News Category: Hip

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.

For anyone with a total hip replacement (THR), hip pain is a red flag. Medical evaluation is important because of the risk of joint infection. Treatment depends on knowing if there is (or isn’t) an infection.

But there isn’t one single or individual test that works best to diagnose or rule out infection. To avoid the high cost of multiple tests, it would be useful for the surgeon to know which tests to order. Cultures of the joint taken directly from the area during surgery are the most accurate.

But this type of testing is not practical for the patient who doesn’t have an infection or who doesn’t need surgery. And there is a fair amount of false-positive test results with intraoperative cultures due to errors in sampling technique. Not only that, but sometimes patients are given antibiotics before the operation (affecting test results) and the surgeon doesn’t know it.

So which tests are sensitive, reliable, and accurate with a low false-positive and high true-positive results? That was the focus of this study on over 200 patients with painful total hip implants. The tests they evaluated included:

Intertrochanteric hip fractures can be difficult to treat. With this type of hip fracture, there is a break or fracture line between two bony bumps on the femur (thigh bone). The larger bump on the upper outer part of the femur is the greater trochanter. The bump on the inside (medial) part of the femur is the lesser trochanter.

A line between these two bumps forms the intertrochanteric line. An intertrochanteric fracture between these two bumps usually requires surgical repair. If there are jagged pieces of bone on either side of the fracture, it’s called a comminutedfracture. This type of break is unstable.

In this article, Dr. S. Lichtblau of the Mt. Sinai School of Medicine in New York presents risk factors for an unstable intertrochanteric hip fracture. The orthopedic surgeon must watch out for these risk factors in older adults. Early identification can prevent a stable fracture from becoming an unstable one.

Identifying risk factors is important because it’s not always possible to know from the X-ray if there is a comminuted fracture. If it’s not repaired at the time of surgery, the whole hip can collapse at the fracture site during healing. The pin used to hold or fix the fracture can break or back out of place. The patient ends up with a shortened limb on that side. And the procedure is considered a failed surgery.

The examiner may be able to tell there is fracture displacement or separation of the fracture fragments by looking at the patient’s preferred hip and leg position. Patients with a shortened limb and hip internal rotation on that side need further evaluation.

X-rays are taken. The surgeon looks for some specific telltale signs of fracture instability at the fracture site. These include loss of contact between the two sides of the fracture line. There may be obvious displacement of the bone with gapping at the fracture site. Severe osteoporosis of the bone (loss of bone mass) requires further investigation. Sometimes more than one radiographic view is needed to see all aspects of the area.

Treatment is based on the location, type, and severity of fracture. If the corrected fracture becomes unstable, the surgeon has three choices. These are 1) revise or change the first procedure, 2) choose a different way to fix or hold the fractured bone while it heals, and 3) change how much weight the patient can put on that leg after surgery. The patient may have to be non-weight bearing on the operated leg for a period of time.

The author notes that although modifying the reduction is an option, it’s not a very good one. The best way to do this is uncertain and the results are variable. Angular (bending) forces through the femur to the hip called varus and valgus can produce increased hip instability.

It may be easier to change the method of fixation. In the first reduction surgery, the surgeon often uses a Dynamic Hip Screw. But in complex, fragmented fractures or stable fractures that have become unstable, a different kind of screw (lag screw) along with a circumferential (circular) wire may be needed.

A particularly challenging fracture is the reverse obliquity intertrochanteric fracture. This fracture line goes in the opposite diagonal direction as the typical intertrochanteric fracture.

Intramedullary nails can help stabilize this type of fracture. This type of fixation device was once used for typical intertrochanteric fractures. But there were too many complications and surgeons had to stop using them. They do seem to work well to stabilize reverse obliquity fractures.

An alternative method of fixation for reverse obliquity fractures is a metal plate attached with a screw. There are several types of plates to choose from. These include the Medoff Sliding plate, the Trochanteric plate, and the Percutaneous plate. The choice of plating depends on what type of compression and fixation is needed to stabilize the fracture.

Careful reduction and fixation of intertrochanteric fractures is needed to prevent displacement, nonunion, or malunion. The course of treatment selected may have to be changed if the fracture becomes unstable. Surgeons must evaluate each patient carefully for risk factors and monitor for any sudden changes. Early identification is the key to successfully treating a stable intertrochanteric fracture that has become unstable.

The hospital stay after a total hip or total knee replacement has been shortened by almost half. To make up the difference in care, outpatient (home-based) rehab has increased. Surgeons from Canada study the effect of this change on outcomes at three and 12 months after surgery. They compared the costs and complications between two groups.

The first group had inpatient rehabilitation after surgery. This involved a longer hospital stay. The second group was discharged sooner and received follow-up care at home. Everyone in both groups had the joint replacement for arthritis or osteonecrosis. Patients with fractures, tumors, or revision joint replacements were not included.

Outcomes were measured using three different surveys (questionnaires). These included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form-36 (SF-36), and the Hip and Knee Satisfaction Scale. These tools helped measure pain, function, motion, and stiffness.

Everyone completed the surveys two weeks before surgery. They were randomly placed in one of the two groups before surgery. There were no differences in the patients placed in both groups in terms of age, diagnosis, body weight, gender, or education. Surgical care was equal between the two groups otherwise. They repeated the questionnaires three months after surgery and again at the end of one year.

Everyone stayed in the hospital for at least five days. All patients received the same basic physical therapy from day one. At the time of discharge, group one was transferred to inpatient rehab. Group two was discharged to home. Both groups continued to see a physical therapist for the same rehab program after transfer or discharge.

The cost of care was calculated for both groups. The focus was on direct healthcare costs. This did not include physician fees, medications, or indirect costs to the patient and/or family.

Analysis of the data showed that the average number of home-based rehab visits was eight. The average number of days in the inpatient rehab facility was 17 days. Infections were more common in the inpatient group but postoperative complications were similar otherwise.

Both groups had dramatic improvement in all areas measured after surgery. Patients in both groups continued to improve for up to the full 12 months of the study. This was equally true for both total hip and total knee patients.

The cost was six times greater for the inpatient group compared with the home-rehab group. In the United States, this difference is reportedly 10 times greater. Since the outcomes were the same, the authors suggest following a home-based rehab program for all ases of uncomplicated total hip or total knee patients. This policy may be especially helpful in facilities where transfer to an inpatient rehab facility is delayed due to a shortage of beds.

Inpatient rehab care is still recommended for anyone with serious health concerns or the likelihood of postoperative complications. These patients can be monitored more closely as needed. To contain costs, home-based rehab should be standardized so that number of treatments and protocols are the same from place to place.

It’s been 10 years since the first total hip resurfacing was developed as an alternative treatment to total hip replacement. 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.

It is used most often in England, Australia, and Western Europe. Several implants have received FDA approval for use in the U.S. We may expect to see results of studies from the U.S. but for now, most data comes from these other countries.

And thanks to researchers and scientists who presented the results of their studies at the First Annual Course on Total Hip Resurfacing, we have some important knowledge about this procedure. In this report, the status of cementless acetabular metal-on-metal implants is presented.

The acetabulum refers to the hip socket where a thin-shelled metal cup is inserted. The femoral component used during hip resurfacing is placed on the outside of the femoral head. The femoral shaft is preserved.

The greatest success appears to depend on choosing the right patient for the procedure. Good bone stock and bone density is essential. Femoral neck fractures are the number one cause of resurfacing failure.

If the femoral neck isn’t strong enough with some give (bending strength), there is a great risk of fracture during the first six months. Women with osteopenia or osteoporosis and men with small bones are most susceptible to this problem. These two groups of patients may not be eligible for joint resurfacing. Older adults (65 years of age and older) and anyone who is obese (body mass index greater than 35) are also excluded.

After 10 years of study, it looks like younger men (between the ages of 40 and 60) are the best candidates. But as the implants, technology, and techniques improve, this may change. Patients especially interested in this bone-sparing treatment alternative are athletes and sports participants. Early intervention for painful, limiting arthritis with joint resurfacing may result in continued sports activity.

Once the proper patients have been selected, surgeons must use careful placement of the implant. Just the right amount of femoral neck-shaft angle is important. Too much varus (inward angulation) can place excess strain on the bone (especially at the neck where fractures tend to occur).

Another important surgical technique is cement distribution. Too much cement or uneven distribution can lead to problems. Damage to the bone can result in fracture. Newer implants are cementless. In the case of the acetabular component, the liner is press-fit into the space without any potentially damaging adhesives (glues or cements). X-rays are used to confirm the position and fit of the acetabular implant.

Much of the research has focused on the effects of metal (cobalt-chromium) alloys. Wear patterns and exposure to tiny metal ions that flake off and enter the blood or urine have been studied in cadavers (joints preserved for study) and in live patients. It appears that acetabular cup angle makes a difference in the amount of metal measured in blood levels.

The resurfacing procedure isn’t perfect yet. The number of femoral fractures is down but sometimes revision procedures are needed. Defects in the bone, excess wear, or loosening of the implant may lead to a second operation. Usually, the joint is converted to a total hip replacement.

For now, the resurfacing technique is considered an alternative (not a replacement) for the total joint procedure. It may save bone and make it possible not only to remain active but also to convert to a total hip replacement years later (if needed).

As surgeons continue to refine the technique and manufacturers improve the implants, hip resurfacing will have improved outcomes. There will be fewer complications. More patients will qualify for this type of surgery.

Technology will also aid in improving the results of this procedure. Advanced CT navigation methods will allow surgeons to reduce errors and improve accuracy of implant placement. And future materials using ceramics and polymers may be developed to reduce internal toxicity to patients.

Many more studies are needed to analyze the effect of resurfacing on motion, activity level, and function. Future studies comparing resurfacing to standard joint replacement has some merit. But the authors suggest one approach may not be superior to the other. They each offer a treatment option to specific (different) patient groups.

Hip joint resurfacing is usually reserved for active, younger adults (40s and 50s). And the results have been very successful. So what’s stopping surgeons from using this technique with older adults (65 and older)?

Hip joint resurfacing is a type of hip replacement that removes the arthritic surface of the joint but takes far less bone than the traditional total hip replacement. During the procedure, the femoral head is shaved and shaped so that a metal cap can be fit snugly over top of the bone. The cap is held in place with a small peg that fits down into the bone. The acetabulum (hip socket) may remain unchanged. But more often it is replaced with a thin, metal cup. The acetabular component is pressed into place in the socket.

Current thinking on this subject is that older patients don’t have the bone strength and density to hold up under joint resurfacing. The danger of a femoral neck fracture is too high. And older adults who are less active don’t need resurfacing. They can get a total joint replacement that will last them the rest of their lives.

But there really isn’t much evidence to support any of these arguments. This is one of the first studies to compare results of hip resurfacing between two age groups. The first group was 60 years old or older. The second (larger) group was younger than 60 (between 18 and 59 years old).

Patients in both groups were operated on by the same surgeon during the same time period. They all received the same type of metal-on-metal resurfacing implant. Both the femoral and acetabular components were resurfaced. Results were measured using clinical outcomes such as pain and function, as well as comparing X-rays and complications.

The results were very similar for both groups. Recovery time was the same regardless of age. X-rays showed equal angles for the cup placement and femoral head and neck. These angles indicate accurate placement of the components needed for good results.

And the number of problems that occurred after the surgeries was also very similar between the two groups. When it was necessary to convert from resurfacing to a total hip replacement, there were more younger patients who needed the revision surgery.

The reasons for failure of the resurfacing was different between the two groups. Hip fracture or shifting of the acetabular cup was more common in older adults. A condition called heterotopic ossification (HO) occurred in the younger group. HO describes a problem in which bone forms outside the joint in the soft tissues.

The results of this study support the use of joint resurfacing for older adults. This is consistent with the few other studies that have also been published. Failure rates and poor function of hip joint resurfacing is the same in older adults compared with younger adults. Quality of bone and deformity of the femoral head and neck are the major risk factors for poor outcomes. And at least from this study, these are not necessarily linked with age.

Adults are living longer and staying more active suggesting the need for treatment alternatives such as joint resurfacing. Age alone should not be the sole determining factor of whether or not someone could benefit from this procedure. The authors do point out that their results only extend for three years, so more time is needed to judge the final results.

Many older adults who have a hip fracture never make it back home again. They transfer from the hospital to a transition unit, skilled nursing facility, or extended care facility. Doctors are actively searching for ways to change this fact.

One area of research is to look for risk factors that can be changed to help patients return home or to an independent living situation. Studies have already been done that show the importance of general health before fracture, mental status, and preinjury walking ability.

In this study, researchers from Sweden investigate the effect of the timing of surgery after hip fracture. They looked at timing as it related to returning to independent living and on the development of pressure ulcers. Over 700 patients with an acute hip fracture were included.

Medical records were reviewed for the following information: time of admission, time of surgery, duration of surgery, and any pressure ulcers that developed. Specific type of surgery was also recorded.

The time to surgery was calculated from the time the patient came into the emergency department to the time of the operation. Delays could occur because of the patient’s health or for system-based reasons (e.g., unavailability of the operating room, surgeon, or anesthesiologist). Specifically, the authors compared patients who had the surgery in the first 24-hours and those who had the surgery after 24 hours (e.g., 36 or 48 hours later).

Treatment included repairing the fracture using a metal plate, wires, and/or screws or reconstructing the hip. Reconstruction was with a hemiarthroplasty or total hip replacement. The hemiarthroplasty removes the head of the femur and replaces it but leaves the hip socket intact.

About half of the patients had hip surgery within the first 24 hours. Three-fourths had it within the first 36 hours and 87 per cent within 48 hours of admission. Two-thirds of the delays were due to hospital staffing or other medical-related issues. The remaining one-third were delayed because of specific patient-related factors.

Delays in surgery definitely increased the risk of pressure ulcers. The longer the delay, the greater the risk. Pain and prolonged immobility associated with an untreated hip fracture contribute to this problem.

And for every 6 hour and 45 minute delay of surgery, the hospital stay increased by one day. It was noted that almost 10 per cent of patients in the study had dementia. This seemed to contribute to a failure to return to independent living, but was not investigated further at this time. The death rate was not different between the group who had surgery in the first 24-hours and those who had surgery 36 to 48 hours later.

Another concern pointed out is the physical effects of fasting during the delay. While the patient is waiting for the operation, food and drink are withheld. This is a precaution against vomiting during anesthesia. But a reduced caloric intake and dehydration can lead to muscle loss and weakness. This condition persists after surgery and can impact healing negatively.

Overall, it looks like a delay in surgery does increase the risk of pressure ulcers, a longer hospitalization, and less chance of returning home. Since many of the delays were related to problems on the medical side of things (e.g., inadequate resources, lack of support services), one way to reduce these problems is to address system-related delays.

Even healthy older adults fear a hip fracture. Studies show that up to 33 per cent of older adults with a hip fracture die within a year. What can we do to prevent this level of mortality? The first step is to find out what are the greatest risk factors for hip fracture. Surviving a hip fracture may depend on modifying as many risk factors as possible.

In this study, over 1,100 patients with hip fractures were placed in a computer database for study and comparison. In order to be included, the patient had to be at least 65 years old. Good mental function and the ability to walk independently were required. Each one was still living independently.

Questions were asked to complete a survey of cognitive function. The medical records were reviewed for information on physical health, postoperative complications, and social data (e.g., age, gender, race, marital status). Type of fracture and events leading up to the fracture were also recorded.

Only patients with a femoral neck or intertrochanteric hip fracture were included. Everyone had surgery to repair the fracture. Number and type of complications was added up. Data on the number of patients who survived, the number who died in the hospital, and death rates for up to 10 years were also collected.

The authors report that most of the patients had at least one other major health problem. A history of cancer and the presence of heart disease were the most common. Many had at least three comorbidities (diseases present at the same time).

Complications were common after surgery. Wound infection, pneumonia, heart failure, stroke, heart attack, and blood clot were the most common surgical and medical problems. Almost three percent of the patients died while still in the hospital. Another 12 per cent died in the first year. By the end of 10 years, the death rate was 75 per cent.

One of the tools used to assess risk was the American Society of Anesthesia’s (ASA) rating of operative risk. Risk during the surgery and right after was scored based on inpatient comorbidities. The ASA scoring system is well known for its ability to predict mortality.

The authors reported the following as major predictive risk factors for death after hip fracture:

Hip osteoarthritis (OA) is a common cause of disability among older adults. With the aging population around the world, research is focused on ways to prevent and respond to this condition. In this study, scientists from Finland examine the social and physical factors that are linked with low physical and social function in patients with OA.

General health status, activities of daily life, and quality of life were measured in patients with hip OA. All measures were self-reported through the use of questionnaires.

This included body functions and effects of personal factors such as age, sex, education, sports activities, and mood (e.g., depression). Measurements such as joint range of motion and muscle strength were recorded by a group of physical therapists.

The results showed there are many factors that arise from hip OA that put the patient at risk for disability. No one single factor was more predictive than any others. Specific factors that were linked with disability included personal factors, educational level, and life satisfaction. Body mass index (BMI), other health problems, and duration of pain were related to disability.

Factors linked with disability and pain in hip OA should be taken into consideration when planning prevention and treatment strategies for these patients. The authors also suggested that tests such as the Timed-Up-And-Go test, hip range of motion, and the Six-Minute-Walk-Test (6MWT) are better measures of function than X-rays showing the severity of hip OA.

Hip osteoarthritis (OA) can cause disabling pain and loss of motion. The natural result is a loss of function. Many studies of treatment for hip OA rely on pain, motion, and strength to assess results. Therefore, it’s important that these measures are accurate and reliable.

In this study, the intrarater reliability of muscle strength and range-of-motion for adults with hip OA is tested. Intrarater reliability refers to the ability of one person to get the same results each time a test is given.

One physical therapist performed all of the hip joint motion and hip muscle strength testing. A handheld tool called a dynamometer was used to test and retest the strength of the hip muscles. The authors described the test position and procedure for each group of muscles.

Two special tools were used to measure (and remeasure) five of the six hip motions. The tools used included a goniometer and an inclinometer. Motions measured included flexion, extension, internal and external rotation, and abduction (movement away from the body). Photos of each test position using these tools were also included. The authors’ method of reliability testing was also discussed.

The results showed good-to-excellent test-retest reliability for all tests performed. The authors attribute this in part to the way the patients were stabilized during testing.

Physical therapists performing strength and range-of-motion testing in people with hip osteoarthritis can rely on the tests as described in this study. Such tests can be used before and after treatment to measure the effect of treatment methods on motion and strength.

There are two ways results can be measured after a total hip replacement (THR). One is by self-report. The other is performance-based. Self-report involves a survey or questionnaire filled out by the patient. Questions are asked to measure pain, stiffness, and function. Self-report tools can be filled out at home and mailed in. Or they can be completed on-line via the Internet. A clinic visit is not necessary.

Performance-based tests require the patient to actually perform tests of physical function. This may include activities such as walking (distance and speed) and sit-to-stand or balancing (skill and timed tests).

Studies show a big difference between self-reported function and performance-based tests. This study was designed to find out why this difference occurs. After completing both kinds of tests (before and after surgery), the results were compared. Once again, results were very different between the two types of tests. The main reason seemed to be pain.

Patients with hip pain were unable to sort out pain and physical function. Even when they could accomplish a task like walking, they rated their function as lower than it really was. This was true even after the pain improved. This finding suggests that even low levels of pain affect how people view their own physical function.

The authors advise using both types of testing after a THR. Using self-report and performance-based tests will provide a better view of the patient’s true abilities. Using different tests also helps assess pain, overall health, and specific activity level.

Patients who report “hip pain” often point to the side of the hip over the region of the greater trochanter. The greater trochanter can be felt along the side of your hip. It is a large bump that juts outward from the top of the femur.

Large and important muscles connect to the greater trochanter. One muscle is the gluteus medius. It is a key muscle for keeping the pelvis level during standing and walking.

Pain over the greater trochanter is called lateral hip pain. But true hip joint pain really occurs in the front of the body close to the groin area or deep in the buttocks. Pain in the area of the greater trochanter is more likely from problems with the gluteal (buttock) muscles.

In this study, patients with lateral hip pain were examined by physical therapists (PTs). MRIs were also taken. The results of these two test measures were analyzed and compared. The study had three areas of focus: 1) Use MRIs to find out which soft tissue structures may be the cause of lateral hip pain. 2) See which structures PTs think are causing the problem. And 3) Look for valid tests to predict gluteal tendon pathology.

On the basis of clinical tests performed, the PTs listed the muscles they thought were involved. They also said whether the problem was muscle weakness, tendon tear, or tendinosis (tendon degeneration).

The PT’s diagnosis was compared to the MRI diagnosis. Using this method of comparing, the researchers were able to test the accuracy of the clinical tests. Overall, there was little agreement between the radiologic and PT diagnoses. The reason for this lies with the MRIs.

MRIs did not show a difference between tendinosis and a partial tear. Just as many patients without symptoms had significant MRI findings of tendon problems. Abnormal bursae were seen in patients with and without lateral hip pain.

The authors point out that the results of clinical tests for lateral hip pain can’t be compared to MRIs yet. There is a need to further refine the imaging before MRIs can be used as a standard for diagnosis.

PTs were able to identify bursitis but not tendon problems. Further research is needed to develop accurate clinical tests to assess gluteal tendinopathy.

Hip fusion for younger patients is not the viable option it once was because of its problematic outcomes. Total hip arthroplasties (THAs) or hip replacements are not always a first option for younger patients either because of the arthroplasty’s limited survivorship. Because of these issues, the metal-on-metal hip resurfacing (MOMHR) has been tested as a potential treatment for this patient group.

Originally, there were concerns that MOMHR caused problems because of lack of blood supply to the femoral head (head of the thigh bone) or because of femoral head loosening of fracture. However, studies have shown that the procedure can be successful as long as the soft tissue covering the femoral neck is kept intact.

Researchers were also concerned about how the bone cement would affect the healthy bone next to it, due to the high temperatures needed. This was addressed by making some changes in the way the cement was applied.

The author of this article looked at the outcomes of MOMHR compared with hip arthroplasties, or replacements. Unfortunately, studies of more than 10 years aren’t available and shorter periods are not as reliable in order to show long-term outcomes. In one study of five years minimum, there was a 98 percent success rate of 144 hips. In another study, using the same system, there was a 99.14 percent success rate out of 230 MOMHR procedures.

some issues that have been brought forth that concerned doctors about the MOMHR included the issue of metal ions, the biomechanics of resurfacing, and bone preservation. In terms of the metal ion issues, there concerns about metal ion exposure that could cross the placenta if a woman was pregnant. However, studies have shown no ill effect on the fetus.

Regarding the biomechanics of MOMHR, it became obvious that the higher volume hip surgeons were able to use templating in order to improve success. Studies have investigated the issue of leg length, comparing MOMHR with arthroplasty and have found that leg lengths and gait analysis were more favorable with the MOMHR than with the arthroplasty.

Bone preservation is less of an issue with MOMHR, however, in some cases, more bone may be removed with MOMHR, depending on the technique and location, when compared to a hybrid arthroplasty.

The author concludes that the current study findings have been adequate for the US FDA to approve its use. There are other designs that will become available, but the MOMHR has given doctors hope that arthroplasties can be avoided in the younger patient population. The success for the procedure lies on proper patient selection and surgeon experience.

Orthopedic surgeons at the Mayo Clinic in Rochester, Minnesota compared speed of recovery in hip replacement patients. They used two different surgical approaches. Patients in both groups were similar in age, diagnosis, and background. Everyone was treated using the same advanced anesthetic and rehab protocols.

The first group was managed with a two-incision technique. One six-centimeter (about two and a half inches) incision was made across the front of the hip. Another smaller incision in the buttock gave surgeons access to the hip. Hip muscles were protected from surgical disruption.

The second group had the mini-posterior-incision method. A seven to 9.5-centimeter (three and a half inch) incision was made along the back of the hip. With this approach, the fascia over the muscle and the muscles of the hip and buttock were split and moved during the procedure. After the implant was in place, then the muscles and soft tissues were repaired.

The surgeons expected a faster recovery time with the two-incision method. Instead, they found that patients treated with the mini-posterior-incision had the advantage. The mini-posterior-incision group was able to walk faster and farther with less assistance sooner than the two-incision group.

The mini-posterior-incision group also returned to daily activities sooner. They were able to start driving, climbing stairs, and walking one-half mile before patients in the two-incision group.

The authors suggest that early improvements in pain and function with minimally invasive surgery may really be the result of other factors. Careful patient selection, new anesthetic techniques, and improved control over postoperative pain may be the true reasons why hip replacement patients recover faster.

New, aggressive rehab programs may also have an influence in speed of recovery. Patients are allowed to put weight on the leg and walk without a walker, crutches, cane or other walking aid as soon as they feel up to it. Patients can advance in their function at their own pace.

The two-incision method of hip replacement is complex and requires considerable skill on the part of the surgeon. Operative time is longer without the benefit of faster recovery. There may not be enough advantages of the two-incision method to use it to replace the mini-posterior-incision approach.

The American Board of Orthopaedic Surgery did a study to find out how orthopedic surgeons are repairing intertrochanteric hip fractures. This fracture occurs between two bony knobs on the neck of the femur (thigh bone). They found a big shift has occurred in how this fracture is repaired. The change has taken place in the last five to seven years.

From the 1950s until the early 1990s, the standard procedure for repairing an intertrochanteric hip fracture was with a sliding compression hip screw and side plate. This technique is referred to as plate and screw fixation. However, in the last 10 years, a new fixation device for this type of fracture has been made available.

A short intramedullary nail placed through the greater trochanter (one of the two bony knobs) with an interlocking screw is used much more often now. In fact, the use of this technique called intramedullary nail fixation increased from three per cent in 1999 to 67 per cent in 2006.

It appears that this change has taken place all over the U.S. It started first in the Southeast region. Then finally made its way to the Northwest. Data shows that the complication rate for intramedullary nail fixation has been higher than for the plate and screw method. Fractures are especially more likely to occur during and after intramedullary nail fixation.

The complication rate appears to be declining over time. Surgeons using the technique with more and more patients may be improving with fewer surgical errors. There is a common opinion among orthopedic surgeons that nail fixation is the best way to treat unstable intratrochanteric hip fractures.

However, there isn’t enough evidence to really support this conclusion. The results of studies done so far show that the intramedullary nail fixation has more complications and the final results aren’t any better than with the plate and screw method. The intramedullary approach is a quicker and easier surgery but the cost is also higher than for the plate and screw fixation.

More evidence-based studies comparing these two methods of surgical repair need to be done.

Hip joint resurfacing has been developed for younger, active patients with debilitating hip arthritis. Joint resurfacing involves smoothing down the surface of the hip joint. Then it is covered with a metal cap on the ball side and a thin metal cup on the socket side.

Because this technology is fairly new, the long-term results are being studied. In this report, the functional outcomes of patients were reported one year after a metal-on-metal (MOM) hip joint resurfacing procedure. Measures included pain, range of motion, and strength. The ability to walk and climb stairs was also measured.

Most of the patients were less than 60 years old. All were very active and had good bone quality. After the MOM procedure, everyone was in a standard rehab program. The rehab protocol used was the same one used for total hip patients.

Patients begin walking on the first day after surgery. They gradually increase the amount of weight placed on the leg and the distance walked. Exercises to improve motion and strength are also increased. Frequency, intensity, and duration are advanced as quickly as possible. This is referred to as a progressive exercise and mobility program.

Three-fourths of the patients had a satisfactory outcome with very few problems. They had high levels of function and activity. One quarter of the group (25 per cent) had less than optimal results. They had persistent pain, loss of hip motion, and decreased strength. These factors resulted in decreased balance, difficulty walking, and limits in what they could do (function).

The authors suggest there is a need for a special rehab program for patients with MOM hip resurfacing. Just using the same protocol used for total hip replacement patients may not be enough. The timing of more intense activities may be important in getting optimal results.

Perhaps having a later phase of outpatient rehab is needed. Such a program could focus on regaining all hip motions. This is especially needed for functional activities like putting on socks and shoes or bending down to pick something up from the floor.

A second phase of rehab after discharge could also focus on improving balance, gait (pattern of walking), and postural stability. All three of these skills could help prevent falls and fracture.

There are two main ways to replace a hip joint. The first is with a partial replacement or hemiarthroplasty. The head of the femur (thigh bone) is removed and replaced. The hip socket called an acetabulum isn’t replaced. The second choice is a total hip replacement (THR). Both sides of the joint are removed and replaced.

Most of the time, hip replacements go smoothly with good results. But sometimes the THR doesn’t work out, and the patient must have a revision surgery. The implant is removed and replaced with another prosthesis.

For patients with a hemiarthroplasty, conversion to a THR may be needed. The patient’s native acetabulum is removed and replaced with a new socket. The femoral head implant must be replaced, too. A smaller head is needed to fit into the new socket.

Both the revision surgery and the conversion procedure come with a risk of hip dislocation. In this study, the rate of dislocation is compared between these two operations (revision versus conversion).

Patients who had either a revision operation or a conversion at one hospital by one surgeon were included in the study. All surgeries were done through a posterior (behind the hip) approach. The soft tissues were cut and repaired in the same way between the two procedures.

Comparing the two groups, there were no differences in ages at the time of the revision or conversion for those who did versus those who did not have a dislocation. Size of the implant parts, angles, and positions of the components were also compared.

The hemiarthroplasty conversion group had a much higher rate of dislocations. Some of the patients had multiple dislocations. Hip dislocations occurred most often in hips with smaller femoral heads. And even when the heads were the same size between the groups, the conversion group still had more dislocations.

In fact, the conversion group had more dislocations for every head size. A large head did not necessarily mean good hip stability. It is likely that cutting into the soft tissues around the hip during conversion is the main reason for later hip dislocation. This factor combined with the downsizing of the femoral head may have increased the risk of dislocation for the conversion group.

This study demonstrates the need to find ways to lower dislocation rates after both hip revision and conversion procedures. The surgeon must pay attention to soft-tissue tension on the femoral head and the greater risk of dislocation after conversion from a hemiarthroplasty to a THR.

Getting back on your feet after a hip fracture can be a challenge. Many older adults with a hip fracture never do return to their former walking abilities. Early surgery and rehab may help. Muscle strength training is often the focus of the rehab program.

In this study, doctors from Japan compared the muscle size of patients’ upper legs after two different types of hip fractures. Half the patients had a femoral neck fracture. The other half had an intertrochanteric fracture of the femur (thigh bone). All patients had surgery to repair the fracture.

The idea was to gear the rehab program specifically to the weak and atrophied (wasted) muscles. But comparing the walking ability to CT scans of the thigh muscles did not show any relationship between muscle atrophy and walking ability. Scans were taken before surgery (at the time of hospital admission) and after surgery (one month later).

There was significant muscle atrophy on both sides (fractured side and uninvolved side). The authors suspect some other factors are more important than muscle atrophy and fracture type. A rehab exercise program specifically based on the type of fracture isn’t needed.

At least this was true for the first month post-op. The authors suggest further long-term studies are needed to know if muscle atrophy matched with fracture type is more important later in the recovery process.

They also looked at age, pain, nutritional status, and the presence of other health problems as possible reasons for decline in walking ability. These preinjury variables appear to be more likely to predict a patient’s ability to walk after hip surgery for a fracture. They should be studied more closely.

Rehab after hip fracture is still very important. Patients who exercise and get back to activity sooner than later have a better outcome. The search for just the right rehab program after hip fracture will continue.

In this article, surgeons from the University of Washington (Seattle, WA) review femoral nonunion fractures. They define nonunion and explain the various types or classifications of femoral nonunion fractures. Diagnosis, risk factors, and treatment are also presented.

A femoral nonunion fracture affects the shaft of the femur (thigh bone). Nonunion refers to the obvious fact that the bone hasn’t healed. But more specifically, healing hasn’t occurred in the first nine months after the injury. At the same time, there has not been any sign of healing on X-rays taken over the last three months. There is no evidence of bone crossing the fracture site. The fracture line is still clearly present.

Patients at risk for this type of nonunion include those who smoke or use tobacco products, who have poor nutrition, or who use nonsteroidal anti-inflammatory drugs (NSAIDs). Poor health or the presence of other health conditions can also increase the risk of fracture nonunion. The type of injury and condition of the soft tissues around the bone may also affect healing.

Sometimes fractures that have been surgically repaired don’t heal. Besides the risk factors already mentioned, the surgical technique itself may delay healing. For example, damage to the blood supply can occur with procedures such as reaming or stripping. These steps are necessary when making a space large enough for a pin or nail to be put down the middle of the bone to stabilize the fracture.

The authors provide a detailed discussion of exchange nailing, plate osteosynthesis, and external fixation. These are surgical treatment methods for femoral nonunions. Exchange nailing is the removal of a nail already present. The canal inside the bone where the nail is located is made larger. Then a larger and stiffer nail is put back into the canal. Exchange nailing stabilizes the bone and gives a larger surface area for bone graft to occur.

Plate osteosynthesis refers to the use of a metal plate to stabilize the fracture. The plate applies direct pressure across the nonunion site. This may be an advantage over nailing for some fractures. And in some cases, plating is used when nailing has failed. Bone grafting can be used to help improve the filling in of bone around the plate. Infection, blood loss, and further damage to the nearby soft tissues are potential problems with plate osteosynthesis.

External fixation is used less often than nailing or plating. Pins through the skin with attached hardware have several disadvantages compared to other treatment methods. Pain and infection at the pin site are common problems. External fixation is used when the fracture site is already infected. The pins can be placed without a large incision, which could further compromise the infection site.

Whenever selecting a surgical approach to femoral nonunion fractures, the surgeon considers the need to avoid infection, blood loss, and malalignment of the fracture site. Surgical treatment is followed by rehabilitation. Electrical stimulation of the fracture site may be used as an additional treatment tool to foster bone healing. The surgeon and the physical therapist work together to optimize patient healing and recovery during the postoperative period.