News Category: Hip

These days if you want to know how other patients feel about their orthopedic procedures, all you have to do is go on-line and look up their blogs (weblog). There are many postings to suggest that, for example, having a hip joint resurfacing is better than a total hip replacement. Recovery is faster, there’s less risk of a dislocation, and range of motion is improved quickly. But what does the research have to say about the differences in outcomes between hip joint resurfacing and total hip replacement? And if there are differences, is it related to the patient or the implant?

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

Usually the patient’s natural hip socket is left alone, or sometimes a thin plastic liner is put inside the socket to smooth out the surface. Most of the time, the round head of the femur gets the resurfacing. Special instruments are used to shape the bone of the femoral head so that a new metal cap can 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.

More and more people with hip arthritis are finding out about this new surgery and asking their surgeon about it. Besides patient postings through blogs and twitter, there are Internet promotions to catch the eye of anyone even mildly interested in this topic. For those who have not heard of twitter, this is a free micro-blogging service that enables its users to send and read very short messages known as tweets. Friends send other friends tweets about their surgery and progress post-operatively.

In order to answer patients’ questions and provide accurate information on the advantages versus disadvantages of these two procedures, surgeons need to know what is the latest evidence-based data. The results of this study may help fill in the information gaps. The authors, surgeons from the Joint Replacement Institute at St. Vincent Medical Center in Los Angeles, California set up a study of 50 hips getting hip resurfacing and 44 hips undergoing conventional hip replacement. All procedures were done by one surgeon in the same hospital during a single time period.

The study was designed to look at patient characteristics called demographics such as age, gender, general health, height, weight, and so on. A second measure used in the comparison was the preoperative clinical condition of the patient: joint range-of-motion, strength, and function. And then, of course, the results or final outcomes from the surgery were compared. Patients were followed for two to four years to give an idea of what were the mid-term results.

The patients having hip joint resurfacing were more often men, an average of three inches taller and 10 to 20 pounds lighter, and had arthritis only in one hip compared with the total hip replacement group. The hip resurfacing patients were in better overall, general health compared with the total hip replacement group. Oh, yes, and the resurfacing group were younger than the other group by a good 10 years.

The surgeon was careful to perform the operations in as similar a fashion as possible for comparison. The incision was made from the back and side called posterolateral. But it should be noted that although hip resurfacing removes less bone, it is not less invasive. The head of the femur has to be dislocated in order to shave it down and cap it. That means the joint capsule and surrounding muscles have to be cut to accomplish the resurfacing procedure. Resurfacing takes more time in the operating room than the standard, traditional total hip replacement. On the other hand, there is less blood loss and need for blood transfusion with joint resurfacing.

In order to keep all things as equal as possible, the patients in both groups attended physical therapy and followed the same rehab program. Activities were not restricted in any way. Patients were told to do whatever they felt up to. According to the results of tests performed on patients in both groups, the hip resurfacing group got better faster, had less pain right away and reported higher activity levels compared to the total hip replacement group.

A closer look at the two groups showed that the total hip group gained more motion because their loss of motion before the surgery was so much greater than the hip resurfacing group. In the end, the two groups had the same hip motion in all directions. And although the hip resurfacing group got faster pain relief, they didn’t always get complete pain relief. More of the resurfacing patients still reported pain during the follow-up period. The total hip replacement patients were more likely to be pain-free at the two- and four-year follow-up visit. But that might also be because they were older and less active.

It’s natural to see the better results for hip resurfacing and think, Ah ha! That’s the better operation to have! But, in fact, the results of this study support the continued careful selection of patients to have this procedure. The good results may be more likely attributed to patient characteristics than to differences between joint resurfacing versus joint replacement. Younger, more active, healthier patients received the hip resurfacing and that seems to be reflected in the results as well. Statistical differences in joint motion and risk of dislocation weren’t observed between the two groups.

Health care for seniors is taking a decided turn in other countries. In Italy, for example, hospitals that focus on the care of older adults are being developed. With the special needs of this population being addressed, problems like hip fracture can be treated with a geriatric-orthopedic multidisciplinary approach. This article reports on efforts to use an immediate weight-bearing early ambulation (IWB-EA) program after surgery to repair a hip fracture.

Immediate weight-bearing after surgery for hip fracture has been proven safe and effective in several studies. But as a general protocol, the medical practice of getting people up and walking again right away has not been adopted universally. There is still a general idea and belief that older adults need time to recover from surgery and should rest in bed for a couple of days before beginning an ambulation program with the physical therapist. And there’s been some thought that older adults with memory or cognitive problems will have a harder time remembering to put weight on the involved leg.

To test out these ideas, surgeons at the Genoa Galliera Hospital in Liguria, Italy studied a group of older adults with hip fracture. Everyone in the study was 70 years old or older and had surgery to stabilize a proximal femur fracture (break at the top of the thigh bone). Before the hip fracture occurred, these patients were all still walking independently without assistance from a walker, crutches, or person assisting them.

The type of surgical stabilization performed depended on the location and severity of the fracture. Some patients only needed to have the bone repaired with metal plates and screws or a long intramedullary pin (down the inside of the bone). Others had to have a partial or complete hip replacement.

Everyone was up and instructed in walking with weight through the involved leg the day after surgery called postoperative day 1 or POD1. A physical therapist supervised the daily (Monday through Saturday) rehab program. Each patient was instructed by the therapist to put as much weight on the involved leg as was comfortable or tolerable. A walker was used for support and stability and the distance walked was increased daily. By the fourth day, patients were started on stairs and progressed to crutches whenever possible. A program of strength and balance training was also incorporated right from the start. Range-of-motion exercises were included with some movement restrictions for the patients who had a hip replacement.

Data collected on the patients included information about themselves (age, sex, living situation, physical and cognitive function) as well as information about their hospitalization (length of stay, type of surgery, day of surgery, destination at discharge such as home or step-down/transition unit). The therapists and nurses also charted how soon after surgery the patients put weight on the leg. They had to stand on the leg for at least two minutes for it to count. When the patient could walk forward at least 15 feet, they were credited with having successfully ambulated.

Those patients who could put weight on the leg and walk (ambulate) within 48 hours of the surgery were labeled compliant or adherent to the immediate weight-bearing early ambulation (IWB-EA) protocol. This was the weight-bearing (WB) group. Anyone who did not achieve this weight-bearing status was considered nonweight-bearing (NWB).

Analysis of the data showed that 78 per cent of the patients could weight-bear and ambulate within 48 hours (most achieved this in the first 24 hours). About half of the remaining 22 per cent (the nonweight-bearing group) eventually made the goal of weight-bearing and ambulation before being discharged from the hospital. Was there any particular reason or individual patient factor that could explain the difference between the weight-bearing and nonweight-bearing patients?

The authors found that it wasn’t their age or cognitive function that made a difference in weight-bearing outcomes. It was the day of the week the surgery was done. Patients who had surgery done on Friday or the day before a holiday were much more likely to end up in the nonweight-bearing group. This finding is important because more patients in the weight-bearing group went directly home from the hospital and much sooner than the nonweight-bearing group.

If early ambulation after surgery for hip fracture can reduce costs associated with this procedure and more patients are able to go directly home from the hospital, then it’s worth looking at staffing patterns in hospitals where these patients are treated. Reduced numbers of physical therapists and nurses and the absence of physicians in the hospitals on weekends and holidays appear to make a difference in how patients progress after surgical stabilization of hip fractures.

The authors suggest that if, as they showed in their study, the model of care for early in-hospital rehab of older adults with hip fractures can reduce the time of functional recovery, then results (especially long-term results) should be explored further. Data of this type may help move more hospitals toward a pattern of earlier recovery through immediate weight-bearing.

Surgeons are faced with many decisions when approaching surgery for patients with a hip fracture. Is the patient in good health? If so, then there’s a green light for going ahead with the procedure. Does he or she have a heart health history? If that’s the case, the patient needs cardiac testing before going into surgery. Studies show that patients with pre-existing heart problems have an increased risk of heart attack and even death after hip surgery for a hip fracture.

But there’s a new twist on that policy of obtaining medical clearance before surgery. Studies now show that taking the extra precaution to conduct a cardiac evaluation doesn’t change the outcome and may even increase the risk of postoperative complications. Delays in surgery come with risks of their own. For every day that goes by without surgery, the risk of infections, pressure sores, and other serious complications of surgery goes up.

But surgeons certainly don’t want to lose their at-risk patients to a heart attack. They are caught between a rock and a hard place as the saying goes. What should they do? Testing takes time and delays surgery but alerts the surgical team of the risk of possible life-threatening cardiac events. Not testing and proceeding full speed ahead gets the surgery done as soon as possible with fewer overall complications.

The results of two new studies suggest that a simple preoperative blood test might be the answer. Measuring blood levels of a biomarker called troponin may alert the surgeon of an increased risk of complications. Those complications mean added days in the hospital for the patient and even possible death. Troponin is a complex regulatory protein that helps produce muscle (heart) contraction. Elevated troponin levels in the blood can signal when a person has had a heart attack.

In fact, there’s some evidence that many patients fall and break their hips because they were having a silent heart attack. This new information might help put to rest the age old question of which came first: the fall or the fracture? Patients with high levels of troponin are the ones who should be held back for cardiac stress testing before having surgery. Anyone with normal troponin levels can proceed ahead with the operation.

There’s another significant problem surgeons must consider with this age group (usually over age 65). And that’s anticoagulation therapy. Many older adults have been on these blood thinners for months to years before breaking the hip. But there’s a risk of bleeding while on these medications. Surgery is not usually recommended until the patient stops taking the drug for at least three to five days. Once again, such a policy delays surgery, which then increases the risk of postoperative problems. There’s no quick and easy answer to this dilemma. More studies are needed to help develop some safe standards in this area.

Taking a look at some of the other large, long-term studies of death rates after hip fracture surgery, it looks like older men (again, 65 years old or older) die more often in that first year after hip fracture surgery than anyone else. Patients dependent on a walker to get around before surgery are also more likely to die after surgery than those who can walk independently before they fracture their hip.

Osteoporosis is a major risk factor in this population, too. Anyone with osteoporosis has a much higher risk of a second fracture six to 12 months after the first fracture. Surprisingly, many patients admitted to the hospital for hip fracture surgery aren’t even tested for osteoporosis. Or if they do test positive (low bone density), appropriate treatment isn’t prescribed when they are discharged.

More and more evidence points to the need for osteoporosis prevention, diagnosis, and treatment. The use of calcium, vitamin D, anti-osteoporotic drugs and specific bone building exercises form a simple recipe for treatment. It has been suggested that having an osteoporosis case manager might be one way to begin turning around the problem of undertreating osteoporosis. There is plenty of data to suggest that the added cost of a osteoporosis case manager is far less than what could be saved by preventing even half a dozen osteoporosis-linked bone fractures.

Surgeons can’t predict and prevent every problem faced by hip fracture patients in need of surgery to repair the problem. But by taking a few simple steps, patients can expect fewer problems and a better chance of going home and continuing to live independently. Those steps include testing preoperatively for troponin levels, reducing and eliminating as many surgical delays as possible, and assigning an osteoporosis case manager to every patient over the age of 50 (and especially those who are 65 and older) with a hip fracture.

For older adults with osteoporosis (brittle bones), it’s not bad enough when there’s a hip fracture that needs repair. But added complications from poor health, from being in the hospital, and from the surgery can be deadly. Pneumonia, heart failure, infections, and pressure ulcers (bed sores) head the list of problems that some seniors face when a hip fracture occurs. And according to this report from the Washington University School of Medicine, a delay in surgery increases the risk of complications even in healthy patients.

When it comes to osteoporosis-related fractures, surgeons and other health care professionals are trying to prepare for what’s ahead. With over 100 million seniors by the year 2025 (that’s only 15 years away), the number of fractures is expected to rise from two million every year now to over four million then. And that translates into billions of dollars in health care costs.

What can be done to reduce the number and severity of complications related to surgery for hip fracture? That’s the focus of this article. First, it’s clear from other studies that a delay in surgery can make things worse. Even a 24-hour delay increases the risk of death. The longer the delay, the greater the risk of pressure ulcers.

What’s causing the delays? One of the significant factors contributing to delays in surgery is the insistence on cardiac testing before surgery. In an effort to prevent heart attacks and other cardiac complications, this practice is actually increasing the risk of such problems. Treating the heart conditions before having surgery seems like it makes good sense. But, in fact, studies show that testing doesn’t really change how these patients are treated — it just delays the surgery they were admitted for in the first place. And now we know those delays can be deadly.

A second, important risk factor for poor outcome after surgery for hip fracture is malnutrition. Decreased bone mass is often linked with poor nutrition. And with an inadequate diet comes weight loss and no fat to protect the bones when a fall occurs. Not only that, but malnutrition also leads to poor wound healing and an increased risk of those pressure ulcers already mentioned.

What can be done when the patient comes in to the hospital with osteoporosis and a hip fracture? Isn’t it already too late to make a difference? Evidently not, according to several studies that showed using intravenous nutritional supplementation followed by vitamins taken by mouth can really make a difference. Nutritional consultation with a specialist is also advised. A nutritional expert can help with the immediate concerns about malnutrition as a risk factor for complications but also set up a plan for home once the patient is discharged. This step is essential in preventing future health problems of all kinds.

Another important risk factor for complications associated with hip fracture surgery is low hemoglobin. Hemoglobin helps carry the oxygen you need in every cell of the body. Without enough hemoglobin, anemia develops. This particular risk factor has many causes to watch out for. Besides the obvious loss of blood from the surgery, there can be internal bleeding from the GI tract.

Many older adults have bleeding ulcers from taking antiinflammatory drugs for their arthritis. Smoking adds to the risk of GI bleeding. One-third of all patients having hip fracture surgery end up needing a blood transfusion. What can be done to prevent bleeding problems? The research supports using a drug called proton pump inhibitor (PPI) right after surgery for anyone with risk factors for GI bleeding. Surgeons are also advised to do everything possible to avoid/reduce bleeding during the operation. This is possible now more than ever before with today’s minimally invasive surgical techniques.

There are other measures that can be taken to decrease postoperative problems after hip fracture repair. These include protective padding over bony prominences to prevent pressure ulcers, antibiotics to prevent infections, and proper pain management to prevent stress-induced heart problems. Preventing blood clots through the use of medications, compression stockings, and pneumatic pumps applied to the lower legs for at least the first 24 hours is standard practice.

Research is underway to find other ways to reduce surgical risks through the use of better anesthesia and improved methods of fracture fixation (brittle bones are difficult to hold together). But the danger isn’t over once the patient leaves the hospital. Now they face a 2.5-fold risk of another fracture. That’s why it’s important to carry through with a postoperative program to address the problem of the osteoporosis through medications and exercise. The authors suggest developing specialized osteoporosis clinics where patients can receive proper education about this condition. Every effort should be made to reduce risk factors for both osteoporosis and for falls.

With every new surgical procedure come refinements and improvements in the technique by surgeons who have the experience and expertise to try something different. In this study, one orthopedic surgeon from the Cincinnati Orthopaedic Research Institute takes on hip joint resurfacing as his project. He worked diligently over a two-year period of time to reduce the size of the incision required for this operation until it could be considered minimally invasive. He reports the results compared with similar patients who had a total hip replacement.

Hip resurfacing is done by entering through the hip from the back (posterior direction), cutting through the hip capsule, and usually, cutting through the hip muscles in order to pop the hip out of the socket. It’s necessary to dislocate the joint in order to gain access to the round head of the femur. It’s the head of the femur that’s shaved smooth and rounded in preparation for a metal cap that is placed over the bone. The cap is held in place with a peg that fits down into the bone.

Essentially, that’s what joint resurfacing is all about. It means less loss of bone and a chance to preserve as much of the natural hip joint as possible until the inevitable total joint replacement is required. Hopefully, the conversion to a total hip replacement will be some years down the road. Younger adults who are more active and who only have arthritis in one hip are the best candidates for hip joint resurfacing.

In this study, Dr. M. L. Swank performed an equal number of total hip replacements and hip resurfacing procedures and compared the results in his patients. Over time, he was able to use a smaller and smaller incision with less and less disruption of the surrounding soft tissues. The early resurfacing surgeries used a 4.5-inch long incision. That was reduced by almost a full inch over time. The total hip replacement was still possible with a much smaller incision (two inches).

By the end of the study, Dr. Swank was able to avoid dislocating the joint by splitting the gluteus maximus (buttock) muscle and using the gluteus minimus to form a pocket. The head of the femur could be slipped into that pocket to perform the procedure. A similar approach was used to perform an equal number of total hip replacements. Although the hip was dislocated in order to cut off the femoral head and replace it, the resection was done under the skin. In the traditional, standard surgery, the head of the femur is popped out of the opening made by the incision and then a saw used to cut through the bone.

Doing it this way made it possible (in both the resurfacing and the total replacement) to access the head of the femur without cutting through all of the soft tissues. In theory, the advantage for the patient is a smaller incision, less pain afterwards, and faster recovery of strength, motion, and function. The results will show if that theory translates into actual measurable changes.

Those results were evaluated using pain, function, and complications as the main benchmarks of success. Pain was equally improved in both groups at the first post-operative evaluation point (three months). Over time, the joint resurfacing group had better overall pain scores compared with the total hip group. Likewise, less pain translated into better function for all patients. Before surgery, the patients who had a total hip replacement had the lowest scores on tests for function. So although the groups ended up with equivalent function a year after surgery, the total hip group had bigger before and after changes in function.

What about complications? There is a wide range of problems that can develop after either surgical procedure. Infections, fractures, implant loosening, hip dislocation, and poor wound healing are the most common complications. Sometimes patients report a painless squeaking during movement. That can occur with either type of implant and usually doesn’t require any further treatment. In this study, there were a few problems in both groups but no trends or major complications to stand out in either group.

In summary, Dr. Swank concluded that it is possible to perform hip joint resurfacing with a minimally invasive technique. With less soft tissue damage and less torque on the femoral head, results were equal to and even improved over the tried and true total hip replacement. This is good news for younger, more active adults in need of a hip replacement but too young for that much bone loss. With very few complications and a rate that didn’t exceed the one for total hip replacements, hip joint resurfacing using a minimally invasive approach is both safe and effective in the hands of an experienced surgeon.

Even with the best imaging equipment, sometimes the surgeon doesn’t really find out what’s causing the patient’s hip pain until he or she is looking inside the joint during surgery. What looks like a labral tear might really be a separation of the layers of articular cartilage in the joint. More and more people (especially athletes and older adults) are showing up in surgeons’ offices with complaints of hip pain that turn out to be femoroacetabular impingement (FAI) with labral tears.

The labrum is a dense fibrocartilage ring around the hip socket. It is firmly attached to the bone and serves to deepen the socket, giving depth and stability to the hip joint. Femoroacetabular impingement occurs when the head of the femur (thigh bone) butts up against the hip joint cartilage and pinches this cartilage. Impingement means pinching.

Normally, the femoral head moves smoothly inside the hip socket. The socket is just the right size to hold the head in place. If the acetabulum is too shallow or too small, the hip can dislocate. In the case of FAI, the socket may be too deep. The rim of the cartilage hangs too far over the head. When the femur flexes and rotates, the cartilage gets pinched. This causes deep groin pain with activities that stress hip motion. Prolonged walking is especially difficult.

The etiology (cause) of the problem is under considerable debate. The discussion in this article among four orthopedic surgeons from around the United States offers some insight into surgeons’ opinions, experiences, and what the latest research has to say about the relationship between the labrum and impingement syndrome. The director of hip arthroscopic surgery at Kaiser-Permanente in California (Dr. Dean Matsuda, who is a hip patient himself) gathered these experts together to ask them some questions about the underlying cause(s) of femoroacetabular impingement (FAI).

Everyone agreed from doing thousands of hip arthroscopic surgeries that femoroacetabular impingement and labral tears go hand-in-hand. And labral tears don’t just happen out of the blue. The majority of hip labral tears probably develop as a result of some structural problems.

But there are some interesting findings about femoroacetabular impingement and labral tears. Younger patients (usually athletes) can have labral lesions without bony impingement. But there are groups of patients like hockey goalies who load the hip in a flexed position over and over leading to chronic impingement and eventual labral tears.

And despite the correlation between these two problems (labral tears and impingement), it is possible to have labral-cartilage lesions without any symptoms of impingement. They know this from autopsies on older adults who never complained of hip pain but had significant labral damage.

Studies have also shown that labral injury can occur without impingement as the start of the problem. That means there is some other reason why the labrum was damaged, but what? Well, improved quality of MRIs is helping to answer that question. It’s becoming clear now that over time slight changes in the normal hip anatomy result in plain old wear and tear (degeneration) of the junction between the labrum and the joint cartilage. That points to structural problems in the hip as the underlying cause of labral tears.

The word normal is highlighted because those same autopsies are also showing us that what we define as normal rarely exists. Most people do have alterations in anatomy that could lead to arthritis from uneven wear. Yet only a small percentage (five to seven per cent) of people with joint degeneration actually experience symptoms of hip pain from osteoarthritis. That’s true even when there is damage to the labrum and decreased hip motion from impingement.

So, what’s really happening here? Who develops labral tears, impingement, and eventual arthritis? And why do they present with hip pain when others who have the same changes in the form and structure of the hip and surrounding soft tissues have no symptoms at all? No one knows for sure but this group of experts agreed that it is likely a combination of several risk factors and mechanisms.

There is the anatomy to consider — structural problems are probably the most important factor (even if it’s not the only factor). Shape of the socket, angle of the femur as it connects with the socket, ligament laxity (looseness), and mechanical properties of the labrum and cartilage head up the list of possible structural causes of femoroacetabular impingement.

New research has also shown that when the labrum is damaged (no matter what the cause), a seal is broken that normally keeps synovial fluid inside the joint. When the labrum is healthy and well-sealed, friction inside the joint is kept to a minimum. Without this protection, fluid is pushed out or leaks out of the joint. This may be a big factor in why osteoarthritis develops.

But there’s also the role of inflammation and the immune system to be considered and explored. Some people seem more susceptible to inflammatory chemicals in the body. And with enough load and postural changes over time, labral tears and/or impingement lead to hip joint osteoarthritis.

So, where does that leave us? Even without full knowledge and understanding of femoroacetabular impingement and labral tears, decisions must be made about treatment. At first, surgeons just removed the torn cartilage and shaved smooth any frayed edges. Now, this procedure is being reconsidered.

Some surgeons propose reattaching the labrum. Others point out that only part of the labrum has any blood supply. The success of the reattachment depends on blood from nearby sources getting to the healing labrum. The strength of the stitches, not healing tissue filling in the gap is another important factor.

Even so, patients do seem to get relief from their hip pain with labral preservation and reattachment. Surgeons are still scratching their heads trying to figure that out — do they get such good results because the surgery helps stabilize the joint? Improve lubrication? Redistribute pressure? Can the protective seal be restored? Does it mean that these folks WON’T go on to develop osteoarthritis?

These are all questions yet to be answered. Based on what research is available so far, this group of experts favor labral repair. Trying to save the labrum and restore the fluid seal in the hip joint is the goal right now. When the tear is more than seven millimeters wide, then repair may not be possible. The group will continue their discussion of treatment options in the next issue of this journal.

Imagine you are late arriving at a very quiet function. You attempt to sneak into the back row but the only seats left are in the front. Every time you take a step, there is an audible pop, squeak, or grinding sound. The noise is coming from your new hip replacement. The results of this study show that 10 per cent of the adults who get a ceramic-on-ceramic implant will end up with a noise of this type.

Three surgeons from Lenox Hill Hospital in New York City pooled their patients together to study this problem. They compared a group of patients who got a ceramic-on-ceramic bearing implant with a control group who got a metal-on-plastic (chromium-cobalt-on-polyethylene) bearing. The control group was matched to the ceramic-on-ceramic group using a computer database. Matching criteria included age, sex, body mass index, and whether or not they had one or both hips replaced.

All patients (regardless of implant type) were tested before and after surgery using a variety of test measures. X-rays were used along with several surveys of questions about daily function, satisfaction, range-of-motion, pain, and walking ability. In addition, patients were asked directly, Does your hip make a noise? The questionnaires were filled out three months after surgery and again at six months, and 12 months. Patients included in the study had at least one full year of follow-up.

The authors were interested in finding out how often the noise occurred in their ceramic-on-ceramic patients and how that compared to patients getting a different kind of implant. They also wanted to see if they could figure out what was causing the noise. The hip X-rays were analyzed for angles and position of both sides of the implant (cup or socket and femoral head or ball that fits into the socket). Any changes in leg length from one side to the other were also recorded.

They found that although less than one per cent of the ceramic-on-ceramic patients ever complained of noises, when specifically asked about it, 10 per cent reported noises of some kind. The metal-on-plastic group was more likely to report a clicking noise rather than a squeak. The incidence was much less (four per cent) in the metal-on-polyethylene group. Squeaking was the most common noise for the ceramic group, but some patients described the noises as popping, snapping, or grinding.

There was no pain associated with the noises. Most of the time, the squeak or other noise occurred once a day or less. Sometimes it only occurred once a week. But for those who had daily squeaking, it had a negative effect on their quality of life. One person who had hip squeaking and chronic hip dislocations gave their results as completely unsatisfactory.

Activities linked with the noises included bending and walking (most common), but also climbing stairs, exercising, during sexual activity, and when putting on pants. Some of the patients could reproduce the noise by stepping up on a low stool. The authors called this the squeak test. Evidently, combining a flexion-to-extension movement of the hip with a weight-bearing load was enough to recreate the problem.

When trying to determine the cause of the squeaking, there were no differences in X-ray findings between those patients with noises and those without noises. They compared sizes of the replacement femoral head to see if that might be linked with noises — it wasn’t.

Since the patients didn’t report noises until six months after getting the implant, it’s possible some kind of wear is the cause of the squeak. In a previously published study, stripe wear was proposed as the possible source of the noise. Squeaking implants retrieved and inspected showed a broad stripe of wear on the femoral head with a matching wear pattern in the socket.

Other experts have also noticed this squeaking or other noises with implants of various materials. A variety of possible causes have been proposed including impingement, a mismatch of bearing surfaces, inefficient lubrication, or metal debris (flakes of metal from the implant get lodged inside the joint).

The authors make note of the fact that over the years, many changes have been made in the design of the ceramic liner that was used in this study. A metal backing with an elevated rim was added to protect from impingement, chipping, and fracture (previously observed complications). It’s not likely that impingement is the cause of the current noises because impingement usually occurs at the end range of motion, not in the middle of a movement.

They will continue to use ceramic-on-ceramic implants for young, active patients. But until the source of the noises can be found and corrected, it will be necessary to inform patients ahead of time that this could be a potential complication of the ceramic implant. If the squeaking does develop, a revision surgery can be done. The implant can be removed and replaced with a metal-on-polyethylene or ceramic-on-polyethylene type of articulation.

This is the first study reported to look at the benefit of aquatic therapy in the early days after joint replacement. Physical therapists in Australia randomly placed patients getting a hip or knee replacement into one of three different treatment groups. The goal was to find out what kind of treatment is best in the early days after orthopedic surgery.

With the recent effort to reduce the length of hospital stays, physical therapists are exploring the most effective ways to treat orthopedic patients. The standard rehab program after hip or knee joint replacement includes a mix of exercises to improve circulation and to prevent blood clots and other complications. Other goals include improving motion, strength, and function (especially walking).

In today’s evidence-based medicine, the question has been raised: what is best practice during the acute postoperative phase for hip and knee replacements? What is the role (if any) of aquatic therapy? Can the hydrostatic forces and warm and gravity-free environment make a difference? Are there additional benefits of aquatic therapy that cannot be obtained through the standard rehab protocol? The authors of this study asked and answered all of those questions.

Aquatic (pool) therapy is defined as physical therapy that is performed in the water. There are good reasons to consider using aquatic therapy after joint replacement. Aquatic therapy uses the resistance of water instead of weights. With the reduced load provided by the buoyancy of the water, certain exercises (e.g., squats, step ups, walking without a cane or walker) can be started sooner in water than on land. Circulation is also improved leading to faster tissue healing and reduced swelling.

Everyone in the study either had a hip or knee replacement. They each received the standard postoperative hospital care by a physical therapist for the first three days after the operation. After that, the patients were randomly assigned to one of three groups.

Group one continued with the standard care. This included circulation and deep breathing exercises, transfer practice, gait (walking) training, and practice going up and down stairs. Stretching and strengthening exercises were also done daily. Group two received a nonspecific water therapy session each day they were in the hospital. Group three had one standard physical therapy treatment each day and attended aquatic therapy everyday while in the hospital.

The aquatic physical therapy was performed at a slow (50 to 58 beats per minute) and fast pace (80 to 88 beats per minute) using a metronome to tick out the speed. The idea of using speed as a tool to enhance movement in water is part of the aquatic therapy. The program included exercises to improve range-of-motion, muscle strengthen, trunk stability, and reciprocal motion (arms and legs swinging rhythmically and repetitively while walking).

Measures used to compare the results of different treatment approaches included strength of the hip abductor muscles, walking speed, and patient self-reported function (disability). Patients in all three groups were tested at the end of 14 days for short-term effects and again at the end of six months. Retesting at the six month time period allowed them to see if the short-term improvements held up over time.

Three tests commonly used by physical therapists to measure results included a handheld dynamometer for muscle testing, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the timed 10-meter walking test. The WOMAC is a survey patients fill out answering questions about pain, function, and stiffness. Muscles tested using the dynamometer included the hamstrings, quadriceps, and gluteus medius.

In order to be considered clinically significant, patients in one group had to have more than a 15 per cent change from before to after treatment. The only reported difference among groups in this study was hip abductor muscle strength. Patients in the specific aquatic therapy program had the greatest improvement in strength. Hip abductor strength is important for trunk and hip stability and normal a gait (walking) pattern.

When all other variables were compared among the groups, the aquatic group had the best short-term improvements, but they didn’t reach the 15 per cent difference. This means they were important measures but not always considered statistically significant.

At the end of six months, there was no difference in outcomes from one group to the next. There were overall trends that seemed to support the idea that aquatic therapy was slightly more beneficial than either land-based or nonspecific water-based exercises.

The authors conclude that for physical therapists who have access to an appropriate pool at their hospital, an aquatic program for total hip and knee is safe and effective. Improved postoperative hip strength has been shown in other studies to be a key factor in functional recovery after hip or knee replacement.

Improved early funtional recovery is more likely with a specific aquatic program (even over just water exercises). There’s more to this success than just warm, buoyant water. Further studies are needed to find out why this is so and which execises (type and amount) are best during the early recovery phase.

Everything seems faster these days — including rehab and recovery from total hip and total knee replacements. In this study from Denmark, a group of researchers compared patients in a standard rehab program for joint replacements compared with an accelerated program. They looked at two things: cost and effectiveness. They found a big cost savings with the accelerated approach for both hip and knee replacements. The accelerated approach was more effective with hip replacements.

There are many ways in which the accelerated treatment plan is different from the standard postoperative care. The idea is to shorten the time to recovery. The goal is to reduce costs without adverse effects on the patient’s recovery. Right from the start, the accelerated group is treated together. Together, as a group, they receive information and patient education about the procedure before hospitalization. The standard protocol calls for individual patient information one-on-one the day of the surgery.

Patients in the accelerated group are all placed together in one separate part of the hospital surgical ward. In the standard approach, joint replacement patients are put in rooms randomly on the Med/Surg floor. One nurse is in charge of the entire rehab team of nurses, physical therapists, and occupational therapists. In the standard care approach, each health care professional works independently and there are various nurses in charge.

Accelerated patients begin rehab with the physical and occupational therapists on the day of surgery. Daily goals are preset. Therapy is intense and designed to get them up and moving as quickly as possible. Movement (mobility) and exercise are performed eight hours daily. The standard group doesn’t start until the first day after surgery and they go gradually at their own pace. Mobilization is limited to four hours each day. In addition, a special focus was placed on fluid intake for the accelerated group, including two protein drinks each day.

Results for the two groups were measured and compared based on length of hospital stay, health-related quality of life, and any adverse effects. These measures were obtained for the first three months after surgery. Costs associated with each approach were added up and compared for a year after the procedure.

Patients included in the study were having elective (not emergency) surgery. Each one had either a partial knee replacement (called unicompartmental knee arthroplasty, total knee replacement or total hip replacement. All surgeries were done by the same group of surgeons using the same surgical and anesthetic procedures.

The patients volunteered to be in the study. They did not have a choice as to which group (accelerated or standard) they were in — this was randomly assigned. There were 45 patients in each group. They were very similar in age, education, general health, and perceived quality of life (as measured before surgery). They all went home from the hospital rather than to a transition unit or other step-down facility.

Costs were calculated using a wide range of charges and losses. For example, productivity loss was calculated by adding up the amount of money patients lost by not being able to work after surgery. The total cost of the surgery, hospitalization, and all medical care (including therapy) was calculated. Costs of patient education, consultation with the surgeon, anesthesia, and medications were factored in. In order to keep a tally for the full year period of time, each patient was given a diary to take home and fill in the information about any medical costs or charges incurred related to their hip or knee replacement.

Here’s what they found regarding complications, costs, and effectiveness for each group. In the standard-protocol group, there was one death reported (due to a blood clot to the lungs) and one patient with a wound infection. In the accelerated-protocol group, one patient had a delayed discharge due to pain and swelling and one patient had to stay in the hospital an extra day because his hip dislocated early on. There were more patients in the accelerated group who had to have a second hip replacement within the first six months after the first surgery.

The average cost of the patient in the standard group was $4000 more than in the accelerated group. In all comparisons made, the accelerated approach always came out ahead in terms of cost-effectiveness. Health-related quality of life improved rapidly for patients in the accelerated total hip replacement group. All patients in the knee replacement groups seemed to have a much slower recovery of heath-related quality of life. Some patients didn’t report peak quality of life for many months after the operation.

The authors conclude that the evidence from this study points to the use of an accelerated pathway after surgery for both hip and knee replacements. The benefit to society in terms of cost savings and to the individual patients is evident. They suggest that it’s not enough to come up with new techniques to speed patients through the hospitalization process in order to save money. Finding value for the patient is as important. From this study, it’s clear that improved health-related quality of health is also possible.

Most people would be surprised to know that total hip replacements (THRs) have been around since the 1930s. Today’s successful use of THRs reflects the many implant changes in design and materials that have taken place since those early attempts.

In this article, orthopedic surgeons from the New York University Hospital for Joint Diseases review the history of THRs up to and including today’s surface replacement arthroplasty (SRA). SRA is a type of hip replacement that replaces the arthritic surface of the joint. But it removes far less bone than the traditional total hip replacement.

Because the hip resurfacing removes less bone, it may be preferable for younger patients who are expected to need a revision (second) hip replacement surgery as they get older and wear out the original implant.

The surface replacement arthroplasty (SRA) is done by dislocating the femoral head 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.

A major advantage of a surface replacement arthroplasty (SRA) is its success in patients under age 65. The rate of implant wear with total hip replacements (THRs) make the use of THRs very limited in younger, more active adults. SRAs provide a solution to the problem of disabling arthritic hip pain in younger adults.

SRAs are made from high-carbide cobalt chrome. This is a metal-on-metal (MOM) design. It gives the hip smooth action. But with repeated motions, flecks of metal ions are released into the joint and into the blood stream. Metal ion release may be a factor in implant loosening. Some patients are hypersensitive to these particles and develop hip pain as a result.

And there’s been some question about the possibility of an immune system response to the foreign debris being linked with cancer.Particles of both cobalt and chromium have been found in organs of the immune system (e.g., spleen, lymph nodes) and in red blood cells and the liver. This will bear warching in future studies.

The SRA surgery is done from a posterior (behind the hip) approach. This allows the surgeon to see the blood supply to the hip and avoid cutting any blood vessels by mistake. It also gives the surgeon better access to the hip casule and soft tissues, which must be released to remove the femoral head. And the posterior approach allows the surgeon to position the femoral cap with just the right amount of rotation.

Long-term outcomes of SRA are not available yet. Since these implants have only been in use a limited amount of time, studies have only reported early-to-midterm results. Survival rates are high (98 per cent) for the first five years. When failure occurs, it’s because of femoral neck fractures, infections, and implant loosening.

Sometimes there’s a loss of blood supply to the bone called osteonecrosis. Osteonecrosis can also lead to implant failure. When osteonecrosis occurs, the patient may need a second surgery to convert the SRA to a total hip replacement (THR).

How does the SRA compare to a THR? Studies show that patients with a SRA have more motion and engage in higher levels of activity. Patients with a SRA can walk faster than those with a THR. Gait (walking) pattern is closer to normal after SRA compared with THR. Resuming normal movement patterns called kinematics with SRA may be due to the larger-sized femoral head with the cap in place.

Problems after surgery and the need for a revision (second) surgery are about the same for both procedures (SRA and THR). Typical complications after either surgery include blood clots, dislocation, and damage to blood vessels or nerves in the hip area.

The authors conclude by pointing out that modern orthopedics have made it possible to treat painful, limiting hip arthritis in young patients. Improvements in metal-on-metal SRAs have reduced failures and extended the life of the implant. There are still some potential problems (e.g., effects of metal ions) that require further study.

Here’s a problem the Baby Boomers probably never thought they would face: not enough surgeons available to perform all the hip and knee replacements that are needed now. And it’s not just the aging Baby Boomers who are affected. More and more younger patients (younger than 65) find themselves in the same boat. Experts say the problem is going to get worse before it gets better.

Right now, almost three-fourths of a million adults in the United States get a new hip or knee every year. That number is expected to top one million very quickly. It is predicted that by the year 2016, half of all patients who need a hip replacement won’t be able to get one. And three-fourths of all patients seeking a knee replacement will be on a waiting list for a very long time.

There are two groups who are going to be affected the most by this problem: adults in the 45 to 54-year age group and adults older than 80 years. In both cases, increased activity and desire for improved quality of life are the reasons behind the increased demand. Emotional health, social function, and physical comfort are all affected by the pain of an arthritic joint.

Advanced technology and improved surgical technique has made joint replacement easier and safer than ever before. There are fewer risks and complications. This is especially true in the older population — another reason why joint replacements are becoming so popular. What’s the answer to this supply and demand dilemma? Some experts suggest that avoiding this problem is possible.

They say that policy makers need to increase the rate of reimbursement to surgeons for total joint procedures. Medicare keeps reducing how much they will pay while the costs of doing business in the health care world continue to rise. Another possible solution is to prioritize patients according to need and predicted outcome. What does that mean?

Well, we know, for example, that patients who have worse function before surgery tend to have poorer outcomes after surgery. Women and certain ethnic groups (e.g., Hispanic, African American) fall into this category. It may be a coincidence that these patients have worse function before seeking out a joint replacement. Or it may be that people in these groups delay treatment for too long. Lack of insurance, cultural issues, or less access to care may also be reasons for this delay. Getting them in for surgery sooner than later may actually improve their results.

All of this points to the need for education. First, for the policy makers responsible for determining reimbursement rates on surgical procedures. Then to aging adults who are starting to develop joint problems. With modified activity, strengthening exercises, and medications, the effects of osteoarthritis can be prevented and managed much longer. It may be possible to reduce the need for joint replacements (or at least delay surgery it without affecting the final results).

Who is going to do this education? Orthopedic surgeons may head the campaign. But the efforts of all health care providers will be important in this area. This includes physical therapists, physician’s assistants, nurse practitioners, and chiropractors. Fitness instructors and personal trainers can also receive instruction in this area that can be passed along to their active clients whose activity level may put them at risk some day for disabling arthritis that requires joint replacement.

Here are a few facts to consider. A quarter of a million people in the United States will fracture their hips this year. One-fourth of those adults die within the first 12 months after that fracture. And only half of those who survive will be able to return home and resume a normal life. Those are very sobering statistics.

Studies show that if this happens to you, your motivation level can be a key factor in your success. Patients who are highly motivated to participate in their rehab program are more likely to have a positive outcome and successful rehab. But how can we measure motivation? And what can we do to increase motivational levels to ensure better results?

These are the kinds of questions physical therapists are faced with everyday. Now that patients go home so much faster after hospitalization, it’s even more important than ever that therapists quickly determine what level of participation they can expect from each patient. And it’s equally important that patients fully participate in their own recovery process whenever possible.

In this study, physical activity was measured objectively using a special device called an actigraph accelerometer. The accelerometer has an electronic sensor that records frequency, intensity, and duration of physical activity. It provides a reliable measure of energy used up during activity by transferring that activity into activity counts. Data on activity counts for healthy, young adults walking on a treadmill is available for comparison.

Patients over the age of 60 who were independent in getting around the house and community before having a hip fracture were included in the study. Some used a cane, walker, or the assistance of another person but all were fully weight-bearing and functional. They all qualified as being what we call community dwelling individuals.

Each patient wore the monitor on the waistband of their pants. The accelerometer was placed on the uninvolved side. The device picks up vertical movements of the trunk and records them as activity counts per minute. One count per minute is equal to four milligrams of gravitational force per second.

During the five days that the patients wore the accelerometer, their physical therapist also recorded their level of participation during their therapy. They used a tool called the Pittsburgh Participation Rating Scale that ranks patient participation on a scale from 1=none up to 6=excellent. The therapist completed the scale for each patient after each session for the five days of the study when they were wearing the accelerometer.

In addition, function was measured using the Hip Fracture Functional Recovery Scale. This is a self-report survey completed by the patient answering questions about daily self-care. Activities included shopping, dressing, eating, toileting, housework, errands, and mobility (walking).

By comparing these three measures (activity counts, participation, and function), it was possible to see some trends within the patient groups. For example, patient with higher activity counts also had excellent participation scores. The more active patients were, the better their function, too. And these results were consistent when reviewed at the end of three and six months.

Therapists are interested in helping post-fracture patients avoid a decline in function, speed up recovery of function, and foster physical activity to improve function. Looking at activity levels and how these match up to final outcomes is useful information.

The therapist can now use this data to look at factors that might help improve participation levels. This could include patient scheduling, pain level, past medical history, or even how active they were before the fracture compared with now.

Since only movement of the lower half of the bottom was tracked, it’s possible activities of the upper extremities may have benefitted the patients without having a way to record or track this influence. Future studies may be able to tackle that link.

Other factors may have affected activity level that were not accounted for in this study such as general health, complications, diagnostic tests performed during the testing period, and so on. It’s possible that varying amounts and types of therapy could make a difference too. What if patients had two therapy sessions each day instead of one? Would the results be any different? And finally, future studies should also be done to measure function using something more objective than a patient self-report.

There’s a move in the medical world to help health care professionals get on the same page. What does that mean? Well, if you have a health problem, condition, illness, disease, or injury — no matter where you live, you should get the same top quality treatment based on the best evidence currently available.

But surprisingly, even with today’s high-speed technology and ultra-fast communications, not everyone has the same information or ideas about treatment. And that’s true even for common problems like hip osteoarthritis.

So clinicians like physicians and physical therapists are putting together clinical practice guidelines whenever possible to help guide current practice. In this article, the latest research is reviewed and summarized to present clinical practice guidelines for hip arthritis. And in a new twist, these guidelines are linked to the ICF. The ICF stands for the World Health Organization’s new International Classification of Functioning, Disability, and Health.

The WHO-ICF model was developed to describe, classify, and measure function when managing patients of all kinds. It’s a tool that can be used by health care professionals and researchers around the world. It will help standardize how we describe and discuss how a condition or disease affects a person’s ability to function. Instead of focusing on what the person can’t do (i.e., their limitations and handicaps), the new approach is to focus on what they can do (function, activities, participation).

The ICF has its own codes to classify body functions, body structure, and activities and participation. For example, with hip osteoarthritis, body function would be viewed as pain in joints or mobility of a single joint. Body structure is labeled as hip joint, muscles of pelvic region, or ligaments of pelvic region.

Activities and participation might be maintaining a standing position, walking short distances, or walking long distances. You can see how different these codes are from our current billing codes used such as primary coxarthrosis, unilateral (which means hip arthritis on one side) or posttraumatic coxarthrosis.

The authors of this 25-page summary explain what evidence they found to help us understand the pathology behind hip arthritis, the risk factors, and how the condition is diagnosed or classified. They collected this evidence from all high-quality studies published between 1967 and 2008. Other categories reviewed included examination measures and treatment used by physical therapists called interventions. Specific treatment interventions summarized included patient education, gait (walking) and balance training, manual therapy, and exercise.

A very nice, one-page summary of the recommendations for each of these sections is provided at the beginning of the article. The authors say the guideline will be reviewed again in five years (2013) or sooner if new evidence comes to light. Here’s a brief summary of the main points and recommendations given for physical therapists evaluating and treating patients with hip osteoarthritis:

Total hip replacements (arthroplasties) are becoming much more common in North America than they ever have been. Although the percentage of complications haven’t increased, the reality is because more people are having the surgery, more people are having problems. One serious problem associated with hip replacements is infection. A deep infection in a knee replacement can cause complications that end up requiring revision surgery to correct.

Doctors and researchers have been looking for ways to decrease the number of people who develop infections in their replacements, including giving antibiotics before the surgery. Another method uses, in conjunction with antibiotics beforehand, a bone cement that has an antibiotic inside. The idea is that this will further drop the risk of infection. Not all doctors agree that it should be used routinely however. They feel that the cost of the bone cement doesn’t justify the few infections it may prevent. They also worry about antibiotic resistance, a real concern in today’s world, and how the cement may affect the new joint.

The authors of this article wanted to study the issue to see if the cost of using the antibiotic-impregnated bone cement for total hip replacements is worth the cost. To do this, they reviewed revision rates, mortality rates, and the costs of the overall treatment. This includes the procedure and related acute-care hospital stay costs only. The researchers didn’t include, surgeon fees, rehabilitation stay, or lost wages from work. The authors point out that the cost estimates are in US dollars with the 2002 value.

The estimated cost ranged from 12,846 dollars to 31,000 dollars for a primary total hip replacement. For the study’s purposes, the cost was figured to be 21,654 dollars. Earlier studies have estimated that revision surgeries, compared to the original replacement ranged from 20 percent more to 60 percent more. For this study, the calculated amount was 34,866 dollars for revision surgery overall, but if the revision was due to an infection, this climbed dramatically to 96,166 dollars.This includes the use of intravenous antibiotics.

Using antibiotic-impregnated bone cement cost depends on the type of antibiotic used. Cement with gentamycin, for example, has been studied the most often and the estimated cost for one packet (40 grams) of the cement would be about 365 dollars and on average, two packets are used in surgery. This compares with 65 dollars for standard cement per pack, with two being needed most of the time.

After analyzing issues such as rate of revision, actual costs of procedures and equipment, as well as the success of the procedures, the results were looked at in two fashions: cost effectiveness of revisions done for any reason and cost effectiveness of revisions that were done because of deep infection. In the first case, using the antibiotic cement resulted in only a 200 dollar savings overall. However, if the revision was due to infection, the savings was higher, but it needed to be above 650 dollars worth of savings to be worthwhile or the patient had to be older than 71 years.

In this case, the researchers concluded that such a treated cement could have been useful in younger patients, however those who are younger tend to have replacements that don’t need cement. So overall, as long as the cost remains high, treated cement doesn’t appear to be a cost effective form of management.

In this article, orthopedic surgeons from Israel report on the natural history of transient hip osteoporosis. Natural history refers to what happens in the disease process and in the bone over time. Osteoporosis is a decrease in bone density potentially leading to weak and brittle bones. Transient means it’s temporary. The condition resolves or gets better over time.

Transient osteoporosis of the hip is rare but not unknown. There are certain groups of people affected most often. These include middle-aged men (ages 30-60) and pregnant women (during the third trimester). This doesn’t mean other people can’t develop this problem. Cases of transient osteoporosis of the hip have been reported in teenagers and women who aren’t pregnant. Such cases are very rare.

How would you know if you had this problem? First, symptoms of sudden hip and groin pain develop that get worse and cause the person to limp. The pain is severe enough to send the patient to the doctor. But X-rays and blood work are normal. The painful symptoms last several weeks to several months. The changes in bone go away gradually, usually within a year’s time.

MRIs are really needed to make the diagnosis. The authors of this study found that out by following a group of 37 men and women with this condition. The patients ranged in ages from 21 to 75 years old. None of the women in this study were pregnant. Although the left hip is affected most often during pregnancy, in this group of nonpregnant individuals, there was an equal distribution between right and left hips. A few of the men went on to develop transient osteoporosis of the other hip.

The investigators took X-rays and MRIs periodically throughout the course of treatment. Imaging studies were repeated during follow-up that extended over a period of years (up to nine years). X-rays did not show any evidence of osteoporosis or other changes to identify the problem. Bone scans suggested osteonecrosis (death of bone) in the head of the femur (thigh bone).

The key finding in MRIs was the presence of crescent lines. These are low-signal lines in the subchondral bone. Subchondral refers to the first layer of bone just under the joint cartilage. MRIs also showed fluid called bone edema. The authors caution that bone edema can be present with stress fractures and bone tumors. So the presence of bone edema doesn’t necessarily confirm that the patient has transient osteoporosis.

Special bone scans for osteoporosis called DEXA were done on 25 of the patients. DEXA stands for dual-energy X-ray absorptiometry. A more up-to-date abbreviation for that term is DXA. DXA provides a bone density measurement that can be compared to the expected norm. A small number of patients had severe enough osteoporosis to warrant treatment with medication. No real reason could be found for the problem. They did all have calcium-deficient diets.

Given the fact that transient osteoporosis of the hip goes away over time, it is considered a benign condition. MRIs are able to differentiate between transient osteoporosis and osteonecrosis. Treatment is very different for these two conditions, so making the distinction is helpful and important.

Conservative care is the standard for transient osteoporosis. Non weight-bearing with crutches is advised until the diagnosis is confirmed and stress fracture is ruled out. Once it’s clear that the condition is transient osteoporosis, then the patient can be progressed to walking with crutches while putting weight on the leg as tolerated by the individual patient. Swimming is encouraged and advised.

MRIs taken at six-week intervals showed a decrease in bone edema even as the patients reported reduced pain and improved function. Everyone in the study got better and the condition resolved on its own. The authors note that anyone with signs of osteoporosis that doesn’t go away with time must be followed carefully and treated more aggressively than when transient osteoporosis is the only problem. In such cases, DXA scans and lab work to look for an endocrine problem are advised.

It doesn’t take a crystal ball to see that there’s trouble ahead for America’s seniors. More and more older adults are in need of a total hip revision surgery. Nearly 18 per cent of all total hip replacements done in the United States have to be revised at some point. Current estimates are that in the next 20 years, the need for total hip revisions will increase dramatically.

There are other factors to consider with this problem. First, the cost. Can we really bear the financial burden of these surgeries? Second, there is already a shortage of surgeons who perform this operation. Joint replacement revision is a subspecialty all of its own.

The procedure is difficult and complex. Surgeons aren’t being reimbursed adequately by Medicare. So while the number of older adults needing this operation is on the rise, the number of surgeons available to perform the procedure is on the decline. That presents an interesting dilemma for all concerned.

As with most problems, there is more beneath the surface than meets the eye. Revision of primary (first-time) hip replacements often comes with its own problems. More bone grafts are needed requiring longer hospital stays. Patients are less likely to be discharged home and more likely to be transferred to an extended care facility.

Longer operative times and longer hospital stays translate into higher total costs. And long-term studies show that these patients are more likely to be rehospitalized within the first 90-days of the revision operation. That adds to the total cost as well.

So how come there’s such an increase in the number of revision operations required? And what can be done to prevent this from happening? Studies show that the relative number of revision operations hasn’t really increased. It’s more the fact that more adults are having their first hip replacement and more of those are being done at a younger age. If patients outlive the life of their implant, then revision surgery is needed. Or if there are complications from the first surgery, a revision replacement might be needed.

Two preoperative factors stand out as possible predictors of a poor outcome after revision surgery. One is preoperative pain. The other is medical co-morbidities. Research shows that older adults with higher levels of pain and lower levels of function because of other health problems were more likely to have a poor outcome from the revision surgery.

If revision surgery is going to be a fact in the near future, then what can be done now to head it off at the pass? Some suggest building more high-volume orthopedic specialty hospitals. Studies show that there are fewer complications when a surgeon performs the same operation on a larger number of patients.

Specialty centers of this type would draw more patients and attract more physicians with a subspecialty practice in revision hip replacements. With fewer complications, costs can be contained. Preventing infection, dislocation, or fractures of the bone around the primary implant could go a long way in protecting the implant and reducing the need for revision surgery.

But the total cost of revision operations aren’t just caused by the surgery itself. Data collected over time also shows that the charge for the implants has gone up. And the total cost for rehabilitation services has also escalated over time. Of course, patients who have to go to an extended care facility instead of home require more services and the cost of those services adds up.

It’s clear that there’s going to be a shortage of qualified surgeons to perform these revision operations. What else can be done about the possible imbalance between supply and demand of specialty surgeons? One natural solution to the problem has already been provided. More non-U.S. trained surgeons are filling surgical positions.

Some suggest putting an end to fee reductions proposed by Medicare. Instead, Medicare reimbursement for primary and revision surgeries must be increased. Otherwise, surgeons will turn to other types of surgeries that pay better just in order to stay in business.

Surgeons have also cited high legal costs of malpractice claims as a deterrent to performing these procedures. Surgeons who perform more than 100 hip and knee replacement operations each year have a much higher risk of being sued for complications such as nerve injury, leg length difference, infection, damage to blood vessels, and implant/joint dislocation. What can be done to reduce complications and the risk of litigation?

The authors suggest developing and using evidence-based guidelines for standard of care, patient safety, reducing complications, and managing patient expectations at the time of the surgery. Added together, these steps represent best-practice procedures for both hospitals and specialty centers. The final result might be total decreased costs as a result of reduced hospital length-of-stay, fewer complications, and fewer revision operations.

Studies like this that review current statistics show a need to try and change what might become a huge medical and economic burden on the current health care system. Addressing the potential inadequate surgeon workforce is just one of the many factors under consideration.

Patients and surgeons alike are interested in a painless and speedy recovery after a total hip replacement (THR). Can it be done? Well, it hasn’t been accomplished yet, but efforts are being made to move in that direction. The use of minimally invasive (MI) procedures may be an important development toward achieving this goal.

The authors of this article are surgeons from The Johns Hopkins University in Baltimore, Maryland. They took the time to look through all the most recent studies on minimally invasive total hip surgeries. They wanted to know which surgical approach works best? What really makes a difference in outcomes? Does it depend on the surgeon’s technique? The patient’s expectations?

Here’s what they found. First, minimally invasive surgery refers to any operation where the surgeon changes how long or how deep the cut is made into the tissue. The hope is that with less trauma to the soft tissues (especially the muscles around the hip), the patient will be able to recover that much faster.

But there is much debate about the exact incision length to qualify as minimally invasive. Is it five inches or less? Three inches? One inch? Is there a difference between minimally invasive and what would be considered a mini-incision? Does it even matter? The authors think so. They say that a truly less invasive approach isn’t just a shorter incision. Minimally invasive means no incision into the muscles. No tendons are cut. And if the joint capsule is disrupted, it is easily repaired.

Do the patients recover faster with one type over another? And there are two different basic approaches used with minimally invasive total hip replacements: the mini-posterior and the two-incision approach. Are the results better with one approach over another?

You can see how comparing all these different types of minimally invasive surgeries adds to the difficulty of sorting out which one works best. There aren’t enough studies out there yet to really make comparisons of all the types, approaches, depths, and so on.

The authors say that right now the studies published on minimally invasive techniques can be broken down into three categories: the mini-posterior approach, the anterolateral approach, and two-incision approaches. They summarized what they found for all three.

There are many advantages to the mini-posterior approach. The group of muscles usually cut to remove the old hip joint aren’t touched. The gluteus maximus (buttock) muscle is split to get to the hip joint, but the length of the split is much shorter. The incision into the joint capsule is also smaller and repaired without any negative effects.

But for all these positives, when surgeons compared the results between a standard posterior total hip replacement and the mini-posterior approach, guess what? No difference between the groups during the postoperative period. Pain levels and walking ability were the same.

There were more studies on the anterolateral approach but not all were of high enough quality to make their results very note worthy. There was less blood loss reported and shorter time in the operating room for the minimally invasive approach compared to the standard anterolateral procedure. Functional outcomes (walking speed, muscle strength) between the two groups were better for the minimally invasive patients. But this was only true for the first year postoperatively. After that, things evened out between the two groups.

Studies comparing the two-incision and mini-posterior approaches are limited and with a small number of patients. In one study, the two-incision operation was reported as more complex and taking longer than the mini-posterior approach. Another study comparing the same two approaches agreed that the mini-posterior approach was faster with less blood loss but reported that the patients recovered faster when the two-incision method was used.

Finding studies that truly compare two different surgical approaches with all else being the same just doesn’t happen. Different types of implants are used. Surgeons have different levels of expertise and experience. The amount of muscle sparing that takes place varies considerably. The type of rehab program after the surgery isn’t the same from place to place.

What might be more important than the type of incision made is the way patients are treated after surgery. Several studies have shown that patients who are on the fast-track after surgery get better faster.

The fast-track means they get a patient-controlled pump to manage their pain. They start rehab sooner, and the therapist provides a more aggressive program. In all cases, patients in the fast-track groups were discharged sooner, could walk better, and were more satisfied than patients following the standard rehab protocol. This was true no matter what type of incision or approach was used to do the surgery.

There’s one other thing to consider about minimally invasive procedures. Even if the minimally-invasive approach doesn’t yield better functional outcomes, patients like how it looks. A shorter incision just looks better, and patients are asking for that. Patients also want an implant that will last as long as possible. And that factor is more important to them than the length of the scar or how long they are in the hospital.

The authors conclude that there are many, many variables to study and compare when trying to decide which approach is the best one for total hip replacements. We’ve only begun to scratch the surface when comparing things like preoperative counseling, analgesia, and rehabilitation programs. While the surgical approach might make a difference, there’s at least enough preliminary information to suggest that the postoperative treatment process may be equally (if not more) important.

What’s every patient’s fear after getting a new hip replacement? Dislocation. The surgeons call it instability. No matter what name you give it, the problem is troublesome for the patient and a complex challenge for the surgeon. In this review article, surgeons from the Shiley Center for Orthopaedic Research and Education in California offer surgeons insight into understanding what can cause this to happen and what to do about it.

There are two different scenarios that can happen around dislocation after a primary (first) hip replacement. The first is the timing: did it occur early or late after the surgery was done? The second is response to treatment — more specifically, what to do when instability persists and doesn’t respond to treatment.

The definition of early versus late dislocations isn’t a time-frame agreed upon by everyone. Some say any instability after the first three months is a late event. Others pinpoint a much later time period such as five or more years after surgery. For sure, the later the dislocation, the greater the risk of recurrent dislocations unless revision surgery (a second operation) is done.

Studies show that most (two-thirds or more) of all dislocations after a primary hip replacement do, indeed, occur within the first year. There’s a fairly even pattern in the number of patients affected during each quarter of the first year. So, if timing is not the issue, then what’s causing these instabilities to develop?

Identifying risk factors for hip instability after primary total hip replacement is important in preventing these events. Reducing or minimizing risks is the first step to eliminating the problem altogether. It turns out there are quite a few possible risk factors such as older age, soft-tissue laxity (looseness), and weakness leading to loss of balance and falls resulting in dislocation.

Patients with other mental or physical problems are also at risk for hip joint instability. Alzheimer’s, dementia, Parkinson’s disease, alcohol and other drug abuse, and rheumatoid arthritis top the list. But there are some other risk factors that are less certain but for which some evidence has been presented. These include gender (female), body weight (being overweight), and decreased hip range-of-motion.

Many of these risk factors can’t be changed (or at least not easily). That leads surgeons to look elsewhere to find ways of reducing the risk of instability after surgery. Their own work then comes under scrutiny. Does the operative approach (making the incision from the front, side, or back) make a difference? Are the type and size of implants selected part of the problem? Does the use of a plastic liner inside the joint or position of the implant make a difference? What about length and depth of the incision?

Here’s what the evidence from studies shows so far:

In some countries with universal or nationalized health care, a joint replacement is considered an elective procedure. That means the person chooses to have the operation but it’s not an emergency procedure. So despite pain and loss of motion or function, that individual must wait in a queue (line) until the resources are available to them. This could take weeks to months. In the meantime, they are advised to stay active. What’s the best way to do that? Should patients exercise on land or in a pool? Is one better than the other? That’s what the researchers involved in this study wanted to find out.

Physical therapists from down under (Australia) compared patients with hip or knee osteoarthritis exercising either on land (group one) or in a pool-based program (group two) while waiting for surgery. The patients were randomized (randomly placed) into one group or the other. They were all found to be medically fit and able to exercise.

Both groups engaged in their respective exercise (land-based or pool-based) twice a week for six weeks. The sessions lasted one hour and were supervised by a physical therapist. Each exercise session cost $6.00 per patient. They were also asked to continue exercising at home at least three times a week for 30 minutes. Exercise could take any form: riding a bike, walking, or doing land-based exercises similar to what they did in class.

In addition to the exercise program, patients in both groups were given instruction (education) about their condition (advanced osteoarthritis). They were taught how to exercise safely. An occupational therapist visited their homes and helped them modify the environment for safety. Each patient kept a log or diary to show when, what, and how long they exercised at home throughout the follow-up period (15 weeks).

Results of exercise was measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Global Assessment of Change (GAC), a timed walk test, and a Chair Stand Test. Mental health was assessed using the Short Form-36 score. Pain intensity was recorded before each exercise class, immediately after class, and the next day.

The study was geared to look for differences between these two exercise forms when combined with education and home environment modifications. The data was analyzed to see if land-based exercise or pool-based exercise worked better for reducing pain and improving function. Was one form of exercise more effective in reducing disability? Did the patients tolerate one type of exercise easier than the other?

They found that either form of exercise had equal results. Land-based exercise was less expensive than trying to maintain a pool. It was also more readily available. Accessible pools designed for therapy with water warm enough for arthritic patients aren’t always easy to find. Some patients were sore after exercise, but there were no other major complications in either group.

The pool-group reported less pain right after exercise and into the next day. That may be a major advantage of pool-based therapy since pain is the main reason patients with advanced osteoarthritis don’t exercise. Most of the individuals in this study were obese, so pool-based exercise with its buoyancy may have been a benefit in reducing joint pain after exercise.

When they took a look at the participants daily diaries, they found a large percentage were compliant meaning they did exercise at home regularly. The home exercise sessions were usually 30 to 45 minutes long. The average person completed exercising at home three to four times a week during the initial six-week study period. This dropped off slightly to two to three times per week during the extended follow-up period. Reasons given for not exercising included not feeling well or not enough time due to other commitments.

The results of this study provided evidence that there are ways to manage arthritis pain for patients waiting to have joint replacements (either hip or knee). Understanding the disease condition, exercising, and modifying the home environment are three steps everyone can take to reduce pain and disability associated with this disease. These tips can help patients facing a long wait for their joint replacement surgery. But the study results also show that anyone with arthritis pain can benefit from these three simple ways to improve quality of life.

In this study, researchers from the Gait and Posture Lab at the University of Montreal in Canada compare walking patterns between patients who had a total hip replacement versus a surface replacement arthroplasty. An earlier study by Mont et al comparing these two groups reported a slower walking speed and decreased muscle force in the hip abductor muscle of the hip.

Results for the patients in the previous study were reported for six to 18 months after surgery. The effects of different implants on gait pattern were measured six to eight months after surgery in this study. The authors thought that a tighter time frame might give them a better way to compare these two patient groups.

Hip joint resurfacing was introduced several years ago to help younger patients who are more active and who would likely dislocate or wear out a total hip replacement. Surgeons found a way to replace the surface of the joint without removing the bone and replacing the entire joint. Bone is saved because the femoral head (round ball at the top of the thighbone) isn’t cut off. And it isn’t necessary to put a long stem down into the canal of the femur since the head isn’t replaced.

All of these features of joint resurfacing make it possible for patients to extend the life of their own joint before a full joint replacement is needed. There is also some thought that joint resurfacing may preserve a more normal load transfer during gait (walking). If that is true, gait recovery could be added to the list of advantages for joint resurfacing over total hip replacement.

The researchers repeated many of the study features of the Mont et al group but the shorter time period and closer attention paid to the speed of walking set this study apart. Since speed affects how people walk, this factor is important. Three groups of 10 subjects were compared. One group of 10 received a total hip replacement. The second group of 10 had hip joint resurfacing. And the third group was the control group — volunteers who were healthy and did not have any hip surgery. All 30 participants were similar in age, height, weight, and body mass index (BMI).

They tried to keep the surgical groups fairly simple in order to make clean comparisons. For example, no one in the surgical groups had any other hip or knee problems that could affect the way they walked. No one was obese, had a neurologic problem of any kind, or had back pain (all of which could also affect how they walked).

X-rays were taken before and after surgery and compared. Special computer software (Imagika) was used to measure various angles, centers of rotation, and differences in leg length between the operated hip and the other (normal) side. A daily rehab program under the supervision of a physical therapist helped patients regain motion and strength.

Each patient was evaluated individually and given a program that best suited their needs. Special attention was paid to the muscles surrounding the hip. All exercises were progressed over a period of 12 weeks until the patients could return to normal, unrestricted activities (including high-impact sports such as basketball, football, or hockey).

Their gait or walking pattern was measured using a special walkway that was 10 meters long and had two force platforms to measure pressure as the person put his or her foot down. Special cameras recorded overall motion (movement pattern) and length of each stride. A computer program analyzed the speed of walking and the rhythm. Together these two things are called the cadence. The therapist also used a handheld device called a myometer to measure abductor muscle strength on both sides. The abductor muscles help stabilize the hip when standing on one leg. The abductor muscles also move the leg away from the body.

Besides X-ray comparisons made before and after surgery, clinical outcomes such as function were compared using a well-known test called the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The results of all the measures taken and analyzed showed that the patients with hip joint resurfacing regained a normal gait pattern faster than the patients getting a total hip replacement. Patients in both groups still had weaker hip abductor muscles compared with the other side.

These findings confirm what other researchers have reported: restoring hip muscle strength after hip replacement is very important. It may be the key factor in gait recovery. That brings us back to the rehab portion of recovery. Several questions arise: is the standard rehab program enough? Do patients need to continue with supervised exercises for a longer period than the usual two-to-three month period of time? Are the exercises they are doing the right ones?

Studies are needed to compare different exercise protocols and find the best one for strengthening hip abductor muscles. But the authors point out that this is only one variable. Other studies have already pointed out that the less invasive nature of hip joint resurfacing still puts this method ahead of a total hip replacement in fostering faster recovery from the surgery. The more surgeons can preserve bone and spare the soft tissues, the better chance the patient has for revision surgery later.

The authors of this study point out that restoring hip biomechanics with careful reconstruction of the hip joint also goes a long way toward restoring normal gait and function. The exact placement of the hip center of rotation is important because it determines how well the abductor muscles can contract to move the leg during gait and other activities.

So for now, it seems that there are many reasons why joint resurfacing has advantages over a total hip replacement for younger, more active adults. In order to maximize these benefits, it will be necessary to continue studying all aspects of the implant design, surgical technique, and rehab protocols. The results of this study move us in the right direction of helping patients regain normal walking patterns including stride length and cadence as quickly as possible.