News Category: Hip

As more and more adults in the United States get total hip replacements, the number of revision (second) surgeries has also gone up. Experts say the reasons for this may be three-fold: patients are younger, many patients of all ages are more active, and implants aren’t designed to last long enough.

With more and more revision total hip replacements, Medicare and Medicaid have had to develop diagnosis and procedure codes for surgeons to use when billing for related services. The diagnosis codes now reflect possible causes of hip revision.

Some of the more common reasons revision surgery is needed include loosening or dislocation of the implant, fracture of the bone or prosthetic device, or other mechanical complication(s). Surface wear of the implant and breakdown of the bone around the implant are two other diagnosis codes available.

At the same time, all revision operations are not the same. The type of procedure done depends on the cause of the problem. In some cases, both parts of the implant (acetabular or socket side and femoral or round, ball at the top of the thigh bone) must be removed and replaced.

Sometimes just one of those components needs revision. If the surgeon has to remove part or all of the implant, it may be necessary to place a spacer to hold the joint in place until a new joint can be put in place. Some implants have a separate plastic liner that fits between the shell or acetabular cup and the femoral head. If this part gets worn or broken, it has to be removed. Each of these surgeries has a code of its own.

Researchers can now use these new codes to track what’s going on. How often are revisions needed? Who needs them? And why? Identifying common causes of failure and types of revisions will guide future research, especially designing better, more long-lasting implants. At the same time, tracking the type of revisions needed will help shape health-care policy.

Insurers and agencies such as Medicare who often pay for these procedures want to know if more resources will be needed in the future to cover the costs of hip revision procedures. Surgeons will be using this information to predict which patients are good candidates for total hip replacement.

This particular study looked at the data collected from over 51,000 total hip revision procedures performed in a single year (2005-2006). That was the first full year after the new codes were published. Information about each patient included age, sex, diagnosis, reason for implant failure, cost of the revision, and length of hospital stay. They also kept track of who was paying for the surgery and where the patient came from (geographical location).

All of this information came from a national database called the Nationwide Inpatient Sample. Each hospital enters this information about patients treated and discharged from their facility. After analyzing the data available on patients having a hip revision following a total hip replacement, the researchers looked for trends in diagnosis, frequency of each revision procedure, and patient characteristics.

Here’s what they found:

Patients are surprised after a total hip replacement by how much it can hurt those first few days. They do okay while sitting or resting, but once they get up to move: ouch! Surgeons are working hard to find ways to control that pain without using opioids (narcotics) with their many side effects.

A new approach has been started by some surgeons. That’s the use of nerve blocks for the first 24 to 48 hours after surgery. In this study, three types of post-operative pain control methods were compared. The first was the standard patient-controlled analgesic (PCA) using a self-administered pain pump. With the push of a button patients can dispense an opioid-based medication. In this study, they used a morphine derivative called hydromorphone.

The second group had a femoral nerve block along with PCA. The third group had a lumbar plexus block (also with PCA). All drugs were given for 48 hours. The nerve block was set up in the operating room after the spinal anesthetic that was used during the hip replacement surgery had worn off.

The block is administered by placing a needle (catheter tip) between the psoas muscle and the quadratus lumborum muscle in the hip area. This places the catheter tip close to the nerve being blocked and is referred to as a perineural placement of the catheter.

Correct placement of the needle was verified by injecting a dye in the area and using an X-ray to confirm proper positioning. The surgeons also used a second method to check the catheter. They connected the catheter to a nerve stimulator. By stimulating the nerve, they could cause a contraction of the muscle controlled by that nerve.

In this way, they made sure the right area was blocked. After that test was completed and the nerve stimulator was removed, then a one-time large dose of drug was injected in the area. The perineural catheter was used to infuse a low dose of numbing agent (ropivacaine) for the next 48 hours.

With a successful nerve block, the patients experienced a numb sensation (to cold and to pinprick) in the skin supplied by the sensory portion of the nerve being blocked. Muscle strength for the muscles affected by blocking the motor portion of the nerve(s) was also assessed. Most often the muscles controlling the hip and knee were affected.

Everyone in all three groups also got an injection of ketorolac while still in the recovery room. This nonsteroidal antiinflammatory was delivered directly to the muscles for pain control.

The real test of these pain control measures was in physical therapy. Pain was measured before, during, and after therapy while moving the hip and walking. Amount of hydromorphone used was recorded. And any side effects such as nausea, vomiting, itching, difficulty breathing, or delirium were also noted.

The authors report the best results occurred when using the lumbar plexus block. As suspected, pain control while at rest wasn’t the issue. The real problem came when patients tried to move the hip. Patients who had the lumbar block had less pain. With less motor block they could walk farther. And they used less hydromorphone for successful pain control, so there were fewer side effects preventing movement. And in the lumbar plexus block group, twice as many patients as in the femoral nerve block group used no opioid at all for the entire 48-hour test period.

The use of PCA alone was linked with more serious cases of delirium or confusion. The PCA group also suffered more negative side effects compared to the groups receiving PCA with a nerve block. Opioid-related side effects were more common in the femoral nerve block compared with the lumbar plexus group. Patients in the lumbar plexus group also rated their satisfaction higher than patients in the other two groups.

The authors made note of the fact that these post-anesthesia blocks were performed in a special care unit in the hospital. This makes it possible to move patients along without holding up the operating room for the next patient. This may be important for private hospitals with concern for improving efficiency and cost-cutting measures (compared with university or teaching hospitals).

In either setting, the use of continuous nerve blocks after surgery for a total hip replacement was quite successful. Continuous lumbar plexus block combined with PCA seems to offer better pain control and faster return of function than PCA alone or with femoral nerve block with PCA.

Some athletes are bothered by a painful snapping at the hip when moving the leg from a flexed to an extended position. There can be a variety of reasons why this happens. Some occur outside the joint such as when a tendon rubs over a bony prominence. Others are caused by something going on inside the joint. It could be a tear in the labrum (rim of cartilage around the hip socket) or a loose fragment inside the joint.

Whatever the cause, treatment is needed to help the athlete get back into action. The question the researchers asked in this study was Can athletes with painful snapping hips return to full sports participation after treatment? And in this case, the treatment was arthroscopic release of the iliopsoas tendon.

Fifteen recreational and competitive athletes were treated and tested. All had painful snapping hip syndrome from the iliopsoas tendon rubbing over a bony bump called the iliopectineal eminence. At first, they had conservative care with rest, stretching exercises, and antiinflammatory drugs. Everyone was treated nonoperatively for at least six months.

When that didn’t relieve their painful symptoms, they had an ultrasound test to confirm the source of the problem. In about half the cases, they found it was from a snapping of the psoas tendon. In the other half, there was snapping of the tendon seen along with fraying or a tear of the labrum. Then the surgeon injected the iliopsoas bursa with a numbing agent.
When that didn’t work, the surgeon performed an arthroscopic release of the iliopsoas tendon. The authors describe the surgery briefly. They make note of the fact that details of the operation (including photos) have been published in a previous article.

The basic procedure cuts the tendon from where it is attached to the lesser trochanter. The lesser trochanter is a bony bump on the upper part of the femur (thigh bone). The surgeon uses a special imaging device called fluoroscopy to see what’s going on and make sure of an accurate release of the entire tendon. For those patients with a labral tear (or other soft tissue damage), the surgeon made all necessary repairs of torn tissue.

Afterwards, all the patients were given post-operative instructions about what to expect and how to proceed through rehab. It’s normal to have a loss of hip flexion until the tendon reattaches to the surrounding soft tissue structures. This takes about two to four weeks. Until healing takes place, motion and strength are both affected.

Control of the leg and coordination during movement were also impaired. Putting weight on the leg and walking would take some time. They were told not to rush it, but to use crutches or cane(s) until normal movement was restored. Most athletes were able to resume normal motion by the end of 10 weeks. With the help of a physical therapist, they advanced through a sport-specific rehab program. The focus was on regaining normal (pain free) motion and control.

A year after the procedure, all 15 athletes had full motion, full strength, and normal sensation. There were no complications and no limitations in sports participation. This compares favorably with the results of previous studies of patients undergoing a partial release of the iliopsoas tendon. Reports of persistent pain, recurrent tendon snapping, and loss of sensation from cutting through nerves are common after partial release.

The authors conclude that arthroscopic release of the iliopsoas tendon for snapping hip syndrome is safe and effective. The arthroscopic approach reduces complications such as nerve injury and infection that can occur with an open incision.

Arthroscopy also made it possible to identify additional soft tissue damage requiring repair. These tears would not have been observed with open incision techniques. With relief of painful symptoms, athletes were able to return to their previous level of sports participation. Relief of painful snapping was permanent with no cases of recurrence.

In this study from Italy, researchers examine the type of hip fractures that occur in Parkinson patients. They offer suggestions for hip fracture prevention in this particular group of patients. This is important because Parkinson disease leaves patients with poor balance, rigidity, loss of arm movements, and a tendency to fall backwards or sideways. All of those factors increase the risk of falling and hip fractures. Finding ways to reduce the risk of falls and fractures in Parkinson patients is the goal.

They started with a group of over 1,000 patients who suffered their first hip fracture ever. The patients with Parkinson disease (38 total) were pulled out and put in their own separate group. A second (control) group was made up of an equal number of patients from the main group with hip fractures. They were matched by age, sex, and type of fracture. No one in the control group had Parkinson disease. No one in either group was a smoker.

The hip joint is one of the true ball-and-socket joints of the body. The hip socket is called the acetabulum.It forms a deep cup that surrounds the ball of the upper thighbone, or femoral head. The femoral head is attached to the rest of the femur by a short section of bone called the femoral neck.

A bony bump on the outside of the femur just below the femoral neck is called the greater trochanter. A smaller bony bump on the femur called the lesser trochanter is located on a diagonal from the greater trochanter. These two bumps on the femur are where some of the hip muscles attach.

There were two main types of hip fractures investigated: trochanteric and cervical. All were caused by a fall. A trochanteric hip fracture occurs in or around the greater or lesser trochanter. This type of fracture is considered extracapsular (outside the actual hip joint).

A cervical hip fracture is intracapsular (inside the hip joint) affecting some part of the actual hip socket or the top of the femoral head. In the general population, trochanteric fractures are typically linked with more severe osteoporosis (poor or low bone mineral density). It appears that trochanteric fractures occur more often in patients who have lower bone thickness.

Everyone in the study had bone mineral density testing done of the uninvolved hip. Four areas were tested: the top of the femur, the femoral neck, the trochanteric area, and the intertrochanteric region (between the greater trochanter bony bump and the lesser trochanteric bump).

They found similar results between the Parkinson group and the control group. Remember, the control group represents patients with hip fractures who don’t have Parkinson disease. Levels of bone mineral density leading to hip fractures were similar in both groups. Trochanteric hip fractures were more common than cervical hip fractures. Bone mineral density was much lower in all patients (both groups) with trochanteric fractures.

Based on this information, the authors suggest several preventive steps for hip fractures in Parkinson patients. First, bone mineral density testing is important. Anyone with Parkinson disease who has low bone mineral density should be taking medication (bisphosphonates) for this problem.

Second, vitamin D supplementation has been shown effective in reducing hip fractures (both in the general population and for Parkinson patients). Vitamin D deficiency is common in patients with Parkinson disease, so this recommendation is doubly important.

And third, medication to control the Parkinson symptoms and an exercise program to help with balance disturbances and falls prevention are important. People with Parkinson disease are twice as likely as others their same age to have a hip fracture. Increasing age is a risk factor in all people. These two variables added together are a bad recipe for falls and fractures. A little prevention could go a long way in reducing falls and injuries from falls.

More and more people are experiencing hip pain. Whether you are a sports athlete or an aging adult, protecting your hip joints is important in preventing hip pain. This is especially true for a condition called greater trochanteric pain syndrome (GTPS); also known as hip bursitis.

The greater trochanter is the large bump on the outside of the upper end of the femur (thigh bone). This bump is the point where the large buttock muscles that move the hip connect to the femur. The gluteus maximus is the largest of these muscles. It attaches lower down on the femur.

If you lie on a hard surface for very long, you will feel the effects on your greater trochanter. Where friction occurs between muscles, tendons, and bones, there is usually a structure called a bursa. A bursa is a thin sac of tissue that contains fluid to lubricate the area and reduce friction. The bursa is a normal structure. The body will even produce a bursa in response to friction.

Sometimes a bursa can become inflamed (swollen and irritated) because of too much friction or because of an injury to the bursa. An inflamed bursa can cause pain because movement makes the structures around the bursa rub against it.

Inflammation in the bursa between the tendon and the greater trochanter leads to greater trochanteric pain syndrome. This problem is common in older individuals. It may also occur in younger patients who are extremely active in exercises such as walking, running, or biking.

Friction can build in the bursa during walking if the long tendon on the side of the thigh is tight. It is unclear what causes this tightening of the tendon. The gluteus maximus attaches to this long tendon. As you walk, the gluteus maximus pulls this tendon over the greater trochanter with each step. When the tendon is tight, it rubs against the bursa.

The rubbing causes friction to build in the bursa, leading to irritation and inflammation. Patients with this problem report pain along the lateral (outside) of the hip, although the hip joint itself is not involved. The pain may radiate down the lateral aspect of the thigh. Friction can also start if the outer hip muscle (gluteus medius) is weak, if one leg is longer than the other, or if you run on slanted or uneven surfaces.

What can be done about this problem? Well, prevention is the first step. A proper relationship between the joint surfaces and muscle to joint interface is important. Good alignment means good joint integrity and normal range-of-motion. Leg alignment and symmetry is a big part of posture and alignment needed for normal biomechanics.

The foot is a good place to start when lining up the legs, hips, pelvis, and spine. Proper shoes that distribute the weight evenly over the foot and up into the legs is important. Athletes in training should especially pay attention to how many miles they put on a shoe and replace them often. New shoes should be purchased when the athlete has met the shoe manufacturer’s limits on the lifespan of each pair of shoes.

Once the foot is in a stable, supported position of alignment, the entire kinetic chain (connection and force spread from foot to ankle to knee to thigh to hip) is supported. This is a large part of the prevention program. Core training is the next step. Strengthening the muscles of the spine, abdomen, and hips can help prevent hip pain.

If this type of conservative care does not help reduce or eliminate the patient’s pain, then more direct medical intervention may be needed. The patient might benefit from nutritional supplements or even steroid injections into the hip. The injections contain a numbing agent and an antiinflammatory. Pain relief is possible in some patients with one or two shots to deposit the active ingredients into the largest hip bursa (located between the iliotibial band and the underlying gluteus medius muscle).

Physical therapy may be prescribed. The therapist will guide you in strengthening the appropriate muscles, including core training. Stretching the overlying soft tissue structures makes sense. Relieving tension in the structures around the greater trochanter reduces friction leading to the pain syndrome. The therapist has several other tools to help realign structures for pain relief.

If all of these techniques have been tried without success, surgery may be a final option. If there is a tendon tear, it is idébrided (cleaned up) and repaired. If the bursa is torn or frayed, the area can also be débrided. The surgeon can even shave the bone down around the greater trochanter to reduce pressure and friction causing painful symptoms. This procedure is called a reduction osteotomy.

During arthroscopic surgery, the surgeon can take a look at all the structures in and around the hip joint. Any loose fragments of cartilage, torn ligaments, or damaged cartilage can be removed or repaired. The surgeon can look and see if the bursa is inflamed or if tendons need débriding or repair.

A rehab program follows surgery. The program is much like what is done to prevent hip problems from occurring. Any muscle imbalances are addressed along with correction of any alignment issues. Core training and stretching of the muscles and iliotibial band along the outside of the thigh are key parts of the rehab program.

Patients who exercise regularly must be advised to follow a program of cross-training paying attention to shoe wear and surfaces they run or walk on. Older adults with signs of arthritis may want to try taking nutritional supplements such as glucosamine and chondroitin. There is some evidence that this approach can be helpful in restoring the joint surfaces.

Pain in the groin or buttocks with a loss of hip motion requires special attention. Early diagnosis and treatment is imperative to avoid degenerative changes in the hip joint later in life. There are many possible causes of this type of hip pain. In this article, surgeons from the Rochester, Minnesota Mayo Clinic focus on femoroacetabular impingement (FAI) as a cause of hip pain leading to hip osteoarthritis.

Femoroacetabular impingement (FAI) describes a condition where the top of the femur (thigh bone) pinches the rim of the hip socket. The area that gets compressed is referred to as the acetabular rim. This type of impingement occurs most often when the hip is flexed and internally rotated.

For a long time, it was believed that FAI only occurred in people with some kind of abnormal anatomy of the hip. There was either a backward tilted angle of the hip socket called retroversion, a larger socket than the ball (head of the femur) inside the socket, or flattening of the femoral head. One type of abnormal shape of the hip was labeled a pistol grip because of the resemblance to the grip of a handgun.

More recent studies have shown it’s possible to develop FAI even when the hip structure and anatomy are essentially normal. But, in general, more people with acetabular retroversion end up with hip replacements because of osteoarthritis than any other anatomical abnormality.

To get to the bottom of the cause of hip pain, a thorough history and examination are required. The surgeon looks at foot position, leg angles, leg length differences from one side to the other, hip motion, and muscle strength. Gait (walking) patterns are evaluated. Special tests such as the impingement test are done to identify the presence of an underlying FAI as the cause of the painful symptoms and restricted motion.

In the impingement test, the patient is lying on his or her back. The examiner flexes the involved hip and internally rotates the leg while at the same time moving the foot away from the body. This last motion is called hip abduction.

Limited joint motion and/or painful motion are signs of FAI. The further the hip is flexed, the more it hurts. Comparing hip motion from side to side may be helpful, but only if the patient doesn’t have the same anatomical changes on both sides.

A second test for posterior impingement can also be done as part of the exam. This test is used to identify pinching of the cartilage along the back side of the acetabulum (hip socket). It is performed by quickly moving the leg into extension and external rotation while the patient is lying on his or her back. The leg to be tested starts in a position dangling off the end of the table. The patient holds the other leg up against the chest in a flexed position. A positive test is indicated by pain in the groin during the test movement.

X-rays, CT scans and/or MRIs may be used to confirm the diagnosis. A special type of MRI called magnetic resonance arthrography (MRA) is becoming very popular. A contrast dye is injected into the hip joint. The dye is absorbed by any areas of damage or degeneration of the cartilage. The surgeon can see if the femoral head has shifted position and/or is stable. Sometimes, a defect in the cartilage is large enough that the femoral head falls into the hole created by the lesion. An MRA would show this type of change.

Another newer type of MRI technique allows the surgeon to see the femoral head and neck and the position of each in relation to the acetabulum. The MRI takes pictures in a 360-degree rotation from above the femoral head. The surgeon can use this information to decide how to reshape the bone during surgery.

X-rays are particularly helpful in seeing structural abnormalities of the bones that can contribute to FAI. Any signs of osteoarthritis (e.g., bone spurs, loss of joint space, cystic changes) are used to classify the condition as grade zero, one, two, or three (no evidence of osteoarthritis to severe osteoarthritis).

Shape and angle of the femoral head and acetabulum can also be visualized on X-ray. The type of impingement can be identified. For example, a comparison of the size of the femoral head to the size of the socket can be made on imaging. Too-large of a socket for the size of the femoral head causes overcoverage. When the leg is flexed past 90 degrees, the femoral head and neck bump up against the pelvic rim (labrum. This is called pincer impingement. Left untreated, the patient can end up with a damaged (torn or degenerated) labrum and even more pain.

A second type of FAI occurs when the pistol grip-shaped femoral head jams into the acetabulum. This is called cam FAI. Many patients have both types of impingement. Women are more likely to have pincer impingement.

The results of all of these tests are important pieces of information when deciding on the best treatment approach. Surgery is often recommended. The surgeon uses all of this information when choosing the best surgical option. The choices include surgical hip dislocation, periacetabular osteotomy, and hip arthroscopy.

Surgical dislocation refers to taking the femoral head out of the socket and making adjustments and repairs as necessary and then putting the head back in place. The operation can be done without cutting through the muscles and with the least amount of trauma possible. Any damage to the labrum can be repaired. Any problems with femoral head and neck mismatch with the acetabulum can be taken care of. This type of surgery allows for preservation of the joint, which is important in young, active adults.

Periacetabular osteotomy corrects the retroversion (determined by a positive test for anterior impingement). The capsule surrounding the hip joint is cut open. The femoral head and neck are reshaped by shaving or cutting off portions of the bone. The goal is to correct the placement of the femoral head in the hip socket.

The third surgical option (hip arthroscopy) to treat FAI allows the surgeon to gain access to the inside of the joint without cutting it open. This avoids pulling the femoral head away from the socket. Arthroscopic surgery also makes it possible to reattach (rather than remove) a torn labrum.

Studies reporting on the results of these three surgical options have helped determine when each procedure is the best choice. For example, surgical hip dislocation works very well for patients with early disease (grades 1 and 2). But this method cannot be used when the femoral head has shifted into the cartilage defect.

Hip arthroscopy works well for some, but not all, patients. Reaching areas in the posterior or back portion of the joint isn’t easy. Open surgery works much better for that. Reattaching the labrum on the back side of the acetabulum is especially difficult with arthroscopy. Certain types of abnormal hip anatomy make it technically difficult to make necessary labral repairs. And entering the hip joint can be very challenging if the patient is obese.

One distinct advantage to all three of these treatment techniques is that conversion is still possible if the procedure fails. Conversion refers to having a second surgery to give the patient a total hip replacement.

Hopefully, with early diagnosis and treatment of young, active patients with FAI, conversion won’t be needed. Managing the problem by restoring as normal hip anatomy as possible is the first step. In the future, the arthroscopic approach may become the gold standard. But for now, surgical hip dislocation is still the most commonly used surgical approach for FAI. It is used with good success for patients with mild to moderate (but not severe) degeneration of the joint cartilage, surface, and surrounding capsule.

Fatigue fractures, also called stress fractures, are caused by overusing a limb. The muscles become unable to absorb the shock to the limb (usually the leg) and the bone itself begins to take the brunt of it. Because the bone isn’t built for this, it eventually cracks. However, the elderly can also develop fatigue fractures but they aren’t caused by over use, rather they are usually caused by insufficiency, meaning there isn’t enough muscle to help protect the bones.

The authors of this article reviewed a patient who had a fatigue fracture. A 61-year-old woman was complaining of right hip pain but hadn’t fallen or had any type of accident that may have caused it. She was still able to walk and function. The doctors did find pain and some swelling in the hip joint and, while the hip moved well upwards, moving it out and in was impossible due to the pain the movements caused. X-rays and magnetic resonance imaging (MRI) then confirmed that there was a fracture, which was diagnosed as a fatigue fracture.

The patient was operated on and was able to resume her normal state of functioning after two months and she felt back to normal after four months.

There were many theories about what caused fatigue fractures in older patients, from muscle fatigue and loss to new and different activities. One researcher, Pentecoste and colleagues, came up with three common characteristics of patients who sustained fatigue fractures of the hip. They were: new and different activity, strenuous activity, or repeated activity, making the same motions over and over. In this patient’s case, the authors felt that her job as a cleaning lady for the previous five years could have been the cause, given the bending and squatting she had to do in the course of her day.

When doctors are assessing patients with hip pain but the patients aren’t limping nor are they in any significant pain, they must keep in mind that fatigue fractures are so subtle that they may not even appear in the x-ray. Therefore, it would probably be a good idea to follow up the x-ray with an MRI or a bone scintigraphy (a test that uses dye to look at the bone).

The hip fatigue fracture has been divided into three classifications: tension, compression, and displaced. Displaced fractures mean that the bone has moved. A group of researchers, Devas, Bickenstaff and Morris, and Fullerton and Snowdy, recommended that patients with compression-type fractures not undergo surgery, as well as those who had tension without opening (in the bone). If the tension fracture did have opening or the patient had a displaced fracture, then surgery would be recommended. Another option is traction and bedrest for some types of tension fractures.

The authors didn’t feel that these recommendations fit their particular patient because the recommendations were based on younger patients and only with one side of the joint fractured. Their patient had a bilateral fracture, which meant two sides were broken on the bone. There is also a concern about leaving an older patient on bedrest for long periods of time, at least three weeks, as this can cause other problems and delays in overall healing.

As with all surgeries, there are complications associated with hip surgery. These include the bones not joining (nonunion), refracture, or bone death of the femoral head, the ball of the hip joint. However, statistics aren’t too reliable as several researchers have come up with differing findings as to how often these occur.

In conclusion, the authors wrote that they recommend surgery for older patients with bilateral hip fatigue fracture and that if a fatigue fracture is suspected, x-rays should be followed by an MRI for clarification.

Finally, patients get a chance to ask whatever questions they like of their surgeon before having a total joint replacement. If you are thinking about getting a new hip or knee, you’ll find the information in this article helpful. Surgeons from two well-known hospitals take a look at questions such as these:

Hip fractures, a very serious injury for the elderly, often occur because the person has thinning bones due to osteoporosis. The other most commonly broken bones in this group of people are the wrist and the vertebrae, the little bones in the spine.

Doctors and researchers have been working on ways to strengthen the bones of patients who had had a hip fracture as a result of thinning bones and studies are finding that treatment with a bisphosphonate, a medication that is given by intravenous in this case, reduces the risk of another fracture.

The authors of this study wanted to compare the rates of osteoporosis treatment, how often it was prescribed, by the orthopedic team and by the primary doctor. To do this, the researchers recruited 62 patients who had surgery for hip fractures. Thirty-one patients were in the intervention group that received medications and 31 were in the control group that didn’t receive medications. The patients all filled out questionnaires and they and their families or caregivers were given a 15 minute class on hip fractures, fracture prevention, and osteoporosis.

Patients in the intervention group had an osteoporosis evaluation while they were in the hospital. They were also given calcium and vitamin D3 to take daily when they were discharged. They had follow-up visits scheduled with an orthopedic surgeon for two to four weeks after surgery. There, the patients were evaluated again and then started on a medication called risedronate for osteoporosis. The patients in the control group also took the calcium and vitamin daily, but when they were discharged, they were only given instructions to call their own doctor for follow up and an osteoporosis evaluation.

The results of the study showed that the patients who saw the orthopedic surgeon were much more likely to receive osteoporosis treatment than if they went to a primary care doctor. All the patients in the control group (24 by the end of the study) did see their primary doctor within six months of the fracture and 95 percent went to see their orthopedic surgeon. But only 39 percent of the patients remembered the primary doctor talking about osteoporosis. None of the control group remembers discussing osteoporosis with their orthopedic surgeon.

Still with the control group, one patient had another within the six months but didn’t begin osteoporosis treatment until after the second break. Seven patients had a dual x-ray absorbtiometry scan, a test that measure bone density and eight began bisphosphonate medication. At the end of six months, only seven of the control group were taking the medications.

Things were quite different in the intervention group. None of the patients in this group (26 by study end) had another fracture within the six months, 26 had the bone density measuring test. Twenty began taking medication for osteoporosis following the fracture and the remaining six couldn’t because of transportation issues. Five stopped taking the medications. At the end of six months, 15 of the group were still taking the medications.

In conclusion, the authors pointed out that the patients who were followed by orthopedic surgeons had a higher osteoporosis treatment rate than those who were followed by their primary physicians. This shows that this evaluation and treatment may improve the overall rate of recurrent hip fractures due to osteoporosis

Hip fractures can be devastating for seniors. A once independent person can end up with a series of medical issues following a broken hip. An intertrochanteric fracture of the hip is the less severe of the hip fractures. If someone breaks the hip further up, there can be problems with blood supply to the bones and leg, while this isn’t the case with an intertrochanteric fracture. This area is rich in blood supply, so keeping the bones healthy isn’t usually something that doctors need to worry about. These are easier to repair in most cases, as well.

The usual approach to repairing an intertrochanteric fracture is by stabilizing the hip or by putting in a replacement, a prosthesis. One of the problems that surgeons often come across, however, is the weakness of the bones surrounding the fracture. Bones must be strong enough to withstand the hardware used to stabilize the bone or for the insertion of the prosthesis, as well as being able to hold in place when the patient begins to walk again. Other issues that may cause problems include previous hip injuries, osteoarthritis, the type of break, and other medical problems the patient may have.

When orthopedic surgeons discuss intertrochanteric fractures, the fractures are classified as stable or unstable. If a fracture is comminuted, or the bone has shattered or broken into tiny pieces, this is an unstable fracture. However, despite this division of stable versus unstable, there is no clear cut agreement among surgeons as to how best treat this type of fracture. The authors of this study examined the medical literature to find the best studies that examined this issue and gathered them together into this review.

Hip fractures can be treated with either surgical or non-surgical (conservative) treatments. Since surgery is the preferred way to manage a broken hip, non-surgical treatments are usually only done if a patient is not a good candidate for surgery, usually because of health problems. The authors found a study of 106 patients, by Hornby and colleagues, that looked at patients who underwent traction and compared them with patients who had surgery to have a screw implanted into the hip to repair the fracture. At the end of the study, the researchers recommended that surgery be performed, if at all possible. Although the complication rate was low in both groups and there wasn’t much of a difference in the levels of pain or discomfort, the patients who had surgery were out of the hospital faster than those who had traction. As well, those who had traction had a higher rate of losing independence after six months than did those who had surgery.

Another study of 150 patients also compared traction with surgery, but this surgery involved removing bone. The researchers in this study had what they called “excellent” results from surgery, but the important thing to note is that the nursing care must be of a very high standard in order to prevent problems, such as pressure sores in the skin, blood clots in the legs, and other problems that can arise when a person is bed ridden for long periods of time.

The authors of this article found a retrospective study, looking back at patients who have already been treated, which examined mortality rates in patients treated for this type of hip fracture who were treated with surgery or non-surgically. The results showed that patients who had surgery had a lower mortality rate than did those who were treated without surgery, overall. But, if the patients who didn’t have surgery were mobilized early, being moved from the bed to the chair and back, their mortality rate dropped to that of patients who had surgery.

One advantage, if there can be an advantage, of this type of hip fracture is the bone area is usually strong enough for good repairs. By applying screws and plates, this type of implant can be successful. Repairs using the inside of the bone, intramedullary , appear to be useful for stable fractures. What this means is a nail or screw is inserted into the bone for stability. Extramedullary repairs use plates along the outside of the bone and are used more often for unstable fractures

In 1991, Bridle and colleagues investigated 100 patients with 41 stable hip fractures. The patients received either a nail for repair or a screw. When the results were analyzed the researchers found no difference between the patients in terms of how long their surgeries took, how much blood they lost, how long they stayed in hospital, nor their ability to move about six months after the surgery. These findings were repeated in another study by two other researchers, Radford and Saudan, and their teams.

More studies include one done in 2001 by Adams and colleagues, who compared the use of a nail and a screw with a side plate. They studied 400 patients. Although there was a slight disadvantage with the patients who received the nails over the screw and plate, there wasn’t enough of a difference for it to be significant. Importantly, the outcome at one year after surgery was the same in both groups.
Several other studies had very similar outcomes.

The authors then reviewed the surgical outcomes, which involved how long it took to perform the surgery (surgery times), loss of blood during surgery, and how quickly and effectively patients were able to ambulate, move about. Surgery times appeared to be very similar between the intramedullary and extramedullary repairs, although there were some studies that found surgeries using sliding hip screws could take longer than others. Blood loss was the same in the surgeries, but two studies did find less blood loss with intramedullary repairs and one said there was less blood loss with the dynamic hip screw repair.

Some patients did experience a fracture in the femur (thigh bone) when intramedullary nails were used, but the researchers found that these were likely due to surgeon inexperience and hardware problems. The rate of fractures has gone down with new designs of nails. Other complications included the bones not healing, but the incidence was about the same in all groups.

Getting patients up and moving following a hip repair is vital for their overall health. Several studies found that all of the discussed treatments were the same in terms of how long it took for patients to begin ambulating again. The authors concluded that there is no agreement among surgeons as to the best way to treat intertrochanteric fractures, but they do recommend the surgical approaches described above.

If repairs aren’t possible in the above-mentioned ways, the alternative is to use a hip replacement or prosthesis. For these types of fractures, replacements are not the first choice treatment because of the location of the fracture. Therefore, the surgery is more complex. It may, however, be a good option for patients who do have a degenerative arthritis or if the fracture resulted in shattered bone.

A study done in 2005 by Kim and colleagues found that there were no differences after surgery between patients who had a cementless replacement and those who had a nail repair called a proximal femoral nail (PFN). However, during surgery, patients who had PFN had a lower rate of blood loss, need for blood transfusions, and mortality rates. Another study found similar findings for after surgery, but also found that the patients who had replacements needed more blood transfusions than those who had screws.

A study that examined patients who received an implant called a bipolar hemiarthroplasty or an internal repair, found that the patients who had the implant recovered more quickly and had lower post-surgery complications, such as pressure sores or breathing problems.

To summarize the article, the authors wrote that surgery for hip fractures is improving due to new and improved techniques and hardware. Surgeons are becoming more familiar and experienced with the available technology and their ability to decide which patients require which surgery. However, because of the wide variety of patients, their fractures, and their medical histories, it doesn’t seem possible to recommend one specific type of surgery over another.

In Finland, information collected about patients with total hip replacements (THRs) is put into the Finnish Arthroplasty Registry. Researchers can draw data from this databank to study various things about THRs. Today, nearly 98 per cent of all Finnish patients with THRs are included in the registry.

In this study, success rates of THR based on age and type of implants used were the main topics. Over a period of nearly 25 years (from 1980 to 2004), there were 50,968 patients in the registry who had their first total hip replacement. Success rates were defined by survival of the implant. Excessive wear and/or loosening of the implant requiring a revision (second) operation was defined as the end-point for survival (failed implant).

To qualify for this particular study, the patients had to be at least 55-years-old at the time of the operation. They all had osteoarthritis (OA) as the main reason for a hip replacement. The choice of implants included in the study was limited. It had to be one that was used in more than 50 hips during that time period. Any implant that had already been shown to have poor results in previous studies was not included.

The patients were divided into three groups by age: 1) 55 to 64 years old, 2) 65 to 74 years old, and 3) 75 and older. They were classified two different ways based on implant type. The first classification method included four groups:

Fractures (especially hip fractures) from osteoporosis (brittle bones) are on the rise worldwide. In fact, hip fractures are expected to increase by 200 to 300 percent in men and women around the world.

There is a drug treatment for osteoporosis. Bisphosphonates such as alendronate (Fosamax) or risedronate (Actonel) help slow down how fast the bone is resorbed (destroyed). Everyday new bone cells are formed and old bone cells are resorbed or destroyed. During childhood, new bone cells are formed faster than old ones are destroyed. In the aging adult, resorption exceeds formation.

Despite the number of older adults with osteoporosis and even a history of hip fracture, not very many people are taking these medications. And for those patients who do have a prescription, taking it on a regular basis is not consistent.

In this study from Belgium, the problem of adherence is presented as a major challenge in the treatment of osteoporosis. Adherence includes both treatment persistence (taking medications over a long period of time) and treatment compliance (taking the drug correctly).

Treatment persistence and compliance are important because the risk of a second hip fracture after the first is very high. Taking bisphosphonates reduces that risk. The mortality (death) rate after a hip fracture is also high (up to 50 per cent). And for those people who survive the fracture, half will never walk unassisted again and 25 per cent end up in a nursing home.

Postmenopausal women hospitalized with a hip fracture were included in this retrospective study. Retrospective means the medical records were reviewed after treatment was over. All women in the study received Alendronate (Fosamax) for one year. The main measures assessed were treatment persistence and treatment compliance.

There were three groups based on when they took the medications (daily, weekly, or switch). Weekly doses are packaged with enough pills for each month (referred to as weekly monthly) or for each quarter (weekly quarterly packaging). Switch is a label for patients in the daily group who went to a weekly dose and patients in the weekly group who changed from the monthly to quarterly packaging system.

The authors used a simple calculation of medication possession ratio to measure compliance with treatment. The daily dose delivered during the first year was divided by 365 (number of days in the year). The daily dose delivered was determined using initial drug purchases and refill dates. A ratio of 80 per cent or more was considered good compliance. Anyone with a ratio less than 80 per cent or who stopped taking the drug was labeled as noncompliant.

Three important facts were uncovered with this study. First, only six per cent of patients who had a hip fracture even received anti-osteoporosis treatment. The use of bisphosphonates accounted for two to three per cent of that total. Second, the death rate was decreased by two-thirds for those patients taking the bisphosphonates.

And third, the compliance rate was 80 per cent or more in less than half of the patients (48.7 per cent). Many women (60 per cent) took it inconsistently with gaps of more than five weeks at a time. It didn’t seem to matter whether patients took the drugs daily or weekly. The medication possession ratio was the same for all three groups.

The authors report a situation of undertreatment and poor compliance with treatment for a medication known to be successful in preventing hip fractures. Although, in theory, prevention of hip fractures is possible with bisphosphonates, in practice, this isn’t happening.

The authors suggest several possible reasons for the gap between evidence-based treatment guidelines and treatment. First, there may be the mistaken idea that once a fracture has occurred, it’s too late for drug therapy. Second, with patients seeing more than one physician, it’s not clear who should treat the osteoporosis. Sometimes the condition of osteoporosis isn’t even identified (even after a hip fracture). Without a diagnosis, no treatment occurs.

Patients may be partly responsible for the lack of treatment. Medications may be prescribed but not purchased due to a lack of money. Or they may be purchased and then discontinued later due to side effects. Some patients stop taking their bisphosphonates because they don’t understand why it’s important to take these medications as prescribed over a lifetime. Since there aren’t very many (if any) obvious symptoms of osteoporosis, it’s easy to think, I don’t really need this drug.

The new and improved dosing (one pill each month instead of daily pills) may help improve adherence and reduce the rate of hip fractures. National programs to cover the costs may help improve drug compliance. Such a program would be in the interest of everyone since the cost of treating hip fractures runs into the billions each year. And most of the medical costs linked to osteoporosis are caused by hip fractures.

Primary care physicians are more likely to see patients on a long-term basis. It makes sense that they will be the ones to diagnose osteoporosis and initiate treatment for their patients. Close monitoring of treatment compliance is advised given the low medication-taking behavior shown in this study.

Exactly how to achieve better patient compliance to an anti-osteoporosis therapy program is unclear. Future studies are needed to improve the number of older adults who receive bisphosphonate medications and who follow the drug therapy program for osteoporosis.

A group of orthopedic surgeons from four well-known orthopedic clinics took the time to review available studies on hip fractures. In this report, they summarize the evidence around treating femoral hip fractures. The information was gathered from the Cochrane database and the Scottish Intercollegiate Guidelines Network (SIGN) database. Both of these organizations are well respected for their critical reviews of the literature.

The concern about treating hip fractures is very timely. More adults are reaching age 65 and older — a time when falls and fractures are so common. And with the increasing number of people expected to reach this age in the next 20 to 30 years, we may expect to see more and more of this kind of injury.

Femoral neck fractures were the focus of this study. There are two basic types of femoral neck fractures: nondisplaced and displaced. Nondisplaced means the bone is broken but the fracture line has not separated. Displaced refers to the fact that the two sides of the broken bone have moved apart and no longer line up.

Both types of fractures, their assessment, and their treatment are discussed. Nondisplaced fractures can be handled nonsurgically (conservative care) or with surgery. The decision is made based on severity of the fracture, the patient’s general health, mental status, and function before the fracture.

Some people aren’t stable enough medically to undergo surgery with the anesthesia or to face the possible complications from the operation. If the patient isn’t in pain and/or the patient has dementia, nonoperative care may be the best choice. There are no surgical complications to further compromise their health.

But nonoperative care comes with a high death rate (90 per cent within the first year). Mortality is linked with pneumonia, pressure ulcers (bed sores), and pulmonary emboli (blood clots to the lungs). Sometimes conservative care is tried but later the patient has to have a total hip replacement. Such cases are referred to as conversions.

Surgery is almost always required to repair a displaced femoral fracture. The risk of nonunion and osteonecrosis (death of bone) is too great without repair of the injury. Surgical fixation is also advised for anyone who is active and mobile. The longer a person is immobile, the greater their risk of problems from blood clots and bed sores. But the surgeon must weigh the risks of surgery, too. Patients can develop wound infections after surgery or complications from the anesthesia.

Surgery for a displaced femoral neck fracture can include: 1) closed reduction and internal fixation (ORIF), 2) hemiarthroplasty (partial hip replacement), and 3) total hip replacement (THR). The authors review each of these options and compare them to one another.

In the case of internal fixation, they tried to find out if one method works better than another. Type of screws (or other fixation used), placement of internal fixation, need for hardware removal, and complications such as nonunion and osteonecrosis were reviewed.

They also looked at surgical times, amount of blood loss, rate of wound infection, and reoperation rate. There was no significant difference from one group to another. It didn’t seem to matter if they used screws, smooth pins, or supportive plates. The bottom-line was the surgeon should use whatever he or she is most familiar and comfortable with.

What about using internal fixation versus a hemiarthroplasty (partial) or complete hip replacement? And is it better to hold the implant in place with cement or go with a cementless approach? How about type of implant? Does the unipolar hemiarthroplasty work better than a bipolar type? And finally, should the surgeon use an anterolateral (front/side) incision or go with a posterior (from the back) approach?

The literature was reviewed with each of these questions in mind. The authors found that for a displaced femoral neck fracture:

Imagine going from having a painful arthritic hip to a squeaking but pain free hip. That can happen after a total hip replacement (THR). What causes this problem? And what can be done about it? Those are the two questions answered in this article.

In a recent survey of 149 patients with a THR, about one in 10 reported a squeaking hip. The sound was most noticeable when bending, walking, using the stairs, and during sexual activity.

There are many theories about what can cause this to happen. The best way to find out for sure is to remove the implant and take a look at what’s going on. But this isn’t always possible. One specimen from the 149 in this study was retrieved and inspected. There was a broad stripe of wear on the femoral head.

The wear pattern on the implant also showed signs of impingement (pinching) of the femoral neck where it meets the rim of the acetabulum (socket). Further testing with an electron microscope showed metal debris along the area of wear.

Rim impingement is probably the number one cause of hip squeaking. But there isn’t just one cause of impingement. Besides socket malposition, there could be a loss of fluid film lubricating the joint. Some patients have lax (loose) ligaments that can lead to impingement.

There’s been some suggestion that an incomplete seal around the socket liner could cause squeaking. Some studies have shown that thicker sockets don’t squeak but thin ones do. It’s possible that the thinner sockets deform when they are put in place. Incomplete positioning of the liner may be the problem there.

It is possible to use sound vibrations to identify the cause of the squeaking. Some researchers have recorded the sounds and analyzed them. Different materials have different recognizable frequencies.

By examining which components vibrate at what frequency it is possible to match the acoustical (sound) sample with the implant. This method isn’t foolproof. Sometimes an incompletely sealed liner resonates at the same frequency as the titanium shell, making it impossible to detect as the source of the squeak.

But overall, it has been shown that certain combinations of implant components are more likely to squeak. The Trident cup with an Omnifit stem has the lowest incidence of squeaking.

But when the Trident cup was put together with the Accolade stem, the vibration was amplified (increased) until it was audible (could be heard). The difference in resonance between the two parts was enough to cause friction that created vibration and then squeaking. Adding this variable to a patient with malpositioned components increases the risk of squeaking.

Knowing all this, what can be done to stop the problem of squeaking in total hip replacements? First of all, the authors suggest a plan of prevention. Placement of the implant in the correct position and correct orientation is number one.

Patients with loose ligaments need some extra care and consideration during the procedure. The authors suggest using a polyethylene (plastic) liner for these patients. And for all patients, matching up the sockets with the right stem is a helpful strategy.

Of course, once the squeak occurs, prevention is too late. It may be time for a second surgery to revise the implant. Some patients (especially those who are pain free and mobile) may prefer to live with the squeak rather than have a second (revision) surgery. Others may choose to have the surgeon remove and examine the implant. Looking at the wear patterns is often enough to point to the cause of the problem. Then it can be fixed.

Doesn’t it seem odd that after 30 or more years using ceramic implants for hip replacements that suddenly there is an increased number of patients reporting squeaking when they move? And this new problem only started in 2006. What’s going on?

Some experts have suggested it’s a problem with mismatched ceramic bearing diameters, malpositioning of the implant, or loss of the protective fluid film. Others have investigated the possibility that the use of short necks in the femoral component or wear debris from metal pinching against other metal could cause this problem.

In this study, the authors show that metallosis caused by impingement (pinching) of the femoral neck against the rim of the acetabulum (hip socket) is the most common cause of squeaking. Metallosis refers to wear debris from the metal parts of the implant. It can cause a painful inflammatory reaction in the soft tissues and bone around the implant.

There were two parts to the study. First, they looked at what happened to 1,275 total hip replacements that had to be revised. They zeroed in on the cases of ceramic-on-ceramic hips that reported noises such as squeaking or grinding.

Then, they reviewed 1,139 cases of primary (first-time) hip replacements using ceramic-on-ceramic implants. This group was further divided into two subgroups based on the type of implants they received. Group 1 had a conventional titanium alloy shell for the socket. Inside that was a ceramic liner. The edges of the shell and the liner were even with each other. This is called a flush-mounted design.

Group 2 was divided into two separate groups. Group 2A had implants with a recessed liner and a conventional titanium alloy femoral stem. With the recessed liner, the edge is not even with the shell. Instead, the edge of the liner is slightly below the rim of the shell. Group 2B had a recessed liner and a beta titanium alloy femoral stem. Beta titanium alloy is made up of molybdenum, zirconium, and iron.

Squeaking was heard most often in Group 2B (recessed liner with beta stem). Squeaking was heard more often in group 2 (recessed liner) as a whole compared to group 1 (flush liner).

The fact that the squeaking started at a specific time period points to the time when surgeons started combining the ceramic-on-ceramic bearings with any of the femoral components available (conventional, beta, thinner stem). So for example, hip implants could include a ceramic liner but a titanium stem. And the titanium could be a pure (conventional) or mixed (beta) alloy.

The results of this study suggest that impingement caused by a beta titanium femoral component (compared to conventional titanium alloy) bumping up against a titanium acetabular rim creates problems with the alumina ceramic bearings. Flush-mounted liners with conventional titanium femoral stems did not cause squeaking. The bottom line is that the problem isn’t with the ceramic bearings as much as it is the materials around the bearings. A recessed liner with a beta titanium alloy combined together seem to cause the most problems.

What we don’t know is the type of debris (e.g., molybdenum, zirconium, iron) put out by beta titanium. Maybe some types of wear debris cause more problems than others. Future studies are needed to improve the materials and the design of hip implants, especially the ceramic ones that can cause squeaking when used with titanium alloy stems.

There are many, many possible causes of hip pain. An accurate diagnosis is needed to direct treatment. But this can be elusive and take a long time to make. In this first part of a two-part series, hip pain is examined in detail. Dfferential diagnosis is the focus of part-one. Treatment approaches are discussed in part-two.

The main topic is a specific hip pathology called greater trochanteric pain syndrome (GTPS). GTPS refers to tenderness felt along the side of the hip. It is a noninflammatory condition that is easily confused for something else.

The physician’s examination takes into account the possible etiology or cause of the problem. Was there some trauma? The mechanism of acute hip pain caused by injury is often a twisting motion. Overuse, repetitive motion, and diseases or degenerative conditions are other potential causes of hip pain.

Pain patterns associated with hip problems start with a deep aching and stiffness in the hip. True hip pain is experienced in the front of the body down into the groin area. Hip pain along the pelvic rim, down the side of the leg, or down the back of the leg is usually a sign that the cause of the pain is extraarticular (outside the hip joint). This could be coming from pinching of the soft tissues, nerve entrapment, or other extraarticular lesions. Loss of motion and/or function can help point to the specific soft tissue structures affected.

Pain patterns are made better or worse by movement, positioning, or rest. Unloading the joint by using a cane, walker, or other assistive device is another way to influence the symptoms. When making the diagnosis, the physician observes how the patient moves from one position to another.

The source of the pain and the location of the pain can be difficult to tell. The patient can’t always isolate it and point to it with one finger. It helps to think of the hip as having four separate compartments. These include; 1) central, 2) peripheral, 3) lateral, and 4) iliopsoas. Each section has its own pain pattern and likely causes of pain for that compartment.

For example, referred pain to the central compartment could be coming from the labrum (fibrocartilage rim around the hip), ligament tears, osteoarthritis, hip dysplasia, or infection. The peripheral compartment is affected by fragments of cartilage (or other debris) in the joint, impingement, and synovitis or infection.

Muscular structures around the joint are involved with lesions of the lateral compartment. This can range from iliotibial band syndrome to bursitis, to problems with the large muscles of the buttocks around the hip. And finally, infection within the pelvic cavity causing a psoas abscesss must be considered in the diagnosis of an iliopsoas compartment problem.

Despite all that we do know about hip pathology, there’s still much left to be explored. Unnecessary X-rays and other imaging studies should be avoided. There are many clinical tests that can be used to sort out possible causes of hip pain. The authors review each test and what their results mean.

Palpation of the various bursa in and around the soft tissues of the hip is described. Tests for integrity of the labrum are provided. The labrum is a fibrous cartilage that helps hold the head of the femur (thigh bone) in the socket. It redistributes the weight and load placed through the joint during weight-bearing and movement. Tears of the labrum can cause hip pain and dysfunction.

Other tests include measuring joint range of motion. Specific motions designed to stress various individual soft tissue structures are described. There are tests for each compartment based on the soft tissue structures within each section. And there are other test maneuvers such as the one-leg mini-squat test, Patrick test, Thomas test, psoas test, and many more.

And finally, the authors encourage physicians to consider unusual causes of hip pain that may look like greater trochanteric pain syndrome. Evaluation of hip pain may require imaging studies such as X-rays or MRIs. Results are viewed cautiously as many changes in and around the hip may be observed but may not be the cause of the painful symptoms. The most obvious pathologies that must be treated include tumors, fractures, hematoma from bleeding after a fall, and infections.

There are high costs associated with a hip dislocation after a total hip replacement (THR). And they are not all financial. The psychologic distress of a hip dislocation and fear of recurring dislocations can be very traumatic.

From a financial point-of-vie, it is estimated that treating a hip dislocation costs as much as 20 per cent of the original surgery. This is true even when the operation can be done as a closed (without an open incision) procedure. An open operation with revision of the hip costs nearly 150 per cent of the primary (first) procedure.

Prevention of hip dislocation is essential to reduce both the financial and emotional costs. But how and when should this be done? Are hip dislocations more likely to occur in the first six weeks after the primary surgery? Six months? Six years? Where is the dividing line?

In this study, one surgeon reviewed hip replacements done over a period of 26 years. He found that one-quarter (25 per cent) of the dislocations happened two years or more after the THR. Looking back at other studies, there appears to be a general trend for increasing risk of dislocation with time. The risk increases by one per cent every five years. After 25 years, the risk increases by seven percent each year.

How can this be prevented? Some studies show that using a larger femoral head helps decrease the risk of dislocation. But dislocation after hip replacement is usually a multifactorial problem. The patient may not follow the surgeon’s precautions about avoiding certain movements and limiting activity level. The implant may not be in the best position. Malpositioning combined with imbalances in tension of the soft tissues around the implant can contribute to dislocations.

Other patient-related risk factors include female gender, younger age, neurologic problems (including cognitive decline), and trauma. Muscle weakness and alcohol abuse are two other risk factors the surgeon must screen for when planning treatment.

Implant-related risk factors include small femoral head, and wear and tear on the polyethylene liner. The liner is placed inside the shell that forms the hip socket. And there are intraoperative factors such as proper patient position during surgery and surgical technique. Choosing the right implant components such as the type of liner or size of femoral head is essential.

Once the implant is in place, the surgeon must check for impingement (pinching) of the bone or soft tissues. Postoperative care is also important. If the patient is noncompliant with the instructions to slow down, then it may be necessary to use a brace or cast until healing has occurred.

Early dislocations are less common but can occur in the first three to 12 months. Most of the time, this is a one-time occurrence. It doesn’t happen again. So unless there is a major problem with the implant type, location, or position, revision surgery to remove and replace the implant isn’t needed. The hip is relocated and the patient is sent to rehab.

After dislocation and before deciding the best plan of care, the surgeon must screen for alcohol abuse, dementia, and/or patient noncompliance. At the same time, soft tissue structures must be examined for competency. Weakness, laxity, or degenerated tissues around the hip may lead the surgeon to use a special type of implant called constrained bipolar or constrained big head femoral component.

All-in-all, a late dislocation has a worse prognosis. There is a 50 per cent increased risk of a second dislocation when the first one occurs two years or more after the implant was done. The authors suggest some specific ways to treat the older patient with a late dislocation. As mentioned, a larger femoral head can be used. And the liner inside the shell that forms the hip socket can be cemented in place.

There is a 90 per cent (or better) success rate with this approach when used with older, inactive patient, especially those who have lax soft tissues.

Hip arthritis is a common problem linked with aging. Adults in their mid-50s are often the first to notice changes that suggest degenerative joint disease. Early diagnosis and treatment are the keys to staying active and healthy.

In this study, a group of physical therapists (PTs) from the U.S. Army-Baylor program evaluated the accuracy of clinical tests commonly used with patients who have unilateral (one sided) hip pain. The goal was to find a way to predict which patients are more likely to have hip osteoarthritis (OA) based on the results of those tests. This is referred to as a prediction rule. In other words, when certain tests are positive, hip OA is probably present.

Since physical therapists often see patients with unilateral hip pain, it’s important to know which tests to use for an accurate, reliable diagnosis. A prediction rule could help cut down on the time it takes to identify (or rule out) hip arthritis. Patients could get the help they need sooner.

The patients in this study were adults from Brooke Army Medical Center (BAMC) over the age of 40. Pain in the buttock, groin, or front of the thigh was a requirement to be in the study. Each person (78 total) was examined by the physical therapist using commonly applied clinical tests and measures. These included hip joint range-of-motion, the squat test, the scour test, and Patrick’s test. There were a total of five tests.

Pain level was recorded for each patient before and after each test. X-rays were taken to show evidence of OA. The results of the clinical tests were compared with the results of the X-rays. In this way, the therapists could look and see which tests were most likely to point to a diagnosis of OA. Finding a successful prediction rule may help patients avoid X-rays when they aren’t needed.

The authors report that 30 per cent of the 78 patients had arthritis based on X-ray findings. Within this group with positive X-ray indications of arthritis, four out of the five clinical tests were also positive. That worked out to be a 91 per cent probability that the patient had arthritis. Analysis of the data showed that when three of the five tests were positive, the likelihood of OA increased to 68 per cent. This was significant but not quite as predictable as when four of the five tests were positive.

Before these tests can be used as a clinical prediction rule, a larger study with more people is needed. Further examination of the tests is also needed. There may be other tests that could serve more effectively as a prediction rule. The next step is to find the best combination of tests to rule out OA (rather than rule in arthritis).

Hip joint resurfacing instead of a total hip joint replacement is fairly new. Resurfacing replaces the arthritic surface of the joint but removes far less bone than the traditional total hip replacement. It saves bone in the femoral neck but also puts strain on the femoral neck leading to fractures. In this study, researchers look at surgical techniques that might increase the risk of a failed implant due to femoral neck fractures.

They used 64 cadaver femora (plural for femur, the thigh bone). They examined the load and shear strain placed on the femoral neck using different positions of the implant. The implant consisted of a cap that fit over the head of the femur with a short stem down into the femoral neck.

Some implants were placed with the stem aligned in an anteverted (tilted forward) position. Some were put in a retroverted (tilted backward) position. And others were implanted in a varus (angled inward) position. Placement was 10-degrees in each direction from the midline (center) of the femoral neck axis. One group (control group) had the stem of the resurfacing component lined up with the normal (anatomic) femoral axis of the neck.

Malpositioning of the femoral implant is known to be a problem. This is the first time scientists have measured changes in the load on the femoral neck caused by different positions of the implant after resurfacing.

X-rays were taken of each femur before and after implantation of the femoral component. The X-rays helped identify the center of the femoral neck and neck-to-shaft angles. Load was placed on the femora and forces measured before implanting a joint resurfacing device.

They placed three times the body weight of a person weighing about 150 pounds. The load was intended to mimic forces on the femur while standing on one leg. Then the bones were retested using the same loads after joint resurfacing.

Shear strain and amount of load needed to cause failure (fracture) were measured. Measurements were taken from 56 different points around the femoral neck. The results showed that resurfacing with placement of the implant in good alignment protects or shields the femoral neck from fracture. This is referred to as stress shielding.

But the amount of load on the femoral neck referred to as shear strain increased even with small amounts of change in angle or tilt of the implanted component. A specific surgical technique called notching of the femoral neck is used during implantation. This also put the femoral neck at a significant increased risk of fracture.

The authors point out several items to consider. First, although the cadaver models showed a strain pattern right away, bone remodeling during healing might change these results. This study could not measure those changes.

Second, only a 10-degree change in alignment was measured. The results may not be the same for any other position of the component. Third, they did not test the component in a valgus (angled outward) position. This would be the opposite of the varus position that was tested. The results might be different for a component in the valgus position.

And finally, how and why notching decreases the bone’s resistance to a fracture was not tested in this study. Further studies are needed to examine each of these additional features of joint resurfacing.

The authors suggest that different loading patterns should be tested. Force applied should be changed to represent various body weights as well. And bone quality should also be examined. Many patients do not have normal strength at the time of the joint resurfacing. This factor could also affect stress shielding of the bone beneath the implant.

It makes sense that the older we get, the greater our risk of hip fracture. But how does risk compare before age 90 and after age 95? The Scottish Hip Fracture Audit was used to find out. This audit is a national, multicenter study of patients over age 50 who are admitted to the hospital with a hip fracture.

Two groups of adults were compared. Patients in the comparison (control) group were between 75 and 89 years old. The extremely elderly group was 95 years old or older. The oldest member of this study group was 106. There were many more women in both groups than men. The ratio of females-to-males in the younger (control) group was 4:1. The ratio was 8:1 in the study group.

Everyone had suffered a hip fracture that was treated surgically. All were able to walk without help before the fracture. Except for age, the two groups were very similar. This made it possible to study just the effect of age on outcomes.

Results were measured and compared using four variables. These measures included death rate, length of hospital stay, living arrangements, and mobility. Type of fracture was also observed and recorded.

The authors report no difference in the total length of hospital stay between the two groups. That included the acute and rehab phases of care. There was a higher mortality (death) rate in the older group. This was true for both the 30-day and 120-day post-fracture rechecks performed by telephone.

Fewer of the extremely elderly patients living at home before the fracture were able to return home. About half of the surviving members of the study group returned home after hospitalization. This was compared to 77 per cent (about three-fourths) of the control group.

Likewise, only two per cent of the elderly adults who were able to walk unassisted (no cane or walker) could recover their former level of mobility. Twenty-two per cent (22%) of the control group was able to regain their mobility independence.

The findings of this study are important because more and more adults are living well into their 90s and 100s. It’s assumed that the number of hip fractures will continue to increase as the size of this age group increases. Although the results of this study are from Scotland, there’s no reason to think the information doesn’t apply to elderly adults worldwide.

The authors suggest that age is linked with hip fractures because of the comorbidities present in elderly adults. Comorbidity refers to coexisting medical problems in this age group, which is a strong predictor of death after hip fracture.

In this study, the extremely elderly group were twice as likely to die within 30-days of the fracture compared to the younger group. The same was true at the end of 120 days (four months postfracture). In fact, only half the patients in the over 90 age group who were admitted to the hospital for a hip fracture returned home. Twenty-five per cent ended up in long-term care facilities. The other 25 per cent died.

And the researchers compared these figures with adults the same ages who did not have a fracture. Survival outcomes showed that death rate was higher in the fracture group compared with extremely elderly in the general population. This helped confirm age as an independent variable linked with higher mortality after hip fracture.

All of these statistics point to increasing medical costs for aging adults. More efforts are being made to help elderly patients prevent fractures but also return home after a hip fracture. Patients with a hip fracture who come to the hospital from a skilled nursing facility or other institution are very, very unlikely to regain an independent living status.

In summary, older age is a way to predict poor prognosis for recovery after a hip fracture. Hip fracture can bring on disability and loss of independence in extremely elderly adults who were living at home independently before the fracture. Severe medical problems increase the risk of death and loss of independence.