News Category: Hip

Groin pain is serious business for athletes trying to stay in the game. Hockey and soccer players are at greatest risk for adductor muscle strain but any athlete in any sport can be affected. The adductor muscles are located along the inner thigh. Adductor strain is a major cause of groin pain in athletes. The temptation to play through the pain can lead to worse problems later. How can these injuries be prevented?

In this review article, a group of sports medicine professionals searched the available studies on the problem of groin injuries in sports. The group included physicians, physical therapists, and athletic trainers.

The focus was on the six muscles of the adductor muscle group. They made it clear right from the start that ignoring muscle strains or getting the wrong treatment can turn a minor problem into a major one. Chronic pain, loss of muscle function, and the end of a promising sports career may be the final results.

How can this be avoided? First, identify who’s at risk. We know that hockey and soccer players have the highest number of groin injuries (preseason and during the season). American football players take third place. Then help these athletes get the training they need to prevent adductor (groin) injuries.

Some studies show that muscle weakness and loss of flexibility can contribute to adductor muscle injuries. When it comes to muscle weakness as a cause of groin injuries, decreased hip abduction (moving the leg away from the body) is a problem. And adductor muscle strength being weaker than the hip abductors is also linked with adductor muscle strains.

The adductor muscles move the leg toward the body. The abductor muscles do the opposite (move the leg away from the body). So, in other words, when the abductor muscles are stronger than the adductor muscles, the risk of an adductor strain goes up dramatically.

Other risk factors include a previous injury to the same area. Players who don’t practice during the off-season are more likely to get injured. Level of playing experience also seems to be a risk factor. Inexperienced players or rookies are also less likely to have a groin injury.

Two major risk factors for recurrent (repeated) groin strains are incomplete rehabilitation and not enough time for complete tissue healing to take place. In either case, the player goes back to the sport too soon. The athlete should expect to be sidelined for at least eight to 12 weeks while completing a rehab program.

An incorrect rehab program can be a risk factor. So what does a good or successful treatment program look like? Well, there are two answers to this question. The first relates to a prevention program to avoid these kinds of injuries.

Adductor strains can be prevented with a proper warm-up, strengthening program, and sports specific training. In fact, studies have shown that injuries are less likely when the adductors have at least 80 per cent of the strength present in the abductor muscles.

Warm-up activities should take about 20 minutes. The warm-up includes three-to-five minutes on a stationary bicycle, stretching the adductor muscles, and performing several adductor-specific exercises (e.g., sumo squats, side lunges, kneeling pelvic tilts).

Adductor strengthening can be done with a variety of exercises such as squeezing different size balls between the legs, using a sliding board, and working against the resistance of various strengths of elastic bands. Sports-specific training refers to mimicking the type of activities required by the game that put stress on the adductor muscles.

In ice hockey, a sports-specific exercise would be to pull the legs together while kneeling on the ice. Slide skating (pulling one leg toward the midline) is another example of a sports-specific exercise. For the soccer player, resisted cross over pulls are done to mimic the action of moving one leg across the midline to kick the ball.

That’s the prevention side of things. On the post injury side of the equation, the rehab program is broken down into three phases: 1) acute (right after the injury), 2) subacute (during recovery), and 3) sports-specific training. In phase three, the athlete is pain free and healed but does not have strong enough or fast enough muscle contraction for the game.

The evidence right now available from sports studies supports the use of rest, ice, compression, and elevation for the injury during the first 48 hours. Pain control and reducing muscle spasm are also part of the acute care phase. This can be handled with antiinflammatories, massage, and passive (pain free) motion.

The athlete is gradually progressed to and through the subacute phase. During this phase, bicycling, swimming, and a general flexibility program are started. Exercises that involve the adductor muscles are added as strength improves.

The athlete is ready to progress to the final phase of sports-specific training when two conditions are met. First, the passive motion of the injured leg is equal to the uninjured leg. And second, the injured adductor muscles have 75 per cent of the strength of the abductor muscles on the same side.

When all three phases of recovery and rehabilitation have been completed, then the athlete is ready to return to practice and finally, competition. Maintaining prevention program as outlined is important in avoiding any recurrence of this problem.

In summary, strengthening exercises are the key to preventing groin injuries and recurrent groin strains. Groin injury prevention programs have been shown to decrease injuries by almost one-third. Groin injuries can be complex with more than one problem going on at the same time. The athlete who does not recover and stay healthy may have other issues that need to be identified and addressed. The important thing is to recover and rehab fully before returning to sports play.

Sports medicine physicians and orthopedic surgeons see all kinds of injuries in the athletic population. One of the less common but very challenging areas of injury to evaluate is the hip. More specifically, the lateral hip (along the side of the upper thigh/buttock area) gets our attention today.

To help professionals involved with lateral hip pain in athletes, the authors of this article provide a review of the area anatomy. Besides the hip joint itself, which is very complex, there are various ligaments, muscles, connective tissue, bursae, blood vessels, and nerves to consider.

Suggestions are offered for the examination, which includes taking a good patient history and conducting a thorough physical exam. For example, there are six bursae in and around the hip that must be examined carefully. These structures are designed to keep tendons and other soft tissues from rubbing against the bone underneath. It is not uncommon for one or more bursae to become painfully inflamed.

Each muscle group must be inspected and palpated. Any changes in the way the patient moves or walks might be traced back to a specific muscle or muscle group. Posture, hip range of motion, and specific sites of tenderness provide helpful clues to what is going on.

Making the diagnosis is based on an understanding of what happened, how it happened, clinical presentation (signs and symptoms), and the results of specific tests. It’s really a differential diagnosis meaning the physician sorts through all the possible problems that could be present. Using the information collected so far, the doctor rules out those that don’t fit the description. Then further tests are done until the final diagnosis is made.

Some of the most common choices in the differential diagnosis include: hip pointer, greater trochanter bursitis, iliotibial band syndrome, snapping hip syndrome, tendon tears, and meralgia paresthetica. Let’s take a closer look at each of these conditions.

Athletes who collide with others or who take the force of a helmeted head into the lateral hip can end up with a hip pointer. This injury or contusion is visible as blood under the skin leaves a large bruise. It is treated with a leave it alone approach. Ice, rest, and compression help the body complete its natural course of healing.

Bursitis is best treated by finding out what is causing the friction in the first place and dealing with that problem. It could be tight, inflexible muscles, tendons, or fascia. Stretching, strengthening, and manual therapy under the supervision of a physical therapist may be advised. Or it could be a postural or alignment problem such as a leg length difference, unsupported flat feet, or even broken down running shoes.

Sometimes a tendon (e.g., the iliotibial band along the outside of the leg) snaps over the bone underneath. This condition is called iliotibial (IT) band syndrome or snapping hip syndrome. The IT band can be so tight that movement causes a pop that can be seen and heard. The athlete is taught how to avoid those movements and how to stretch the involved soft tissues. In chronic cases that don’t respond to physical therapy, surgery to release or lengthen the tight tissue may be needed.

That brings us to lateral hip pain caused by tendon tears. The tendons involved most often are from the buttock muscles (gluteus medius and gluteus minimus). Because of the way these muscles attach to the greater trochanter (part of the femur or thigh bone), tendinitis of the gluteal muscles can look just like bursitis or iliotibial band syndrome.

And finally, meralgia paresthetica must be considered whenever there is numbness along the front and side of the thigh. Meralgia paresthetica is caused by entrapment of the lateral femoral cutaneous nerve. This nerve can get pinched or compressed by tight clothing, after surgery to remove bone from the pelvic crest, a large belly associated with obesity, or in association with diabetes.

All of these conditions are considered self-limiting meaning they will eventually go away in time. Treatment is first with conservative (nonoperative) approaches. The most common plan of care is for oral anti-inflammatory drugs, rest, and physical therapy. The therapist will work on correcting postural issues or malalignment, stretching and/or strengthening, and modification of aggravating activities or movements.

The physician who can recognize and accurately diagnose hip problems in athletes is an important member of the sports team. A quick differential diagnosis and injury-specific treatment can get the player back into play faster and with fewer additional injuries.

In this report, surgeons from Brazil present the cases of four patients (all adult men) who had arthroscopic surgery to remove a tumor from the hip joint. In all four men, the tumor was a type called osteoid osteoma. The diagnosis was made with imaging studies including X-rays, CT scans, and MRIs.

Osteoid osteoma is the most common of the benign tumors involving bones. Most of the time, osteoid osteomas affect males between the ages of 5 and 24. A benign tumor doesn’t spread or metastasize like a malignant tumor can. But that doesn’t mean it isn’t symptomatic. Depending on the location of the tumor, intense pain and weakness are common.

Anti-inflammatory medications are used for first-line treatment. Sometimes removal of the tumor by surgery is necessary. It is now possible to perform this procedure using an arthroscope (long thin needle with a tiny TV camera on the end).

Arthroscopic surgeries are common in the knee but gaining access to the hip is a little bit trickier. With improved instruments and increasing experience with arthroscopy on the part of surgeons, it is now possible to successfully operate on the hip using this approach.

Instead of making a long incision to open up the hip and then dislocating the hip in order to get to the tumor, surgeons can now enter the joint with a long thin needle (the arthroscope). It’s called a scope because of the tiny TV camera on the end that allows the surgeon to see inside the joint.

The arthroscope makes it possible to magnify the area and project it onto a computer screen. This helps the surgeon make clean, clear cuts around the tumor without disrupting the rest of the bone and joint. This type of tumor removal is called en bloc resection.

With en bloc resection, the entire tumor is removed along with an edge of normal healthy tissue all around the tumor. Getting those clear margins helps ensure that the tumor won’t come back. In the case of a malignant tumor, en bloc resection prevents the tumor from spreading.

All four patients in this study presented in the physician’s office with hip, buttock, or groin pain that was worse with activities. Getting in and out of a car, going up and down stairs, and exercise were known aggravating factors (i.e., made the pain worse). The pain was also worse at night, which is a red flag symptom of tumors. In two of the patients, the tumors were in the socket side of the joint. The other two patients had tumors in the upper portion of the femur (thigh bone).

The results of surgery (measured at regular intervals) showed complete elimination of pain and improved function. There were no complications during or after the procedure. Patients could put full weight on the leg right away but the surgeons suggested partial weight-bearing with crutches for the first 30 days while the bone filled in the empty (weak) spot where the tumor used to be.

The authors conclude that osteoid osteoma of the hip is a rare condition. When the tumors are small, en bloc arthroscopic removal is possible. Full recovery has been demonstrated in these four cases. When the tumors are large or hard to reach without opening the hip up all the way, then radiofrequency ablation can be used. This heat treatment destroys the tissue making it possible to avoid surgery altogether.

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.

The American Academy of Orthopaedic Surgeons (AAOS or Academy) asked a panel of nine surgeons from around the United States to review the status of metal-on-metal hip resurfacing and give us a summary. The panel addressed four specific questions:

1) How revision rates compare between metal-on-metal hip resurfacing and total hip replacements.

2) Is it possible to tell which patients are going to have a successful resurfacing result?

3) Which one works better; hip resurfacing or replacement?

4) Are the results better with hip resurfacing when the procedure is done by experienced surgeons only on certain pre-selected patients?

Let’s start by reviewing just what is a hip resurfacing procedure? 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.

The operation begins by making an incision in the side of the thigh. This allows the surgeon to see both the femoral head and the acetabulum (or socket). The femoral head is then dislocated out of the socket. 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. A special tool called a reamer is used to remove the cartilage from the acetabulum and shape the socket to fit the acetabular component. Once the shape is correct, the acetabular component is pressed into place in the socket. Friction holds the metal liner in place until bone grows into the holes in the surface and attaches the metal to the bone.

Now, who should have hip resurfacing instead of a complete joint replacement? Because the hip resurfacing removes less bone, it may be preferable for younger patients who are expected to need a second, or revision, hip replacement surgery as they grow older and wear out the original artificial hip replacement.

Resurfacing can be used both for patients with osteoarthritic changes of the hip as well as for those who have dysplasia of the hip from birth. Dysplasia means the hip socket is too shallow to hold the femoral head in place. Partial or complete hip dislocation is often the result. Hip resurfacing may be more successful for hip osteoarthritis than for hip dysplasia but further study is needed before making any recommendations here.

Risk factors for resurfacing failure include small component size (used more often in women than men) and age (risk increases with age; older than 75 has the highest risk of failure). Younger age (less than 55) is more of a risk factor for total hip replacements.

Other factors have been studied such as smoking, body mass index (BMI), activity level, and menopausal status. None of these seemed to be significant in terms of success or failure of the resurfacing procedure. But the studies done so far are fairly limited in scope. The panel could not make any firm statements regarding the effect of these particular patient characteristics on outcomes or revision rates for hip joint resurfacing.

That brings us to the question of which is better: resurfacing or hip replacement? The answer to this remains clouded by the fact that the patients in the two groups are so different by age, weight, and activity level (younger, lighter, and more active in the resurfacing group).

The number and type of complications were also equal between hip resurfacing and total hip replacements. The three major complications associated with these two procedures are infection, loosening, fracture, and dislocation. Overall patient satisfaction was also equal between the two groups.

As for the final question about the difference in results for joint resurfacing based on surgeon expertise and type of patients selected –well, there was some evidence that surgeons experience and surgical technique made a difference. But the studies weren’t high quality. The panel could not make any conclusions with confidence in this area.

Where does that leave us in comparing the outcomes and effectiveness of hip joint resurfacing compared with joint replacement? The panel points out that the quality of evidence is lacking. Study design, research methods, and quality of analysis just don’t measure up in this area. More studies are needed in matched patient populations directly comparing these two treatment techniques. Long-term studies with follow-up over 10 years or longer are also needed.

This report as a summary of modern metal-on-metal hip resurfacing wasn’t meant to provide an official position or recommendations from the Academy. The goal was to summarize the findings of studies to date and offer an educational tool for surgeons who are providing care and treatment for this particular group of patients.

Have you ever heard of coxa sultans? Sounds like a member of the Arabian royalty. But it’s really an annoying hip condition that results in a snapping sound and feeling that occurs in some people whenever they bend or flex their hip. Coxa sultans is better known by a more descriptive term: snapping hip.

In this article, physical therapist and professor at Boston University, Dr. C. L. Lewis presents a review of the snapping hip condition. She used a search engine to find all the articles published on the topic up to and including November 2008. She reviewed all the studies available and wrote a summary for us.

Classification, risk factors, and clinical presentation are presented. Dr. Lewis also offers insight into the diagnosis and treatment of this problem. Physical therapists can benefit from this information when evaluating and treating patients, especially athletes who are bothered by this condition.

The first thing to know is that the problem could be coming from inside the hip joint (intra-articular), outside the hip joint (extra-articular), or both at the same time. Intra-articular linked problems that can lead to snapping hip syndrome include anything that can get caught inside the joint (e.g., cartilage, fracture fragments).

With intra-articular lesions, the patients are more likely to report catching, locking, painful clicking, or a sharp stabbing sensation. Words used to describe snapping hip from an extra-articular source tend to be snapping, clicking, or popping. Pain is a feature more often with intra-articular causes of a snapping hip (less likely with extra-articular causes).

Most of the time, extra-articular symptoms are caused by the iliotibial (IT) band moving across the greater trochanter. In plain English, this means a fibrous band of tissue along the outside of the thigh rubs across a bony prominence of the hip.

The iliopsoas muscle that flexes or bends the hip can also rub against nearby soft tissue or bony structures resulting in snapping, clicking, or popping. In some people, this muscle is divided into two parts. One part flips over the other coming in contact with the pubic bone in the process, thus causing this snapping phenomenon.

The symptoms aren’t always helpful in determining where the origin of the problem is. Instead, the therapist relies on risk factors, provocative tests, and in some cases, imaging studies.

Individuals affected most often are dancers, soccer players, weight lifters, and runners. Women tend to have internal (intra-articular) snapping hip more often than men. The cause could be labral tears or hip dysplasia (shallow hip socket). The labrum is a rim of fibrous cartilage that goes around the hip socket. It helps deepen the area and holds the femoral head more securely in the socket.

Other risk factors include repetitive hip flexion greater than 90 degrees, traumatic hip injury. previous hip surgery, and slight changes in what is considered normal alignment of the femoral neck angle. A smaller femoral neck angle results in a change in the length and pull of the hip muscles.

A real key in making the diagnosis is the result of provocative tests. These tests are designed to aggravate the problem and reproduce the symptoms. The therapist tests the motion of the patient’s leg. Hip flexion, extension, adduction (moving toward the body), and internal rotation are the most likely motions to reproduce the symptoms and confirm the diagnosis.

X-rays and other imaging studies aren’t always needed. But they do sometimes add some helpful information. For example, hip dysplasia and changes in the femoral neck angle will show up on X-rays. Changes in the soft tissues such as the bursa or tendons don’t show up on X-rays. That’s why MRIs are sometimes ordered instead.

More recently, work has been done to show that real-time ultrasound is a useful (and less expensive) way to diagnose the problem. The test shows movement of the tendons and muscles that might be contributing to the snapping sensation. Pain relief with injection of a numbing agent directly into the hip joint or hip bursa can also be helpful in diagnosing snapping hip.

Once the problem has been diagnosed, then what? Treatment is usually with conservative (nonoperative) care. Antiinflammatories may be prescribed by the physician. The therapist shows the affected individual how to stretch properly. Rest is advised along with elimination (or at least moderation) of activities and motions that aggravate the problem.

It may be necessary for the therapist to work with the patient to re-program how and when the hip muscles are activated. This is called neuromuscular re-education. If physical therapy is unable to alter the symptoms, then the physician may try injecting the hip. And if that doesn’t work, then surgery is the final treatment to try.

The type of surgery done depends on what’s causing the problem. The surgeon may lengthen the iliotibial band in a procedure called a Z-plasty. The shape of the incision made to lengthen the band is a Z, hence the name. This procedure can leave the athlete or dancer with significant hip abduction weakness (moving the leg away from the body).

If the snapping is coming from the iliopsoas tendon, the surgeon may lengthen it or release it (cut through it) altogether. Surgery doesn’t always take care of the problem. Some patients are still left with the snapping problem — along with weakness and/or other complications from the surgery. And in some cases, there is more than one problem going on (e.g., labral tear AND iliopsoas tendon rubbing over the bursa). Symptoms can persist until all sources have been removed.

In summary, snapping hip syndrome is a very real problem that can be annoying and even painful. As many as one in 10 average adults is affected. This figure is higher in certain athletes.

Help for the problem comes in the form of conservative care including antiinflammatories, rest, and physical therapy. Because there can be more than one thing going on in and around the hip contributing to a snapping hip, diagnosis can take time.

Improvement with treatment but without elimination of the symptoms tells the therapist there may be something else contributing to the problem. With patience and persistence, it is possible to successfully treat snapping hip in the majority of affected individuals.

The first Baby Boomers are turning 65 next year (2011). A Baby Boomer is someone born in the United States between 1946 and 1964. Some of those folks already have hip or knee joint replacements. Many more will be candidates for total hip replacement in the next 10 years. Chances are the type of hip replacement they receive will be very different from what their parents or even grandparents might have been given.

That’s because we are now on the third-generation of hip replacement implants. That means the implants have changed in major ways three times since they were first introduced more than 40 years ago. Changes in implant materials, surface, and component parts (e.g., liners, sockets, femoral head and stem) are the subject of this review article.

In some ways, today’s surgeons face even bigger challenges than those early surgeons. The rate of implant failure requiring another operation remains fairly high. Patients are getting implants at an earlier age and wearing them out faster in part because of greater activity levels than ever before.

Other risk factors for implant failure include patient problems such as being overweight and surgical factors (e.g., failure to balance muscles properly, improper placement of the implant, surgeon inexperience). And implant materials, bearing surfaces, toughness, and wear mechanisms can contribute to implant wear and tear and ultimate failure.

This last factor (important bearing surface) is the topic of today’s article. Types of surfaces, their advantages and disadvantages, and future alternatives are all presented for your consideration in making a choice about your preferred type of hip implant.

Let’s start with the metal-on-polyethylene implant. This is probably the most commonly used hip implant. The socket has a plastic liner. The round head of the femur that fits into the socket is metal with a metal stem that sets down inside the femoral shaft to hold it in place. It’s the least costly of all the types available. It goes in easily and doesn’t have to be set into the bone exactly-so to have a good result. But there are some problems. Most notably, it wears out faster than other types and isn’t as stable. Older adults who are fairly inactive are the best candidates for the metal-on-polyethylene implant type.

Next comes the ceramic-on-polyethylene. The plastic liner is the same as the one used in the metal-on-polyethylene implant. The difference here is in the material used for the stem and femoral head: ceramic instead of metal. Ceramic is hard and scratch resistant. That’s important in keeping wear debris out of the joint. There is a risk that the ceramic will crack or fracture and it doesn’t hold up as good as the ceramic-on-ceramic implants.

Those ceramic-on-ceramic surfaces have the lowest friction, roughness, and biologic reactivity. The surface is resistant to wear and tear so this type is used most often for younger, more active patients. And, of course, it can be used with anyone who has metal sensitivities. With both surfaces made of ceramic, there’s an even greater risk of implant fracture. Pieces of the ceramic can get imbedded in the joint capsule making it difficult to remove the broken implant. The two other disadvantages of ceramic-on-ceramic are the cost (most expensive) and the fact that these implants can squeak loudly enough to be heard.

The last choice with an equal number of pros and cons is the metal-on-metal implant. This type of implant does create tiny flecks of metal that enter the blood, urine, and organs and to which patients may react. This type of implant is not advised for women who can get pregnant or anyone with kidney disease. The implant is the most stable and gives more athletic adults greater freedom to run, jump, and participate in sports activities.

The authors provide an in-depth review of all the research, study, and subsequent changes that have been made over the years to come up with each of these implant types. New technologies have been developed to improve strength, stability, wear rates, and implant sizes. In the process, scientists have been able to improve hardness, lubrication, and scratch resistance while lowering friction.

Thinner shells combined with an ability to polish itself have made it possible to reduce wear and prolong the life of the implant. The self-polishing feature makes it possible for scatches that develop to smooth away with movement. Manufacturers have been able to create an implant with a larger femoral head to increase joint stability while preserving mobility (motion). The risk of hip dislocation is lower with a larger femoral head size.

There isn’t a perfect implant that can be used for everyone. Each type has its own advantages and disadvantages. The surgeon tries to make the best choice for each individual based on age, size, activity level, and sensitivity to materials (ceramic, plastic, metal). In the future, we can expect to see new surface coatings developed that will reduce debris while extending the life of the implant. Long-term studies 20 to 30 years after implantation will give us more feedback on what works best for which patients.

Most of us are familiar with older adults who fall and break a hip — or break a hip and fall. It’s an unfortunate event that adds insult to injury. But young adults are also at risk for hip dislocation from trauma. This time it’s more likely as a result of a high-speed car crash. The incidence of hip dislocations is on the rise, not just from motor vehicle accidents, but also from falls, sports injuries, and getting hit by a moving vehicle if you are a walker.

At first, you might think, Oh, that’s no problem. They can heal easily and quickly and go their merry way. But, in fact, the risk of hip joint arthritis on that side goes way up after a traumatic hip dislocation at a young age. Even more so when there are other injuries along with the dislocation. Bone fractures, torn ligaments, and damaged joint cartilage are often present when the force of the injury is enough to dislocate the hip.

What’s the best way to treat this type of injury with an eye toward future complications like osteoarthritis? In this article, two orthopedic surgeons from the Indiana University School of Medicine discuss what the evidence is for the surgical management of traumatic hip dislocations of this type.

The first thing we learn is that a simple hip dislocation (without a fracture) only results in hip arthritis in one out of every four patients. It’s the dislocations accompanied by a fracture of the joint surface called an acetabular fracture that present later with problems including arthritis. About 88 per cent of those complex fracture-dislocations damage the joint resulting in death of the bone (osteonecrosis) and osteoarthritis.

Can anything be done to prevent these serious complications? The first step is to get the patient to an emergency department or orthopedic surgeon for immediate care. After an examination, X-rays, or other imaging studies, the full extent of the injury may be revealed and the proper care can be given. Damage to the nearby blood vessels, nerves, and soft tissues (such as tendons, ligaments, and muscles) can affect recovery as well.

Anytime the surgeon thinks there might be a loose body (fragment of cartilage, bone, or other soft tissue floating inside the joint), there is reason to do an arthroscopic exam. The surgeon uses an arthroscope to look inside the joint, confirm the diagnosis, and remove the object. CT scans may be done before arthroscopy to show the location and size of any debris in the joint. In fact, studies show that CT should be done because many times loose bodies are present but unseen even with arthroscopic exam.

Dislocations can be (and should be!) reduced. Joint reduction means the surgical team put the hip back in the socket. The goal is to avoid further trauma to the bones and joint. The combination of a dislocated hip and loose body is certainly a recipe for long-term problems. Loss of blood supply to the joint should also be identified and corrected. In the process of reducing the hip, every effort is made to protect the already damaged joint from further stretching injury.

The specific reduction technique used depends on the specific injury. Dislocations can occur forward (anterior), back (posterior), out to the side (lateral), or halfway between (e.g., anterolateral, posterolateral). The technique for putting the joint back in place is specific to the direction of the dislocation. Photos of the maneuver used for reducing a posterior hip dislocation are included. The techniques used for other types of reduction (e.g., Bigelow technique, Allis maneuver, East Baltimore lift) are also described in detail.

The patient must be relaxed (usually asleep under anesthesia) for the reduction to take place. The sooner the better for the best result. Chances of a closed reduction (without making a surgical incision to open the leg) are greater if the attempt is made right after the injury. The longer it takes to get the right kind of emergency medical care, the more time the muscles have to tighten up in pain — and that increases the difficulty of resetting the joint.

When the hip doesn’t go back in easily and/or when there are other injuries present that need attending, then open reduction (surgery with an incision) may be required. Rehab after closed or open reduction is the final step in the management of traumatic hip dislocations. There isn’t a lot of evidence to support one rehab protocol over another. Points of controversy include whether the patient should remain on bedrest or can put weight on the leg, how much, and how soon after surgery.

Sometimes the best management approach is determined by looking at the results patients get using different types of protocols. Right now, based on available results from current studies, it appears that simple dislocations treated quickly with reduction have the best chance of a good-to-excellent result. Anterior dislocations seem to yield the best results. Anyone with multiple problems and/or complications is at risk for delayed recovery with less than excellent outcomes.

And patients aren’t out of the woods if they recover quickly. Reports of osteonecrosis (death of bone from loss of blood) have been reported up to eight years after the initial injury. Osteonecrosis is more common when there is both a hip dislocation and a bone fracture involving the hip socket.

All-in-all, the evaluation and treatment/management of traumatic hip dislocations requires a skilled surgeon who can take charge, identify what’s wrong and the best way to treat it, and get folks into the operating room sooner than later. The authors conclude that much more study is needed to provide surgeons with evidence as to the best approach to take to get the best results in the long-run.

It doesn’t happen very often that someone with hip dislocations is told it is best to leave well enough alone — in other words, don’t operate, just leave the hips be. But that is the case for a group of Puerto Rican people with Steel Syndrome.

Steel Syndrome, named for the physician who first reported on this condition is a rare problem among Puerto Rican children. As the word syndrome suggests, each child with this diagnosis has the same features: bilateral hip dislocations, elbow dislocations, short height, scoliosis (curvature of the spine), fused wrists, and abnormally high arches of the feet.

The children have a similar look about them. Besides being short, their faces are long and oval-shaped. The head is slightly larger than normal with a prominent forehead. The ears are small, low, and rotated backwards slightly. The bridge of the nose is broad. Mental (cognitive) abilities are reportedly normal.

At the time that Dr. Steel first studied this syndrome, there were 23 people identified with this syndrome. Since that time, another 14 people have been added to the group. A total of 32 of those two groups were followed long-term by the authors of this article who bring us the results of treatment.

When Dr. Steel did the original study, he found that efforts to surgically reduce the dislocated hips (put them back in the socket) were unsuccessful. That was back in 1993. This report brings us up-to-date on those early patients as well as takes a look at the new patients found with Steel Syndrome.

But first, let’s take a look at what is known about Steel Syndrome. As mentioned, it is found among a particular ethnic group (Puerto Ricans). Genetic studies have shown that it is probably caused by a genetic mutation. But the specific gene linked with the physical changes seen with this syndrome has not yet been identified.

It doesn’t appear that Steel syndrome develops more in one particular geographic location (place on the island) than another. Boys and girls were affected in equal numbers. And there was no intermarriage among the parents to account for this syndrome.

The main focus of this new study was the results of treatment for the hip dislocations. What makes the type of hip dislocations in people with Steel syndrome different from other syndromes is the fact that the joints are not hyperlax (super loose or flexible). This unique clinical feature makes this syndrome of interest to orthopedic surgeons.

Although surgical treatment for the scoliosis was done for one-third of the group, the results of those surgeries will be evaluated and reported separately. For those with elbow dislocation, limited motion and a funny looking bump because of the dislocation were the main problems. Treatment improved the cosmetics (how the elbow looks) but didn’t improve the elbow function. The wrist and foot problems didn’t bother any of the patients and therefore didn’t require any treatment.

So that brings us back to the issue of the dislocated hips. Comparing patients who had surgery to try and correct the dislocation with those who had no surgery, the group with untreated dislocations had better results. That was true no matter what type of surgery was done (e.g., closed reduction with spica cast, open reduction, osteotomy, skeletal traction, Pavlik harness).

Failure was reported for all patients who had surgery to reduce the dislocated hips. The hips remained either subluxed (partially dislocated) or fully dislocated. Patients in the untreated group had less pain, more function, and less disability. There were also fewer emotional and behavioral problems among the children who had untreated hip dislocations. School performance was better for the untreated group with fewer limitations all the way around.

The authors conclude that Dr. Steel was right when he recommended against treatment for hip dislocation in Puerto Rican children with Steel Syndrome. It may seem like unusual advice from a surgeon, but the evidence available so far does not support efforts to reconstruct the hips in this particular group of children.

Imagine trying to be quiet while entering a church or synagogue service during a silent moment only to have your new hip replacement squeak loud enough to be heard by all. Or picture yourself walking your daughter down the aisle for her wedding. With every step, that hip replacement creaks like a rusty barn door. Anyone with this odd complication can’t help but ask, Doc, what is causing this new hip to squeak like that?

An investigation at the Thomas Jefferson University Hospital in Philadelphia, Pennsylvania might just have an answer to that question. They divided patients receiving a ceramic-on-ceramic implant into two groups based on implant design and then compared the results.

Group one got an implant that had a special coating on the stem made of a titanium-aluminum-vanadium alloy. The stem was shaped with a C-taper neck and had a wide, thick midsection. The stem portion of a hip replacement fits down inside the long shaft of the femur (thigh bone). Group two was given an implant with a stem made of a different combination of metals: titanium-molybdenum-zirconium-iron alloy. The design was a V-shape instead of a C-shape and the midsection wasn’t as thick as in group one.

The ball-shaped head of the femur was made of ceramic. It fit inside a metal cup (socket replacement) that was lined with ceramic making the implant a ceramic-on-ceramic joint. Many patients prefer a ceramic-on-ceramic implant because the ceramic wears well and glides smoothly. And fewer patients have problems with inflammation like those who have implants that are made of plastic.

So what causes the squeak that’s so loud anyone standing nearby can hear it? No one knows just yet! Sometimes metal-on-metal implants squeak or make some other obvious noise but the noise seems to disappear after awhile. Not so with the ceramic-on-ceramic implants. And squeaking isn’t the only problem. Some patients end up with clicking. No one included in this study had clicking, just squeaking.

Everyone in the study was operated on by the same surgeon. The surgeon was careful to make note of the size of the ceramic head in case that was contributing to the problem. X-rays were taken after the implant was put in place to verify the position and alignment of the new joint. Patients in the two groups were matched so they were equal in age, sex, height, weight, and body mass index (BMI).

Only four of the 135 hips in group one reported squeaking (that’s only about two per cent). On the other hand, 18 per cent of the patients in group two developed squeaking. There was no predicting when the squeaking might begin. Some patients developed the noise within the first month while others didn’t notice it until many years later. Replacing the ceramic cup with a plastic liner eliminated the problem in all cases.

Crunching the numbers (statistical analysis) showed that patients with the thinner V-shaped neck and titanium-molybdenum-zirconium-iron stem were seven times more likely to develop a squeak. This stem is more flexible with a lower frequency of resonance. Vibrations created by the ceramic-on-ceramic movement are amplified (made louder) when there’s a lower frequency. And evidently, the oscillations can be amplified enough to generate a sound that can be heard.

The authors conclude by saying patients don’t have to give up the good quality of motion provided by ceramic-on-ceramic hip replacements. Surgeons just have to avoid using implants with the V-40 neck and choose the stiffer, C-taper stem instead. They should also make sure the materials are not made of the titanium-molybdenum-zirconium-iron alloy.

Any one who has had a total hip or total knee replacement knows that a major concern after surgery is the formation of blood clots. Blood clots can break loose and travel to the heart or brain causing heart attacks or strokes. Standard postoperative treatment includes prevention of blood clots. In medical terms, this idea is called thromboembolism prophylaxis.

One of the tools surgeons rely on the most for blood clot prevention is the use of a low-molecular-weight heparin (LMWH) medication. This drug is a blood thinner more commonly known as Warfarin or Coumadin. Another way to prevent blood clot formation is to avoid any bleeding episodes because that’s when the blood forms clots to help stop the flow of blood.

Sometimes patients can’t be given the prophylactic medication because of the risk of bleeding that comes with using those drugs. Having an alternate treatment approach like compression would be very useful. Right now compression stockings are routinely used after any surgeries involving the lower extremities (legs).

In this study, surgeons compared the use of two different methods used to prevent blood clots: low-molecular-weight heparin (LMWH) and a new compression device. Two groups of patients receiving a total hip replacement were treated with one or the other.

They were followed for 12 weeks to see how many bleeding episodes occurred and how many blood clots developed in each group. They wanted to find out how safe are these devices? And how effective are they? In other words, do they prevent bleeding and/or blood clots? Does this type of compression work better than taking the standard medication? If it did, it would certainly reduce the bleeding risks that come with taking heparin.

The compression device used was applied to the legs right in the operating room before the patients even went to the recovery room. The device used was a portable, battery-operated unit — small and compact, not like the standard compression devices that are big, bulky, and keep patients from moving around or walking.

The portable compression unit was used by most of the patients in the compression group for 20 of 24 hours over a period of 10 days. It’s ease of use made it possible to get patients to continue using it at home as directed. And the unit has a timer that displays when and how long the device is worn. This feature gives the physician information on patient compliance with the program.

The compression group of patients didn’t get Warfarin or Coumadin, but they could take one baby aspirin every day after the surgery. About half of the compression group decided to use the aspirin. Aspirin is an anticoagulant meaning it helps keep platelets from sticking together to form a clot. The second group got their first injection of LMWH (Lovenox) within 24 hours of the surgery. Additional doses of Lovenox were given every 12 hours until they left the hospital. At discharge, the heparin group continued to receive a once daily dose for up to 17 total doses.

Everyone was followed closely for any signs or symptoms of bleeding or blood clots. A special ultrasound test of the veins in the leg looking for blood clots was performed 10 to 14 days after surgery. CT scans of the lung were done on anyone suspected of having a pulmonary embolism (PE) or blood clot in the lungs. The results showed no difference between the groups in terms of the number of blood clots that formed in the legs.

The big difference was that the patients in the compression group didn’t have even one episode of major bleeding. Six per cent of the heparin group did have significant problems with bleeding — some even had to receive a blood transfusion. There were some minor bleeding problems in both groups but this was fairly equal: 37 per cent in the compression group and 42 per cent in the heparin group.

In summary, the authors started out the study thinking that this new portable compression device could reduce the number of dangerous bleeding episodes in patients after hip replacement surgery. And they were right! They suggest it may be possible to replace heparin with the compression unit. This idea is based on the fact that there was significantly less major bleeding while at the same time, the same number of blood clots forming. And the unit was easy to use, so patients applied it as directed.

Of course, more studies are needed to confirm the safety and effectiveness of these little take home compression devices. It will be necessary to see if the unit works just as well for all patients or just certain ones. Will some patients do better than others? Does age, body mass index, or general health make a difference? How much time is really needed applying the compression. These are just a few of the questions that must be answered before the use of low-molecular-weight heparin is abandoned for a nonpharmacologic approach to post-operative bleeding and the formation of life-threatening blood clots.

Total hip replacements, called total hip athroplasties, are major surgeries with significant recovery time. The are also becoming increasingly common and in demand. As a result, there is a push to improve surgical techniques. As in most surgeries, surgeons are trying to find ways to be less invasive, making as small as possible incisions and moving as little around as possible inside. Some surgeries are now done arthroscopically, which means that very small incisions are made and the surgeon uses long instruments to reach inside and follows progress through a camera that sends the image to a computer screen.

In hip surgery, larger incisions are needed, but surgeons aren’t agreeing on how small does an incision have to be before it can be called minimally invasive. Some surgeons feel it is the length of the incision (less than 10 centimeters long) that defines it, but others say that the incision size doesn’t matter – what matters is not doing any damage to the muscles near the hip. While both may have a point, the less damage that is done to the muscles and other soft tissues, the faster the likelihood of the patient recovering more quickly.

The authors of this study point out that few studies have been done using the patient’s gait (walking) to determine how well the hip replacement has worked, instead of using pain levels, for example. In this study, they wanted to compare the standard surgery that requires them to cut into the glutteal muscle to minimally invasive surgery, shown by how well the patients walk after healing.

To do the study, researchers studied 40 patients who underwent total hip replacement surgery. The patients did not know which surgery they had, the standard one (20 patients) or the minimally invasive one (20 patients). Both groups received the same hip implant, but the methods were different. Treatment after surgery was also the same for both groups. Physiotherapy began on the first day after surgery and the patients were encouraged to begin walking on the first day as well (using crutches). It was recommended to continue using crutches for three weeks after surgery. Weight-bearing was allowed after three weeks if they felt comfortable doing so. Hospital stays for the patients varied from 10 to 13 days.

In order to assess the patients, the researchers evaluated them one day before surgery, 10 days after surgery and again 12 weeks after surgery. The researchers measured and assessed the patients’ gaits. While it may have been expected to find that patients who had the more invasive surgery may have more problems with their gait after surgery, that is not what the researchers found. Examining the gain in 3D, they found that both groups of patients had basically the same velocity of their gait, strength, step length, and stride length. Both groups did tilt their pelvis a bit to compensate, but it was pretty well the same in both. One patient in the standard surgery group was seen to have an Trandelenburg gait after 10 days. This gait is seen when the patient’s upper body leans forward to the weaker side, but the gait became normal for this patient by the next follow-up visit.

There were no complications in either group, although two patients (one in each group) dislocated their hip at home by accident.

The authors concluded that there were no significant differences between the two types of surgery in patients’ gait.

Hip replacements, or arthroplasties, are becoming increasingly common in developed nations. Some replacements are partial and others are total, depending on the extent of the damage and the surgeon’s choice. However, in younger people, the less that has to be replaced, the better because the younger the people are at the time of the replacement, the higher the risk of them having to have revision surgery later on – perhaps more than one. Every time revision surgery is done, bone is removed, so if too much is removed early, then revision surgeries may not be possible.

One way around having to replace the whole hip is by performing a hip resurfacing arthroplasty, which involves replacing on the damaged part of the hip, in essence, resurfacing it. Resurfacing allows the surgeon to attach the replacement in the joint without having to go into the leg bone, the femur, which may add to its popularity when it is feasible to do it. According to statistics, five years after resurfacing, 96 percent of patients have functioning prosthesis (implant) and after seven years, 95 percent do. Although this surgery is often very successful, resurfacing surgery does have complications. In one to three percent of cases, the femoral neck, the top of the femur, fractures. The prosthesis loosens in one to two percent of cases.

The authors of this study wanted to see if they could identify the different types of fractures, using prosthesis that had been removed from the patients, in order to understand why they broke in the first place.

To perform the study, researchers obtained 152 femoral head parts (remnants) and the femoral part of the hip replacement that failed. Of the 152 hips, 107 had to be revised because the prosthetic had broken. The remaining hips were replaced because a component failed, the prosthesis loosened, or the patients had groin pain.

The researchers did not know what the original diagnosis was for all the patients, but 62 patients had been diagnosed with advanced osteoarthritis. A few others had been injured, had rheumatoid arthritis, or had osteonecrosis of the femoral head, a condition where the bone cells die off for an unknown reason.

After analyzing the parts they had and the information that was available (sex, age, body mass index, the type of device used and its design, and how many surgeries had been done for each patient before this revision), the researchers found that the average time that the prosthesis broke was about five months after surgery. The researchers broke down the fractures into different categories:

– Type A: acute biomechanical fracture
– Type B: acute postnecrotic fracture
– Type C: chronic biomechanical fracture

Type A fractures did not have any evidence of osteonecrosis or other biological issue that could have caused the break. This break was found in nine of the hips. Type B, on the other hand, had a fracture line related to the osteonecrosis of the bone and this occurred in 55 of the hips. Type C fractures occurred in 43 of the hips. While there weren’t as many type A fractures, those that did occur happened much earlier than the other two, around 41 days instead of 149 to 179 days. The researchers also found that the type A fractures almost always occurred in the femoral neck.

The authors concluded that osteonecrosis was the most common cause of fracture-related failures of the prosthesis. As for the biomechanical failures, they suggest that this could be due to incidents that may occur during surgery, such as notching the femoral head or not positioning it properly.

There are many instances when surgeons find it necessary to place a needle into the hip joint. Sometimes it’s to diagnose a problem. In other cases, it’s to treat the problem. For example, hip injections have been used to treat a painful hip after surgery, to deliver steroids to reduce inflammation, or antibiotics to fight infection.

In all cases, a needle is used to withdraw fluid from or deliver agents to the joint. How accurate is this technique? Can a surgeon really point and shoot — that is to say, can the surgeon use anatomical landmarks to accurately place the needle in the joint? The authors of this study say, not without some imaging assistance. Let’s take a look at how they came to this conclusion.

A small number of adults (16 men and women) with hip osteoarthritis participated in the study. They each received three separate hip injections, one week apart. The injection was hyaluronic acid used to coat the joint and aid smooth movement. Three methods were used to confirm needle placement in the joint: the backflow method, fluoroscopy, and arthrography.

The backflow method introduces the needle into the joint and a small amount of saline (salt) solution is first injected into the area and then withdrawn to confirm correct needle placement. If the surgeon is unable to aspirate (pull back out) the injected saline, the needle is not in the joint.

Fluoroscopy is real-time X-ray. The surgeon can see on a screen exactly where the needle is in relation to the joint as it moves through the skin and down through the soft tissues to the joint. Arthrography (arthrogram) relies on a dye injected into the joint to show that the injected agent actually made it inside the joint. Arthrography requires the use of fluoroscopy to see the contrast medium.

The study was set up so that first, the surgeon used anatomical landmarks to guide the needle into the joint. This is called a blind injection. A lateral approach (from the side) was used. Then, fluoroscopy was done to double-check the needle placement. And finally, an arthrogram was carried out to see if the injected hyaluronic acid made it.

Each injection was performed this way each time on each patient. The authors provide step-by-step details of how the injections, fluoroscopies, and arthrograms were done. Data was collected on the accuracy of each injection at each step.

Here’s what they found. Blind injection was accurate in placing the needle two-thirds of the time. But interestingly, only half the time did the hyaluronic agent show up inside the joint on arthrogram. The chances of getting the agent inside the joint were definitely better when using fluoroscopy to guide the process.

Backflow was not reliable. In about 18 per cent of all cases, backflow was positive (suggesting that the needle was in the right place to deliver the agent) but the arthrogram was negative: no hyaluronic acid was actually in the joint. In these cases, the backflow method showed a false-positive response. And there were many other times (almost 80 per cent of all injections) when the arthrogram showed a correct needle placement but the backflow response was negative (not present). This is an example of a false negative.

The authors concluded that even though it is possible to perform a blind injection accurately, it is not a reliable technique. Backflow cannot be relied upon either. The expense saved and protection of the patient from X-rays may not be worth it if the procedure is a failure. Using fluoroscopy isn’t enough either. It may show that the needle is correctly placed but doesn’t definitely prove it as this study demonstrated.

The next step in further examining this problem is to repeat this same study with a larger number of patients to confirm the findings. The authors suggest using other means of confirming needle placement (e.g., ultrasound, MRI, CT scan) and comparing one technique to another to find the best one. More studies like this one using live humans (rather than cadavers) are also important.

Anyone who has had a hip replacement knows that there are certain precautions that must be followed to avoid dislocating the new hip. Everyone from the doctor to the physical therapist to the nurse and even family members are there to tell you don’t do this and don’t do that. Sleeping at night on your back with a wedge strapped between the legs is the worst. Patients have complained enough that surgeons are taking a second look at this issue.

There is some suggestion that maybe those precautions aren’t really necessary after all. With today’s updated surgical techniques and less invasive procedures, perhaps the risk of a hip dislocation just isn’t as real as it once was. To find out, surgeons from Lehigh Valley Hospital in Allentown, Pennsylvania conducted this randomized prospective study. Half the patients were in the standard restrictions group. They had to avoid bending the hip past 90 degrees and couldn’t ride in a car for the first month following surgery.

The other half were in the early group. There were no hip flexion or car riding restrictions placed on these patients. They were told not to cross the legs but could bend at the waist or from the hip as long as they were comfortable doing so. They could even sleep i any position they wanted without even a pillow between the legs. Sitting on a toilet could be done without the special raised toilet seat required in the standard precautions (restricted) group.

All patients in both groups had the same hip replacement operation (a modified anterolateral procedure). A single surgeon who specializes in total hip replacements performed all the operations. A description of the surgical procedure used and detailed information about the hip implants were provided in this article. The patients were matched between the two groups for age, socioeconomic background, and size (body mass index).

Simply stated, the early group did better in all ways and with no more complications than the standard restrictions group. There were no hip dislocations reported in either group. The early group switched from a walker to a cane sooner than the restricted group. The early group got rid of the cane sooner. They stopped walking with a limp significantly before the restricted group. They were back behind the wheel driving much sooner, too. All-in-all the early group was so successful, the authors ended the study and switched all of their appropriate patients to an early rehab protocol.

Patients in the accelerated group reported being much happier with the results. They felt their quality of life was much improved compared with the restricted group. The rapid recovery of function and ability to return to daily activities without problems were two reasons why the early group was so pleased with this post-operative approach.

The authors concluded that postoperative hip precautions don’t add any benefit to patients and actually keep them from doing what they are able to do. Until further studies are done, patients should be hand picked for this type of approach. They must be in good health and willing to follow their surgeon’s advice. Only certain surgical techniques allow for the elimination of restrictions. A pre-op program of education and instruction is advised so that patients know the potential risks of doing more than is reasonable following this type of surgery.

There has been a concern raised lately about the use of medications called bisphosphonates for postmenopausal women with osteoporosis. This drug is supposed to reduce the risk of bone fractures by inhibiting (stopping) bone resorption. By preventing bone cells from being broken down, bone density and therefore bone strength, can be maintained. But reports of problems with the long-term use of these medications have caught the attention of the medical community.

Right now, experts think the problems associated with bisphosphonates are rare but we need some data to support that conclusion. Orthopedic surgeons from the New York University Hospital for Joint Diseases wrote this report to help add to the data presented so far. They reviewed their records looking for patients on long-term Alendronate (Fosamax) therapy who fractured the femur (thigh bone). Long-term use of this drug means they were on it for more than five years. They found seven cases of either subtrochanteric or diaphyseal femoral fractures.

Subtrochanteric refers to a fracture at the top of the femoral shaft. Diaphyseal fracture is a break in the shaft of the bone. All seven cases were postmenopausal women with osteoporosis who had been on Fosamax for an average of eight years. Some had been taking the drug for up to 13 years. Ages ranged from 53 to 75 years old. They all had injuries referred to as low-energy trauma. That means they fell from a standing position (or lower). Some of the women broke both legs at the same time. Others broke one leg and later broke the second leg.

X-rays were used to determine the condition of the bone and presence of emerging stress reactions on the other side (opposite hip to the broken one). A stress reaction is a microscopic disruption in the bone. The bone has not widened, separated, or moved apart as is usually seen with a true break. Given enough compression and load on the weakened bone, a stress reaction can progress to a complete break. These stress reactions aren’t always painful. So when a fracture develops, the physician should X-ray the opposite side to see if any stress reactions are developing. Most of the women in this study who had signs of bone fracture starting to develop had already reported thigh pain, so that’s a symptom to pay attention to.

Based on the findings from this chart review, the authors say that they now always take X-rays of the other side in anyone on bisphosphonates who breaks a hip. Bone scans and/or MRIs may be ordered when X-rays are normal but the history and exam are suspicious. Hip fractures occur much less often than wrist, arm, or pelvic fractures in this population. Most people who have a subtrochanteric or diaphyseal fracture have been involved in a car accident or the bone is so osteoporotic, it just breaks without any trauma. Low-energy fractures from a standing height (or lower) are much less common.

The authors have also changed how they follow-up women who develop femoral bone fractures while on Fosamax. They stop treatment with the drug and refer the patient to an endocrinologist for a more thorough work-up. The endocrinologist takes a closer look at the patient and helps make a decision whether or not bisphosphonates can still be used after these rather unusual hip fractures.

They suggest that the next step in research efforts should be to identify risk factors or groups of people who are susceptible to the negative effects of long-term use of bisphosphonates. It seems that in some people, putting a stop to bone turnover called bone turnover suppression does result in more bone cells (that’s good!) but it’s bone that is more brittle and more likely to break (that’s bad!).

Bone turnover refers to the death of old bone cells and birth of new bone cells, a natural process that occurs in all adults. After menopause, there is more bone resorption (death) and less new bone formed resulting in a net loss of bone density and strength. That’s why they start taking bisphosphonates in the first place. Why some women on Fosamax develop these hip fracture and others do not requires a careful investigation to help doctors develop a way to screen for fracture risk for anyone on long-term bisphosphonates.

If you need a steroid injection into the hip for pain from osteoarthritis, there’s only a 50-50 chance the agent will actually reach its intended destination. That’s the conclusion of this study from Turkey. Using anatomical landmarks to position and advance the needle is called a blind injection. Using this technique with any success is like tossing a coin and shouting heads or tails and then being right (or wrong).

What can the physician do to increase his or her accuracy? Use some type of imaging to guide the needle. That could include magnetic resonance imaging (MRI), ultrasound (US), fluoroscopy (real-time 3-D X-rays), computerized tomography (CT scans), or arthrography. Arthrography is a tool doctors use to find the source of patients’ symptoms. By injecting a special substance or contrast dye into a painful joint, doctors can see soft tissues and joint structures to find out what may be causing pain and other symptoms.

In this study, physicians used fluoroscopy to guide and place the needle into the hip joint. Injecting a joint like this is called an intra-articular injection. They found that even with the special X-rays to guide them, placement was still only accurate in three out of four patients. To ensure complete accuracy for all patients, it was necessary to use arthrography. The contrast medium showed conclusively whether or not the needle had gained entrance into the joint cavity.

Physicians may be interested to know that using the backflow method of blind injection isn’t reliable or accurate either. Backflow refers to the way physicians check blind injections for accuracy. After advancing the needle into what the surgeon thinks is the joint cavity, a small amount of saline solution is spurted into the joint and then aspirated (drawn back out) as proof that the joint cavity has been reached.

The physician who performed all of the injections in this study had 10 years of experience doing these types of intra-articular injections. But after doing a blind injection with backflow, fluoroscopy was used to confirm placement. There was almost a 20 per cent rate of backflow (one out of five patients) when the physician wasn’t really inside the joint.

In summary, intra-articular injections of the hip joint can be helpful in alleviating painful symptoms from osteoarthritis. Careful technique is required on the part of the physician performing the injection. Blind injections are less expensive than injections performed with imaging. Blind injections can be done right in the physician’s office. And the patient isn’t exposed to radiation. But blind injections are not advised. For complete accuracy, imaging and arthrography are required.

With the increasing popularity of intra-articular interventions, studies are needed to find the absolute best way to accomplish these injections. This study kept its focus on comparing fluoroscopy versus arthrography. Similar studies are needed to compare the results with all available imaging tools to find the most accurate and reliable method of injection. The authors also suggest studies are needed to compare the two directions injections are given from (the front of the hip or the side of the hip). Degenerative changes from arthritis can change the structure of the hip making needle placement even more challenging than on a normal, healthy hip.

There’s one good way to find out if something new is working. Try it on a group of people and compare it to a second group who didn’t get the same thing. That’s what senior orthopedic surgeon W. Thomas, MD from Rome, Italy did. He used a special osteoconductive gel over the surface of cementless hip replacement implants in 60 patients and compared results with 60 patients who got the same implant without the gel.

Osteoinductive means fosters bone growth. And that’s exactly what this gel does — it contains proteins that act as growth factors to stimulate bone growth. This new gel is made up of bone chips, platelet-rich plasma (the growth factors), and bone marrow. Bone marrow contains stem cells that can form into any other cell, including new blood and bone cells needed to form new bone tissue.

Cementless implants are press-fitted into the bone. They are held in place by the porous (roughened) surface of the implant next to the bone. During the natural process of healing, the inflammatory process brings new blood cells to the surgical site and the stem cells form new bone cells to fill in and around the implant. Growth factors speed up the whole process.

With the osteoinductive gel, the hope is that the process will not only be faster, but also provide joint stability sooner. That could mean patients can get back to full function as soon as possible with fewer complications. And since the gel is made up of the patient’s own body parts, it’s safe from rejection or transfer of diseases from someone else. At this point, you may be wondering how do they harvest the patient’s cells?

When the old, arthritic hip joint is taken out, the bone marrow from inside the upper shaft of the femur is collected. The top of the femur and the hip socket (also removed in preparation for the new implant) are ground up and used as bone stock. The bone is rich in bone cells that promote bone growth. The bone stock also contains morphogenic protein, another type of growth factor. Once the gel is all mixed up, it is smeared all over the implant socket and stem before inserting these into the patient’s hip.

After surgery, everyone was treated the same. They all started muscle strengthening exercises right away and were up standing within 24 hours and walking within 48 hours. Crutches were used to assist the patient in the first few weeks to month. Patients were allowed to go from two crutches to using only one crutch at the end of the first four weeks. A single crutch was used for another couple weeks up to a month (depending on the patient’s progress).

The results were very good. Although the operation took longer for patients receiving the gel, there was less blood loss and faster recovery by all measures. There were no major complications reported. Outcomes were measured and compared using special X-rays called dual energy x-ray absorptiometry (DEXA) to view the healing bone. You may have heard of DEXA scans used to measure bone density as a test for osteoporosis. The more sophisticated machines used to look inside the body at the hip were used in this study. Comparing DEXA scan results for both groups, the gel group had significantly faster bone growth in the first 40 days after surgery. By the end of three months (90 days), bone growth was equal between the two groups.

A second measure was made using a test of function called the Harris Hip Score. The gel group doubled their function in the first 40 days with a gradual progression of improvements from then up through the first six months. Similar results were observed in the control group (no gel) but with a lower level of improvement noted after 40 days. In both groups, functional improvement reached a plateau and did not change further by the end of the 12-month post-operative period.

What does this all mean and why is it important? With the osteoinductive gel, cementless implants can get integrated into the bone much faster. In doing so, the risk of fibrous (scar) tissue filling in between the implant and the bone is much less. That creates a more solid, stable joint to handle weight-bearing loads of adults who want to move, walk, and play! Biologic fixation is improved with the bone stimulating gel, which in turn, decreases the risk of implant failure.

Bottom-line? The authors say faster functional and clinical recovery within six months. You can’t argue with that!

The Charnley hip replacement has been around since the 1960s, when it was pioneered as a low-friction hip replacement. Hip replacements (arthroplasties) are, in general, one of the most carefully watched and followed surgeries in the United States, including the Charnley replacement. The authors of this article wanted to update the results of hip replacement recipients 35 years or more after they received their replacement.

To perform the study, researchers used records of 262 patients who had received, altogether, 330 Charnley hip transplants when they were an average of 65 years old. Most (74 percent) had osteoporosis, followed by rheumatoid arthritis (5 percent). Some of the hips had had previous surgeries. Among the 262 patients, 249 had died before this study (with 314 hips total) and one was lost to follow-up. This left 12 patients (15 hips) were left to study. Seven were women (nine hips).

Looking at the long-term follow up over the 35 years after surgery, the researchers found that 290 of the patients had their original hip implant at the time of the study or at the time of their death. Seven of the patients who were alive still had to undergo a hip revision surgery at one point. Among that revision group, one hip had to have yet another surgery because of loosening. Of course, the longer the patients lived, the higher the chances of hip revision surgery. This is seen in these statistics:

– 15 percent of the hips required revision at 20 years after surgery
– 23 percent required revision at 25 years after surgery
– 32 percent required revision at 30 years after surgery
– 47 percent required revision at 35 years after surgery

The authors concluded that studying long-term outcomes of hip replacements gives researchers a good basis from which they may work on newer designs that may be functional for even longer periods.

Competitive and recreational sports athletes can develop painful groin symptoms from a pulled muscle. The condition is called adductor enthesis. Adductor refers to the group of four leg muscles that attach to the pubic bone in the pelvic/groin area. Enthesis is the place where the tendon meets the bone. Usually this spot is a mixture of fibrous and cartilage soft tissue. Overuse from repeated kicking and/or sprinting sets up an inflammatory response that eventually becomes chronic with telltale changes in the soft tissue structures.

The condition is diagnosed through a combination of patient history, clinical tests, and MRIs. The groin pain may occur only after activity or it may be described as occurring with activity but without restricting movement. More severe pain will restrict activity; some athletes with adductor enthesis have chronic (constant) pain that may get marginally better but never goes away.

In this study, athletes evaluated and treated at a sports medicine clinic for groin pain were treated with a steroid injection combined with a numbing agent. To be included in the study, each athlete had to test positive for three tests: tenderness with palpation of the adductor longus where it inserts in the pubic bone, pain with stretching of the adductor muscles, and pain with resistance to the adductor muscles. The adductor muscles are the main muscles used to pull the leg toward the body. Stretching the adductors occurs when the leg is moved away from the body. When these tests are positive, it confirms that the pain isn’t coming from inside the hip joint. That means the pain is extra-articular (outside the joint).

Before the injection was done, X-rays were taken to confirm normal hip structure and alignment. Anyone with hip problems was excluded from the study. An MRI of the groin was also obtained. A contrast dye was used to look for any pathology of the enthesis. Tears in the fibrous cartilage insertion of the adductor muscles can show up as an abnormal enhancement as the dye seeps into the open (damaged) fibers. Not everyone with groin pain and positive muscle/tendon tests had a positive MRI. Those who did were put in one group. Those with positive muscle/tendon tests but without obvious changes on MRI were placed in a second group. All were treated with the injection followed by a physical therapy rehab program. The only difference between the groups was whether or not the MRI was positive for adductor enthesis.

The key focus of this particular study was the fact that the patients were all recreational athletes. In a previous study, this same group of researchers performed the same study on competitive athletes. The aim of this study was to compare the two groups (competitive versus recreational athletes). Recreational athletes are defined as those individuals who participate in sports less than four days each week. They do not have a coach. Competitive athletes engage in sports activity at least four days a week under the supervision of a coach. Any type of sports involvement was acceptable and happened to include swimming, squash, cycling, rugby, golf, soccer, and triathlon.

Five minutes after the injection was given, the patients were re-evaluated using the same three tendon tests: palpation, stretching, and resistance. Results were recorded (pain or no pain) and the tests were repeated at six weeks, six months, and one year later. In every case, the pain was relieved immediately. That means even patients with no findings on MRI benefited from the injection.

Now, did these positive results last? Well, one-third of the patients in group one (no evidence of a problem on MRIs) had a recurrence of their groin pain during that first year. For some patients, the pain came back as early as seven weeks after the injection. For others, they had pain relief that lasted at least three months. What about group two (those who did have a positive MRI showing tendon pathology)? Same thing: about one-third of the group had another bout of groin pain anywhere from two weeks to 19 weeks after the injection.

And how did the results of the recreational athletes compare with the competitive athletes who had the same problem, same tests, and same treatment? Well, the MRI findings did predict results of injection. Patients with visible tendon enthesis damage were more likely to experience pain recurrence affecting their ability to play one year after the injection. Competitive athletes with a negative MRI who had the injection, got better and stayed pain free.

The authors summarized by saying that MRI findings do not predict treatment outcome for recreational athletes using steroid injection for adductor enthesis. Quite the opposite is true for competitive athletes whose MRI does predict the final results. Comparing the two groups, it looks like there were two main differences that might account for these findings. One, the recreational athletes were older and had their groin pain longer. And two, because their lives did not depend on competing in their sport, they could rest and take it easy during painful episodes and after the injection treatment.

The authors suspect that the recreational athletes also competed at a lower level of intensity. They could alter their technique to accommodate their symptoms without worrying about their competitive edge. The result is less repetitive microtrauma of the adductor enthesis. They also noticed the recreational athletes with negative MRI and mild pain seemed to have the best results with a second injection when the symptoms came back.

Steroid injections aren’t routinely recommended for athletes with groin pain. Those who do not benefit from rest and/or physical therapy and who test positive for tendon pain with palpation, stretching, and resistance may be the best candidates for injection therapy. The surgeon can take into consideration the level of the playing athletes (recreational versus competitive) when ordering and interpreting contrast MRIs.