important when performing surgery to repair a torn labrum.

    Orthopedic surgeons from the Iran University of Medical Sciences teamed up with researchers from the Department of Anatomy at the Legal Medicine Research Center in Tehran (Iran) to perform this study. They examined the hips of 35 cadavers (hips preserved after death for study). They used a special colored silicone that was injected into the blood vessels around the hip labrum.

    The donor hips came from 28 cadavers ranging in age (at the time of death) from 20 to 50 years old. Cause of death was unknown but there was no damage to the hips and no sign of previous surgeries to the area.

    Twenty-four hours after the silicon injections, they carefully took the hips apart and examined the blood vessels (now clearly visible from the injected dye). They found the beginning point (source) of the blood supply to the labrum and followed it to its insertion site into the hip joint capsule.

    Beautiful color photos are provided to show the structures of the hip (e.g., bone, capsule, labrum). The blood vessels throughout the area show up as a green color in full detail. For the first time ever, the vascular ring pattern around the labrum is clearly seen. The authors describe the location and pattern of these blood vessels.

    For those readers who find the photos difficult to understand, there is a schematic drawing to outline the ring of vessels around the labrum. Each blood vessel is labeled by name. This structure has been given the name: periacetabular vascular ring. Peri- means “around” and acetabular refers to the hip socket. So, periacetabular gives us the sense that we are looking at the blood vessels around the hip socket.

    Seven of the hips had a visible labral tear. All specimens came from males. The presence of these labral injuries made it possible for the researchers to answer another big question. Is the blood supply to the labrum disrupted when the labrum is injured?

    In all seven cases, the answer was No. The periacetabular ring was fully intact despite damage to the labrum.

    By finding the source of the blood supply to the hip acetabular labrum, these researchers were able to show that the blood vessels do NOT come from the joint capsule or the subchondral bone (layer of bone just underneath the cartilage).

    Instead, there is a special layer of loose connective tissue between the hip joint capsule and the surface of the labrum (next to the capsule). This tissue lining contains a separate blood supply to the labrum now referred to as the periarticular vascular ring.

    Knowing that injury to the labrum does not include damage to the blood vessels is an important finding for surgeons attempting to repair a torn labrum. This knowledge is essential as studies have also shown that repair (rather than removal) of a torn labrum yields the best results for patients with this type of injury.

    Further studies are needed in this area. For example, the authors did not see exactly how the blood vessels enter the labrum. They know it comes from outside the hip joint through the ring described. But they did not dissect the cadavers in such a way as to show this additional detail.

    On the basis of their findings, the researchers suggest taking a closer look now at current techniques used to repair a torn labrum. Every effort should be made to avoid damaging the periacetabular vascular ring.

    It appears that if the loose connective tissue containing the vascular ring is not disrupted, then no damage is done to the labrum’s vascular supply. Labral repair with preservation of this capsular-sided connective tissue will enhance healing.

    Is the Evidence in Favor or Against Surgery for Femoroacetabular Impingement?

    Hip pain, abnormal joint mechanics, and loss of hip function describe the three most difficult problems with femoroacetabular impingement (FAI). FAI occurs in the hip joint.

    Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. 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.

    Current understanding of this hip deformity has resulted in surgery to correct the deformity. The short-term goals are to relieve pain and improve function. The long-term goal is to prevent hip osteoarthritis.

    But does the evidence support this treatment approach? Are there complications or problems after the surgery that might outweigh the benefits received? In order to find out, researchers at the Washington University School of Medicine in St. Louis conducted this study.

    They reviewed five major database systems looking for any articles published on the topic with reports on long-term results. This type of literature review is called a systematic review.

    They examined the study design, level of evidence, number of patients in each study, and number of years in the follow-up period. A minimum of two years follow-up was required to be included in the final studies chosen for review.

    The ages of the patients, any unique features presented, and type of surgery performed were all analyzed. Results were measured in terms of hip function and number of additional surgeries and failures.

    Failure was not always defined the same from study to study. In some cases, continued pain after surgery was considered a failure. In other studies, osteoarthritis requiring a joint replacement was counted as a failure.

    The authors also considered the type of surgical procedures performed to see if one technique was more successful than others. Arthroscopic versus open incision approaches were also compared. And data on complications such as infection, fracture, broken or bent screws, or loss of blood to the area was also collected.

    They found that reduced pain and better hip function were two by-products reported in all studies. More than two-thirds (68 per cent) of the patients and as many as 96 per cent had positive short-term results. But there were quite a few complications reported in some studies. As many as one-fourth of the patients had to convert to a total hip replacement.

    In summary, modern understanding of femoroacetabular impingement has led to the development of surgical correction of the deformity to prevent osteoarthritis. Is there enough evidence to support this treatment approach? In the short-term, yes but there isn’t enough proof yet that the benefits persist long-term.

    The authors suggest there is plenty of room for further study before decisions can be made about the best way to surgically treat femoroacetabular impingement. It makes logical sense that restoring the hip to a more normal anatomical shape would prevent arthritis from developing over time. But the evidence to support this approach is limited and not necessarily high-level evidence.

    The main problems are the lack of consistent study design and use of inconsistent reporting measures. With so much variability in how studies are conducted, it’s difficult to compare one study to the next.

    At the very least, they could see that patients who already had severe arthritic changes at the time of surgery were the least likely to have a good result. Other pre-operative factors that could predict a poor result included older age and severe pain. Those findings suggest surgeons should give patients with these factors careful consideration before performing surgery to redesign the hip.

    Surgical Treatment of Femoroacetabular Impingement of the Hip

    The title of this article will catch the eye of any surgeon because it includes the phrase: Systematic Review. The statistical significance of any conclusions from a systematic review is worth noting. That’s because such a review combines the results of many smaller studies to give an overall view of the results of treatment like surgery for femoroacetabular impingement (FAI) of the hip.

    Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. 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.

    Most studies on this condition are case studies. That’s because no one surgeon sees 100s or 1000s of patients with this problem. Case studies are good because surgeons have to start somewhere when trying to see the effects of treatment.

    The problem with published case studies is that this is considered a low levels of evidence. A surgeon wouldn’t want to treat any patient with methods considered “successful” based on low level of evidence.

    Conducting a systematic review like this one allowed the authors to examine the data on 970 different patients (collected from 23 reports of case studies). Now surgeons can see what the latest findings are and evaluate their own practices based on what is statistically significant.

    This systematic review was set up to find information that might answer the following four questions:

  • Does surgical treatment for femoroacetabular impingement (FAI) work? In other words,
    does it decrease patients’ hip pain?

  • Are there certain people with FAI who should not have surgery?
  • When the labrum (rim of cartilage around the hip socket) is getting pinched, should
    the surgeon shave it off or try and repair it? Reattaching the torn labrum is called labral refixation.

  • Can surgery for FAI slow down or even stop the progression of hip osteoarthritis that
    usually occurs with this condition?

    Results of any treatment can be measured in different ways. Severity of symptoms, change in function (better or worse), hip motion, and patient satisfaction were the most commonly reported in the case studies included in this review.

    Different groups used different tests to assess these measures including the Western Ontario and McMaster Osteoarthritic Index (WOMAC), the Harris Hip Score (HHS), the Visual Analog Scale (VAS), the SF-12 Health Survey, and the nonarthritic hip score (NAHS).

    For comparison sake, it would be better if everyone always used the same test measures when studying this condition. Without that, a systematic review is the next best option for combining results and testing the significance level.

    Here’s what they found. First, surgical treatment for FAI did improve symptoms and function. Improved motion, decreased pain, and better function were reported. But patient satisfaction levels were not high across the board.

    For those patients whose pain didn’t improve and especially those patients who ended up having a hip replacement, reported patient satisfaction was low. In some studies, the rate of dissatisfaction and/or conversion to hip replacement was as high as 30 per cent.

    Treatment failure in these studies wasn’t always because of the severity of cartilage damage. Just as many patients with severe damage had good outcomes as those who had a failed treatment. The reasons for those differences remain unknown and will require further study.

    For now, we know from this systematic review that in answer to the four questions, 1) surgery for femoroacetabular impingement (open or arthroscopic) has good results, 2) labral refixation has better results than labral resection (removal), 3) severe damage to the joint surface and surrounding cartilage (these are considered advanced arthritic changes) is a risk factor for poorer outcomes, and 4) the treatment effect on future arthritic changes remains unknown for now.

    The authors offer some additional thoughts from their analysis of the many case studies included in this review. First, the optimal treatment of femoroacetabular impingement (FAI) remains unknown. Some patients may benefit more than others from surgical intervention. It should be the goal of future research to identify who can benefit the most from each type of treatment (conservative or nonoperative versus surgical).

    Identifying patients with severe or advanced arthritis before surgery to repair FAI should be a priority. Right now, even with X-rays and MRIs, it isn’t always possible for the surgeon to know the full extent of the damage. Sometimes, it isn’t until getting inside the joint that the surgeon can see what’s really going on.

    And finally, no one has done a study directly comparing open and arthroscopic methods for surgical repair of femoroacetabular impingement (FAI). This is an important gap in the available knowledge about treatment of this condition. Future studies with high levels of evidence are needed to guide surgeons in choosing the most optimal treatment approach for individual patients with FAI.

  • How Many People Have Hip Deformity Leading to Arthritis?

    There is a condition of the hip called femoroacetabular impingement (FAI) that can lead to early hip osteoarthritis. In an effort to prevent arthritis, there are some experts who suggest routine screening for this problem and early treatment.

    But the cost of performing X-rays and/or MRIs on everyone may not yield cost-effective results. That’s why these Canadian researchers tested 200 adult volunteers (ages 21 to 50) for the presence of femoroacetabular impingement (FAI). None of them had any previous hip problems.

    Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. 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.

    The goal of the study was to determine the prevalence of the Cam-type of FAI in the general adult population. Prevalence refers to how many people have a particular condition at any one point in time. The cam-type of impingement is the most likely to set up conditions ripe for joint wear and tear. This type 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 tilt or 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. This abnormal contact between the femur and acetabulum is the leading cause of labral tears and degenerative hip arthritis.

    The authors tried to establish what might be considered normal in terms of the femoral head-neck contours. Knowing what falls within the range of normal limits helps identify those who are outside those parameters. Measures used to assess the volunteers for the presence of Cam-type femoroacetabular impingement (FAI) included hip internal rotation, positive impingement sign, and contour/angle of the femoral head-neck junction. MRIs were used to provide information on hip contours and angles. With 200 volunteers enrolled in the study, there were a total of 400 hips to report data on.

    A study like this that recruits volunteers from the general population and checks to see how many have femoroacetabular impingement is helpful. By studying people who have no symptoms but who have the problem, it is possible to see over time whether or not they will develop arthritis. It also helps find risk factors for impingement. In this study, they specifically looked at age, gender (male versus female), body-mass index (a measure of obesity), and ethnicity. These potential factors may put people at increased risk for impingement and then for going on to develop arthritis later.

    Most of what they found out in this study supports results reported from other studies. For example, there were about 14 per cent of the participants who had femoroacetabular impingement. Other studies report a prevalence of 15 per cent. Men were affected by this particular (Cam) type of femoroacetabular impingement (FAI) much more often than women (25 per cent of men compared with only five per cent of women).

    The authors point out that the prevalence of hip osteoarthritis in the general population is only around eight per cent. The much higher 14 to 15 per cent prevalence rate of femoroacetabular impingement (FAI) suggests something else is going on here. There may be genetic or environmental factors contributing to the development of FAI that haven’t been discovered yet.

    There were some significant findings from the measurements taken of each volunteer when compared with their MRI results. The elevated angle measured on X-ray (called the alpha angle) wasn’t diagnostic of femoroacetabular impingement by itself. (Though it was a predictor of hip pain and joint cartilage damage).

    But when combined with restricted hip internal rotation, the angle could be used to predict impingement. A positive impingement sign (a test performed by applying manual pressure through the hip) was a reliable indicator of a problem with the labrum (rim of cartilage around the hip socket).

    The key finding in this study was the high rate of asymptomatic femoroacetabular impingement in the general adult population. Asymptomatic means they were not aware of the problem and were not having any symptoms from it. Further studies are needed to finish what these researchers started: finding out what alpha angles are normal and what the cutoff angle is to diagnose femoroacetabular impingement.

    More studies are also needed to see if early diagnosis and treatment really can reduce the progression of this condition to osteoarthritis. The question of whether or not early testing on all adults is cost-effective was not answered by this research.

    More Important Information on Femoroacetabular Impingement

    Dr. J. W. Byrd, a prominent orthopedic surgeon at the Nashville Sports Medicine Foundation presents part two of a two-part series on femoroacetabular impingement (FAI) in athletes. This article focuses on treatment and what to expect after treatment.

    Femoroacetabular impingement (FAI) occurs in the hip joint. Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. 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.

    Although we know a lot about the causes of this condition, what to do about it remains in question. Can it be prevented is the first question. Should we even try to prevent it is the next question.

    Some athletes have abnormally shaped hips but don’t ever develop symptoms. It has been suggested that we need to figure out who is at risk for pain and other problems from FAI before launching into a prevention program for everyone.

    On the other hand, if some easy screening tests were done to find athletes at risk, then perhaps a careful wait-and-watch program would be helpful. Or maybe some simple changes in activity would be all that is needed. Preventing substantial changes in the hip and the need for surgery would be a worthy goal.

    Conservative (nonoperative) care really requires early recognition. So, it’s a “catch-22” kind of situation. There’s no evidence that screening and prevention help but without catching the problem early, conservative care quickly gets replaced by a more invasive approach with surgery.

    What kind of treatment is available right now? On the conservative side, there’s not a lot to offer. Athletes are told to avoid full squats (especially during weight training) because this position really compresses the hip joint.

    Every effort is made to maintain joint motion but the abnormal shape of the hip makes this difficult as well. At the very least, athletes are encouraged to keep up with their core strength training to help them compensate for lost motion.

    When the athlete is unable to get relief from pain with a conservative approach, surgery is often advised. Surgery is also recommended when imaging studies show damage to the joint. Dr. Byrd presents a detailed description of the kinds of arthroscopic surgical procedures that can be done to treat femoroacetabular impingement.

    With the arthroscope inserted into the joint, the surgeon takes a careful look around to see what’s going on inside the hip. If there are any loose fragments or frayed edges of the cartilage, these are removed or shaved off. This procedure is called a debridement. Every effort is made to preserve this rim of cartilage around the hip socket called the labrum.

    The surgeon can use high-speed surgical tools to remove bone and reshape the head of the femur and the acetabulum (hip socket). Any other damage to the hip socket or surrounding structures is repaired. With drawings and photos taken inside the hip during arthroscopic surgery, Dr. Byrd shows how each type of impingement can be surgically corrected.

    The postoperative recovery period may include a specific rehabilitation program. It depends on what the surgeon did. A simple debridement requires less postoperative caution than reshaping and repair procedure. The concern is for regaining hip motion, maintaining joint stability, and preventing complications.

    The more complex procedures will require the athlete to keep weight off the hip and avoid twisting motions for at least a month. This can be accomplished by using crutches. The athlete is gradually allowed to return to light activities at first. Avoiding twisting motions is enforced for a full three months. It will be six months or more before the athlete is allowed to return to full sports participation.

    What can the patient expect after it’s all said and done? Will the remodeled hip hold up? Will it be possible to resume an athletic career? Let’s take these questions one at a time. What to expect: the joint will never be “normal” after surgery. But the changes made will allow many athletes to return to the sports they love.

    Studies done so far show that up to 90 per cent of athletes with femoroacetabular impingement repaired surgically get back to their previous level of sports participation. With longer follow-up, other studies have shown that this number dwindles over time.

    There is some evidence that arthroscopic surgery yields better results than open surgery. More study is needed to confirm this is true and perhaps identify which athletes would do better with arthroscopic versus open surgery.

    Treatment of Asymptomatic Osteonecrosis of the Femoral Head

    Adults who have a painful hip from osteonecrosis of the femoral head often have the same problem in the other hip but it is “silent” or asymptomatic. In other words, there’s no pain. If it wasn’t for the telltale signs on X-ray, the affected individual wouldn’t even know there was a problem.

    Is this a case of out of sight, out of mind? Is it best to leave it alone or treat the condition early to prevent any further damage that can occur within the joint? Let’s take a closer look at osteonecrosis first and then see what the experts have to say.

    Osteonecrosis means “bone death”. Loss of blood supply, bone death, and collapse occur over a period of months to years. The femoral head is the round ball at the top of the thighbone that fits into the hip socket. Osteonecrosis can be caused by steroid use, alcohol, trauma, and blood-clotting problems like Sickle Cell Disease. In some cases, no cause can be found.

    The first goal in treating symptomatic (painful, limiting) osteonecrosis of the femoral head is to save the bone. The second goal is to keep function while relieving pain. But what about that asymptomatic hip? Is treatment needed at all? What’s the natural history (i.e., what happens over time if it is NOT treated).

    Some surgeons advocate what is referred to as careful neglect. This is a watch-wait-and-see approach. Some of the phrases used to defend this position include no sense in muddying up the waters or best to leave well enough alone. But there are just as many orthopedic surgeons who say head it off at the pass. In other words, treat it early and prevent the problem from getting much worse.

    The voice of reason and experience comes through loud and clear on this one: study patients who have this problem and see if there are any predictive factors of disease progression. Those patients who have significant risk factors for progression of disease without treatment should be teated early in the course of their disease development.

    It is possible that the question of how (and when) it’s best to treat asymptomatic osteonecrosis of the femoral head has already been answered but lies buried in the medical literature. That’s why these surgeons reviewed all of the articles published on this topic up to the middle of 2008. This type of study is called a systematic review.

    Information collected from the studies that were high enough quality to be part of the review included patient age, how long they were followed, location and size of the bone lesion, and use of certain medications (e.g., steroids) or excessive alcohol. They also looked at personal medical history of lupus, sickle cell disease, kidney disease, kidney transplantation, and human immunodeficiency virus (HIV).

    By combining all the hips studied into one group, they found that 394 of the total 664 hips developed symptoms and eventual collapse. That’s a percentage rate of about 59 per cent (more than half, almost two-thirds). The destruction took place over a period of time from as little as two months and as long as 20 years.

    There were some telltale factors to help predict who might go on to a symptomatic phase. The size of the lesion was the main risk factor. The larger the lesion at the time of diagnosis, the more likely destruction and collapse were to occur in time. Patients with sickle cell disease were also at great risk of disease progresion. Patients with lupus were much less likely to progress to collapse.

    The authors concluded that based on the systematic review there is enough evidence to support a more aggressive approach to treating asymptomatic hip osteonecrosis. Large lesions are likely to get worse, so don’t wait. A wait-and-see approach may be okay for smaller areas of bone death but the patient should be followed closely. Any sign of progression should be addressed right away.

    Medium-sized lesions present a different dilemma. In those cases, the surgeon may evaluate the location of the osteonecrosis when making a decision about the best treatment. Repairing damage along the medial (inside) portion of the femoral head is not as crucial as destruction along the lateral (outside) femoral head. X-rays and a series of MRIs taken from different angles might help show the full extent of the damage when making the decision of conservative (nonoperative) versus operative care.

    In summary, both the lesion size and location are two big factors in making the wait-or-treat decision about asymptomatic femoral osteonecrosis. The bottom line is that every effort should be made to save the joint without subjecting the patient to unnecessary surgery. Knowing the natural history as it was presented here helps surgeons know how to educate and advise their patients who are trying to decide between conservative and operative treatment.

    Is There a Fast Yet Safe Way to Recover from Total Hip Surgery?

    Many seniors put off having a total hip replacement despite the pain and loss of function that the arthritic joint is causing. They are afraid that it will hurt even more after the surgery and that it will take a long time to recover. At least right now, they can walk without a walker. After surgery, the thought of using a walker or cane is enough to keep them away.

    Yet every year there are nearly one million adults who do have a total hip or total knee replacement. And that figure is expected to increase to four million in the next 20 years. So while some are hesitant, those who aren’t may experience an even faster recovery time thanks to the results of this study.

    Surgeons from the Cleveland Clinic in Ohio divided a group of 103 total hip patients into two groups. One group (73 patients) had the traditional post-operative treatment after hip replacement. The second group (30 patients) tried a new rapid recovery program.

    The rapid recovery program combines several factors to enhance recovery. First, the surgeon uses incisions that don’t cut through the abductor muscles. The abductor muscles are along the inside of the thigh and help bring the legs together. Second, nurses supervise the use of pain medications. Pain management begins in the operating room where patients receive a special injection of numbing agents around the joint just operated on.

    And third, the patients are seen right away by physical therapists on the multidisciplinary team. The traditional program allows patients to rest the first day after surgery. They get up and move much more slowly with the traditional approach compared with the rapid recovery program. Getting up the day of surgery and walking small amounts frequently throughout the day is part of the rapid recovery program. Walking is followed up with an exercise program that is supervised by the therapist twice a day.

    The results speak for themselves. Patients in the rapid recovery program went directly home two days (sometimes three days) after surgery. Patients in the traditional treatment group were more likely to be discharged to a rehabilitation center around day 4 after surgery. If the traditionally treated patient went home directly from the hospital, then a treatment program continued at home.

    Walking distance was twice as far in half the time for the rapid recovery group. That result alone brought smiles to the patients’ faces as they reported a much higher level of satisfaction compared with the traditional group. But there was another positive finding from this study. The rapid recovery group reported significantly less pain and less use of pain medication.

    The goal of the rapid recovery program was to cut costs while still maintaining patient safety and excellent results. Decreasing the number of days patients are in the hospital while increasing their level of independent function by the time they are discharged is possible.

    The authors of this study conclude the results show what they call compelling evidence that the rapid recovery program accomplishes the intended goals as stated above. They suggest that the importance of physical therapy right away translates into cost savings as well as increased patient satisfaction.

    This type of post-operative treatment plan deserves further attention. Before it can be used by all patients, it will be necessary to compare complications and long-term results between these two groups. And it will be important to compare the three key factors (surgical approach, anesthesia and pain control, PT program) to find out if one of those variables is more important, more powerful, or more successful in contributing to the outcomes.

    Early Recognition of Hip Impingement Important to Prevent Joint Damage

    Just the slightest change in the morphology (shape and structure) of the hip joint can cause problems for some people. Athletes are affected most often as they push their bodies past the normal limits of motion repeatedly. Some of those problems such as femoroacetabular impingement (FAI) can lead to early joint osteoarthritis.

    As the author of this article points out, early recognition of femoroacetabular impingement (FAI) is important. Early intervention can help prevent painful, debilitating arthritis when the athlete hits his or her 30s to 50s. What is FAI and what can be done about it?

    Femoroacetabular impingement occurs in the hip joint. Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. 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.

    The first type of femoroacetabular impingement (FAI) is called pincer impingement. This type occurs when the rim of the acetabulum (hip socket) sticks out farther than normal.

    There are several causes of this problem. There can be an overgrowth of cartilage forming the rim or even extra bone that forms in the area. Sometimes the hip socket is tilted backward slightly. In either case, every time the athlete flexes the hip, the rim that’s sticking out too far pinches the labrum against the neck of the femur. The labrum is a fibrous rim of cartilage around the socket to help give it some depth. It is a normal part of the hip biology.

    The second type of femoroacetabular impingement is called CAM impingement. Normally, the head of the femur is a smooth, round shape. It is even all around so it can rotate inside the socket evenly. But any change in the shape can cause it to hit one point of the socket more than the others as the head of the femur moves inside the socket.

    The asymmetrical rotation of the pistol-shaped femoral head is called the cam effect. Anytime something repeatedly rubs against something unevenly, there is uneven wear, tear, and damage. In this case, when the hip is flexed or bent, the unevenly shaped femoral head doesn’t glide over the labrum as it should. Instead, it bumps up against the edge of the cartilage. Over time, the labrum gets worn down to the bone.

    And finally, the third type of femoroacetabular impingement is a combination of the two just described (pincer and cam). Cam impingement is more common in males and brings on symptoms earlier than the pincer type. The combination of both types together causes problems sooner than if only one type was present.

    How does the orthopedic surgeon know that the hip and/or groin pain a patient reports is coming from femoroacetabular impingement? And how do they know what type it is? The diagnosis begins with a patient interview and history. Then comes a physical exam. The physician looks at pelvic and hip motion and palpates muscles and tendons for areas of tenderness.

    There may be a telltale snapping of the iliopsoas tendon as the patient moves the leg from one position to another (flexion to extension, external rotation to internal rotation). Several other tests can be done to identify what’s going on.

    As is often the case, one problem can lead to others. With femoroacetabular impingement, hip bursitis can develop. The gluteal (buttock) muscles may be extra tender or sore from trying to compensate and correct the problem.

    The clinical exam is followed up by imaging studies including X-rays, MRIs, and CT scans. X-rays show the presence of any extra bone build up as well as the position and alignment of the bones and joint. Using different X-ray views, the radiologist and orthopedic surgeon can see the shape of the femoral head and look for any asymmetries (i.e., where the head is no longer an even round shape).

    MRIs can show any damage to the labrum but not necessarily to the surface of the hip joint. The presence of edema (swelling) under the bone may show up and requires further evaluation to decide if it is from femoroacetabular impingement or some other cause (e.g., cyst, tumor, stress fracture). Using MRI with a dye injected into the joint (called magnetic resonance arthrography or MRA) provides greater detail of the joint surface and may be needed.

    CT scans help show the exact shape of the bone and reveal any abnormalities in the bone structure. CT scans might be the most helpful when arthroscopic surgery is planned. It gives the surgeon a better idea of what needs to be done to reshape the bone. If the procedure is going to be done with an open incision, then the CT scan isn’t necessary. The surgeon will see everything once the area is opened up.

    More details about planning treatment for femoroacetabular impingement (FAI) will be provided in part 2 of this article series. This first article focused on accurately diagnosing the problem. Since it is known that FAI leads to damage of the hip that can end an athlete’s career, early recognition is important to prevent the severe problems that often develop.

    An Update on the Anatomy, Biomechanics, and Repairs of Hip Labrum

    There isn’t one part of the body (no matter how small) that doesn’t have a specific function — and often more than one job to do. That’s also the case with the labrum, a horseshoe-shaped bit of fibrous cartilage lining the hip and shoulder sockets.

    In this review article on the hip labrum, orthopedic surgeon Marc R. Safran, MD from Stanford University provides a detailed description of the labrum anatomy. Advanced technology including light microscopy has made it possible to take pictures and study the many layers of dense connective tissue that make up the labrum.

    Blood supply, type of nerve endings, and biomechanics are explained. The symptoms and effects of a labral tear are discussed. Surgery is often needed to repair or remove the damaged tissue because it can’t heal itself and can cause severe, disabling hip pain.

    The labrum is small but mighty in effect. As recently as 1998, it was believed that the labrum had no apparent role in bearing weight through the hip. Since that time, scientists have discovered multiple functions of the labrum.

    For example, the labrum increases the size of the joint surface and the joint socket. Another term for the hip socket is acetabulum. This increase allows for a more even distribution of load across the whole joint.

    Another task the labrum carries out is to act like a suction cup creating negative pressure in the joint. The seal that forms holds the lubricating synovial fluid inside the joint. The net effect is that the labrum reduces joint friction, a protective feature against degeneration leading to arthritis.

    Tiny receptors in the labrum signal the location and movement of the joint. The receptors are called mechanoreceptors. Awareness of tiny changes in joint position is called proprioception. The role of the labrum in proprioception is clear but not fully understood yet.

    When combined together, the various functions of the labrum help maintain joint stability. With all these wonderful functions of the labrum, you can imagine that any damage to the labrum can create some serious problems.

    Hip pain is the first indication that something’s wrong. Sometimes there is a clicking sensation and the hip can even get locked up if the torn labrum gets caught between two structures of the hip. Loss of hip motion is the outcome of either of these symptoms.

    Surgery is usually the recommended course of action for a symptomatic labral tear. Patients often ask if the problem can correct itself with time and rest. The answer to that question is maybe. The labrum doesn’t have its own internal blood supply. Without a good blood supply, healing isn’t possible.

    The labrum depends on the blood vessels in the acetabulum (hip socket) and surrounding soft tissues. Someof the tiny blood vessels from these others areas reach the labrum to supply oxygen and healing nutrients. Some areas of the acetabulum have more blood than others. So depending on the location of the labral tear, self-healing might be possible. In other words, healing may occur when the tear is closest to the best blood supply.

    But most of the time, surgery to remove the ragged edges of the torn labrum is required. This procedure is called debridement. Without an intact, functioning labrum, it is believed that the risk for joint degeneration and arthritic changes increases. Studies to support this idea have been done on cadavers. Cadaver studies involve using human hips preserved after death and used for study of problems like this one. Similar studies in live subjects have not been reported.

    What researchers have been able to measure are the before and after results in live humans with labral tears following labral surgery. As mentioned, the main procedure used is debridement. The surgeon shaves off the ragged edge of the torn labrum and smoothes the remaining edges.

    A more extensive surgery called a partial labrectomy may be needed. This involves removing part of the labrum. Studies show that partial labrectomies have better outcomes when there isn’t damage to the underlying layer of cartilage attached to bone. The success rate drops from 90 per cent without chondral lesions down to 21 per cent for those patients with chondral defects.

    One of the real difficulties in measuring results of partial labrectomy is the fact that researchers don’t really have a specific tool to use. Outcome ratings are possible for patients who have had a hip replacement but those questionnaires assess pain and function in older, less active, arthritic patients.

    Right now, the pressing need is for a similar tool to be developed and tested for use with labral tears in younger, more active patients who don’t have arthritis. Then it would be possible to compare the results between a partial labrectomy and the newer procedure in use: labral repair. During a labral repair, the surgeon uses stitches and surgical anchors to reattach the torn labrum.

    Results of labral repairs have not been published yet in English-language medical journals. Most of the research that has been done has been published in European or Spanish-language journals. When valid and reliable tools are available, the results of debridement, partial labrectomy, and labral repair can be compared.

    There’s no sense in doing surgery if the results are going to end up being the same as if the patient didn’t have the procedure. Likewise, if there is one operation that works better than another, surgeons can make better informed treatment decisions for individual patients. With a better appreciation of labral anatomy and function, choosing the best plan of care for complete recovery will be the goal.

    German Surgeons Report on Sports Participation After Hip Resurfacing

    Hip Resurfacing is a new way to manage painful joint destruction at an age too young for a total hip replacement. Active adults thinking about having this procedure done want to know — how active can I be after recovery? Can I run? Play tennis? Join a soccer team? Go skiing?

    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 that are expected to need a second, or revision, hip replacement surgery as they grow older and wear out the original artificial hip replacement.

    Special powered instruments are used to shape the bone of the femoral head so that the new metal surface will fit snugly on top of the bone. The cap is placed over the smoothed head like a tooth capped by the dentist. The cap is held in place with a small peg that fits down into the bone. The patient must have enough healthy bone to support the cap. The hip socket may remain unchanged but more often it is replaced with a thin metal cup (the acetabular component).

    In theory, the level of physical and sports activity might cause the component parts to loosen or wear out. There is an additional fear of fracture or hip dislocation. But in reality, we really don’t know if these problems are likely or not. Surgeons may caution patients to reduce their participation in high-level impact sports in favor of low-impact sports. Instead of playing tennis, soccer, or volleyball, they might be advised to stick with fitness and weight training or riding a bicycle. Some of the more active, athletic patients may think this is pretty boring and unacceptable.

    They may be looking for solid evidence to prove these restrictions are necessary. There’s really no evidence to support one approach over another (i.e., inactivity versus activity). Reports like this one from Germany will get the ball rolling and help guide future recommendations. Data was collected by surgeons who operated on active adults and then followed them after total hip resurfacing. Information was gathered information on their sports level and physical activity.

    It was a short-term study (two years follow-up) with a moderate number of patients (152 hips). There is a need to continue following this group (and others) to find out how the resurfacing holds up — especially with various low, intermediate, and high-impact activities. What do we know so far?

    The patients were all diagnosed with hip osteoarthritis. There were men up to age 55 and women up to age 60 included. Everyone was tested for osteoporosis. Anyone with weak or brittle bones was excluded (left out) of the study. Everyone followed the same post-operative plan with partial weight-bearing on the leg the first two weeks. There were some motion limitations (hip flexion past 90 degrees, internal rotation, and crossing the legs were not allowed) the first six weeks after surgery.

    The results were based on several things: before and after reports of activity level, range of motion, need for pain medication, and age. The participants were asked if there were any activities they had to give up after the surgery and how long it took to get back to their desired level of activities.

    They found that adults under age 55 were more likely to stay active and at a higher level of activity. Men were more active before surgery but the participation level between men and women evened out after surgery. Only a small percentage (two per cent) of the people in the study gave up their sports involvement. Tennis and skiing were the two activities patients gave up most often.

    The number of patients involved in high-level sports definitely decreased after the hip resurfacing procedure. Some of the changes made were based on their physician’s recommendation. Some changes in behavior was attributed to their own fears and uncertainties. As far as post-operative complications go, there were few but not very many. These included hip one hip dislocation, one hip fracture, and one displaced acetabular component (cup). The most common problem after surgery was a change in the length of the leg compared to the uninvolved leg. Leg length differences were observed in almost half of the patients (42 per cent).

    In summary, there are no universal or standard recommendations for activity level following a hip joint resurfacing procedure. Only a few studies have even looked at this problem. Based on the results of this study, it looks like remaining active is a possibility. The natural response is to shift from high-impact to intermediate- or low-impact activities and to participate less often. Whether or not this is entirely necessary remains an area for future research and discovery.

    What Can Be Done About a Squeaking Hip Replacement?

    If you’ve ever had squeaky shoes while trying to sneak into a movie theatre, church, synagogue, or down a quiet hallway, you know how annoying it can be. Imagine if that noise was coming from your hip replacement! At least with a squeaky pair of shoes, you can take them off. Squeaky hip replacements are not so easy to correct.

    The problem of squeaking hips after joint replacement has increased in the last 10 years with the increased use of hard-on-hard bearings. What do we mean by hard-on-hard bearings? The two main parts of the hip that are replaced include the round head at the top of the femur (thigh bone) and the cup-shaped hip socket.

    The materials used for these component parts can be ceramic-on-ceramic, metal-on-metal, or metal-on-polyethylene (plastic). Metal-on-metal and ceramic-on-ceramic are the hard-on-hard bearings. Ceramic-on-polyethylene and metal-on-polyethylene are considered hard-on-soft bearings.

    So what is it about the hard bearings that leads to squeaking in some patients but not in others? This question has puzzled many surgeons for quite a while now. Research into the problem is beginning to shed some light on the situation. It appears that there are three main factors involved and usually more than one reason for the squeaking.

    Patient factors such as body size and mass (larger), height (taller), and activity (hip flexion) may be part of the problem. There’s not much a person can do about their height to change the squeaking. But they can be advised to avoid activities or movements that cause the squeaking.

    Sometimes, it’s not the patient at all but rather the way the implant was placed in the hip. The wrong angle, a slight twist of the cup (socket) piece, or a little bit of both has been linked with squeaking.

    But the most likely factor is the implant itself and in particular, the materials it is made of. The newer implants made of titanium alloy are more flexible and less stiff. This feature could increase the vibrational force that creates friction and squeaking. Other contributing factors include loss of fluid lubricating the hip, tiny particles of metal or other debris from the implant, or damage to the surface of the implant.

    When surgeons remove squeaking hips, they often find a stripe along the implant where stress and friction have worn it down. Since squeaking occurs most often with hip flexion (bending, walking), the location of the stripe suggests edge-loading wear. Edge-loading refers to the upper/outer (superolateral) edge of the liner of the socket coming in contact with the upper (superior) surface of the femoral head.

    Squeaking doesn’t develop until the patient has had the implant for quite a while (six months or more). The time delay is consistent with the stripe wear just described as well as the loss of lubricating fluid. Likewise, metal debris caused by impingement (one part of the implant is pinching against another) accumulates over time.

    What can be done about this problem? Well, the first step is to determine what’s causing the problem and find ways to avoid it in future patients. But for those who already find it impossible to sneak into a room after a meeting has already started — that requires a different solution.

    Since pain is not usually an issue and the hip moves just fine, removing and replacing the implant isn’t the first treatment choice. Often the squeaking is intermittent (comes and goes). Having the patient pay attention to when the hip squeaks and then avoiding those movements or activities is the first step.

    But if the problem continues, the patient should see his or her surgeon for a follow-up evaluation. It could be that the cup liner is cracked or fractured and needs to be replaced. If the cause is a malpositioned implant or imbalanced soft tissue tension, then surgery may be needed to correct those issues.

    Efforts are being made to improve implant design while studying the causes of squeaking hips. The hard-on-hard bearings (metal-on-metal and ceramic-on-ceramic) are still great implants (especially for young, active patients) so there’s no need to stop using them. We just need to find ways to prevent the problem — perhaps better surgical techniques will be part of the solution. Only time will tell.

    Diagnosing Posterior Hip Pain in Athletes

    Pain along the back of the hip can be a very complex and puzzling condition to figure out. It’s a fairly rare problem and affects athletes involved in golf, dance, or soccer most often. This article was written to help physicians diagnose with accuracy the problem and the cause.

    The best way to evaluate and diagnose patients with posterior hip pain is always with a systematic and logical approach. That means knowing the anatomy, possible causes of hip pain, how to classify the disorder, and ultimately, knowing how to treat the real underlying problem.

    Because the patient’s symptoms are often vague and hard to pinpoint, special tests and imaging studies aid in the diagnostic process. The physician must also keep in mind that pain along the back of the hip could be coming from elsewhere — like the sacroiliac joint, low back, or knee. It could be from a muscle strain, hernia, degenerative disc disease, fracture, or even from a hip dislocation.

    One thing we know for sure. Based on how the nerves to the skin, soft tissues, and muscles work, posterior hip pain is rarely coming from inside the hip joint. The most common source of this type of pain is from the muscles or bursae.

    The bursae are tiny fluid-filled pads between layers of muscle or between muscle and bone. They cushion the force of load and strain on the area where they are located. But they can get pinched, compressed, and inflamed causing a well-known condition called bursitis.

    How does the physician sort this all out? First, by taking a very complete patient history. What happened? How did it happen? What are the symptoms? When did the problem start and how long has it been bothering the athlete? What makes it better or worse? Through a series of questions, the examiner can often tell if there is anything more serious going on (e.g., fracture, tumor, systemic disorder).

    Making sure there isn’t some other medical condition behind the pain is important because hip pain can be coming from the gastrointestinal or reproductive systems. Treatment for those types of problems is very different from treatment for muscle or other soft tissue issues.

    Testing begins with an assessment of posture, alignment, motion, strength, and flexibility. Most of the time, there are enough clues from the patient history and exam to make an accurate diagnosis.

    But sometimes, it’s necessary to take X-rays or order other imaging studies like MRIs, CT scans, ultrasound studies, or even arthrography. That last test involves injecting a dye into the joint and taking pictures to see if the dye seeps out of the joint into the bone or tissues around the joint.

    Arthrography is really a test for problems inside the joint and the authors already made note of the fact that this is a rare source of posterior hip pain in the athletic population. With athletes, MRIs are the best way to evaluate the soft tissue structures around the hip.

    The authors offer a discussion centered on six of the most likely causes of posterior hip pain in athletes. These include: 1) pain coming from the lumbar spine, 2) problems in the sacroiliac joint, 3) muscle pain, 4) piriformis syndrome, 5) hamstring rupture, and 6) femoroacetabular impingement.

    Let’s take a quick look at each one of these problems. Herniated discs that put pressure on the sciatic nerve are the most common cause of referred pain from the lumbar spine. Hip pain occurs in this instance because the L3 lumbar nerve root that can be pinched by a bulging or herniated disc also supplies sensation in the hip. A problem at L3 can produce symptoms in both places: the low back and the hip. The tip off is that with sciatica, there is back, buttock, and often leg pain.

    Next is the sacroiliac joint. This is where the triangular-shaped sacrum is wedged between the two pelvic bones. Any problem with ligament strains, infection, fractures, or alignment in this area can cause what is felt as posterior hip pain. This problem can also send pain down the back of the leg, so further testing is often needed to tell the difference between pain coming from lumbar spine versus the sacroiliac joint.

    Strain, overuse, or tear of any of the muscles that insert into the hip, low back, or sacroiliac area can cause posterior hip pain. Palpating for tenderness and testing hip muscle strength are the key diagnostic tests here. One muscle in particular to check for is the piriformis. The piriformis rotates the leg outward, a movement referred to as external rotation.

    For some people, contraction of the piriformis muscle presses on the sciatic nerve. This is another problem that can refer pain down the leg. But it’s one problem that doesn’t show up well on X-rays, MRIs, CT scans, or other imaging studies. The physician may try treating the symptoms conservatively with antiinflammatories and physical therapy. If the symptoms don’t go away, then it might be necessary to perform electrodiagnostic tests to confirm the diagnosis.

    Ruptured hamstring muscles are much easier to diagnose. First of all, there is usually a history of trauma or specific injury the athlete can remember as the starting point of the problem. Muscle weakness is common with partial or complete tears. Surgery (as early as possible) is the most effective treatment for this problem.

    And finally, there’s femoroacetabular impingement. This refers to pinching of the soft tissues somewhere around the hip joint — usually along the backside of the joint when the symptoms present in the buttock area. Certain hip motions will reproduce the pain and that’s the main test for the problem. MRIs or CT scans are helpful in looking at the anatomy and seeing what might be contributing to the impingement problem.

    Today’s improved testing methods, updated technology, and better understanding of anatomy have made it possible to identify differences between and among these six possible causes of posterior hip pain. By performing a systematic examination and evaluation, the physician can complete the clinical workup and come to an accurate diagnosis.

    Treatment decisions follow based on the cause or etiology of the problem. Most of the time, conservative (nonoperative) care works well to relieve pain, restore motion, and improve function. When athletes fail to improve with conservative care, then surgery may be considered as the next step. In a small number of problems (usually tendon or muscle ruptures), surgery is the first-line of treatment.