News Category: Hip

Hip pain can be difficult to assess. It could be coming from inside the joint or from structures outside the joint. Muscles, tendon, bursa, or capsule could be involved. The symptoms can even be referred to the hip from the sacrum, sacroiliac spine, or low back.

In this study, physical therapists evaluate the interrater reliability of four commonly used hip tests. Reliability tells us how consistently the test measures what it is supposed to measure. Interrater reliability shows how well the test measures results when used by different examiners.

The four tests included were FABER test, flexion-internal rotation-adduction impingement test, log roll test, and greater trochanter tenderness.

FABER stands for flexion, abduction, external rotation. It is the position the hip is placed in when the test is performed. The results help identify where the pain is coming from (hip, low back, sacroiliac joint). The impingement test combines hip motions that show if the labrum is getting pinched. The labrum is a rim of cartilage around the hip socket.

The log roll test is done with the patient lying on his or her back with the legs straight. The examiner holds the patient’s heels and rolls the feet/legs in and out. This corresponds to motion within the hip and tests for ligament laxity (looseness).

The greater trochanter is the bony prominence of the hip felt along the outside of the hip area. Tenderness over this area is considered a sign of bursitis.

All patients included had hip pain as their primary symptom. Everyone was 18 years or older. All four tests were performed on each patient by both a physical therapist and an orthopedic surgeon. The tests were done within one hour of each other. The examiners did not know what results the other had recorded.

The results showed an acceptable level of interrater reliability for three of the four tests. The impingement test had low reliability. The next step in finding clinical tests that can be used to evaluate hip pain is to assess the validity of these tests.

This is done by comparing the test results with arthroscopic findings. Validity is a measure of how well the test accurately identifies a condition. The authors note that validity studies of these tests are currently underway.

In this report, physical therapists (PTs) describe a tpical home care program for patients after a hip fracture. With shorter hospital stays and faster discharge times, many older adults need the services of a PT to regain function.

Activities of daily living can be very difficult to manage alone after this disabling injury. The patient often needs assistance walking and managing stairs. Studies show that patients who are able to return home after a hip fracture have better results than those who go to a skilled nursing facility or nursing home. And there are fewer deaths among patients who receive home care PT after a hip fracture.

The current status of home care PT includes active range of motion exercises and functional training activities. These training activities include moving in bed (rolling over, sitting up), getting in and out of bed, and tub or shower transfers. Balance and safety training are also included. Some therapists add stretching and resistance training. Balance training, breathing exercises, and aerobic conditioning were included by some, but not all, therapists.

This information was summarized from a survey taken of over 1,000 PTs providing home care. The authors describe the process by which the survey was developed, tested, and given. Details of data collection and analysis were also reported. A few regional differences were noted but for the most part, answers to survey questions were very similar.

The next step is to identify treatments that lead to the best results or outcomes for home physical therapy after hip fracture. Some studies already show that exercise with resistance is needed. With this added feature of the treatment program, mobility disabilities may be decreased. Specific exercises and the intensity, frequency, and duration of the chosen exercises remain to be determined.

Ongoing research is needed. For example, adding an aerobic exercise or high-intensity exercise may be needed.There may be There may be a specific combination of exercises that work best to restore function after hip fracture. Physical therapists are the most likely group to further extend this research and report new findings. The final result may be a home care PT program that provides faster and more complete recovery after hip fracture.

Today, surgeons have moved past the question of whether or not a total hip replacement (THR) can be done with one or two small incisions. We know it is, indeed, possible. Today’s research is focused instead on quality and results of this minimally invasive method.

Studies so far show that the outcomes of surgery aren’t much different with a long (invasive) versus small (minimally invasive) incision. In this article, two orthopedic surgeons review and summarize research comparing minimal with standard length incision for THRs.

The minimal incision method can be done from one of four directions or methods. There is the posterior approach, the anterolateral approach, direct anterior approach, and the two-incision approach.

The length of the incision is usually between one and a half and two inches. There may be one or two incisions made. The posterior approach is the most popular. The incision is made along the buttock muscles at the back of the hip. Patients are less likely to limp with the posterior incision. But the risk of dislocation is greater for patients with a small femoral head size.

The anterolateral approach starts in the same spot as the posterior incision. But instead of going down the middle of the gluteus muscles, the cut is made in front of the gluteus muscles. Blood loss and length of hospital stay are less with this approach.

The direct anterior approach has been around for 30 years. It has the advantage of giving the surgeon access to the hip through less soft tissue. However, the risk of dislocation, fracture, infection, and nerve injury is greater with this method.

The two-incision approach places one small cut along the front of the hip and one in the back. A special X-ray device called a fluoroscope allows the surgeon to view an image of the hip on a computer screen.

Computer navigation of this type gives the surgeon a more detailed image of the anatomy. This may help with placement and fit of the implant. This is very helpful when direct vision of the site isn’t possible because of the small size of the incisions.

Studies show very fast early recovery with the two-incision approach. Patients may go home on the same day as the surgery. The downside is that it takes quite a bit of experience on the part of the surgeon to master the technique. And patients are exposed to longer periods of radiation.

The authors conclude that as minimally-invasive techniques for THR become increasingly popular, more study is needed on the outcomes. Rates of complications, amount of blood loss, and length of time in surgery must be studied more closely. Speed of recovery, cosmetic result, and patient satisfaction should also be considered.

Recent developments have made it possible for young, active adults with arthritis to have bone-preserving replacement surgery. The procedure is called a total hip resurfacing. This article presents a review of this concept.

Hip resurfacing involves smoothing down the uneven and damaged joint surfaces. Then a metal cap is placed over the head of the femur (thigh bone). A metal liner is placed inside the hip socket.

When hip resurfacing was first introduced, there were some concerns about the femoral head. Would the heat from the cement next to the bone damage it? Would the blood supply to the femoral head be cut off by the procedure?

Surgeons have studied these problems. They found ways to modify their techniques to keep this from happening. But long-term studies are still needed to show how the metal-on-metal hip resurfacing (MOMHR) holds up 10 and even 20 years later.

So far, five-year follow-up studies report a 98 per cent survivorship rate. Functional outcomes are excellent. Problems such as infection, loosening, and dislocation are rare. Plus the MOMHR gives patients a higher level of activity and greater range of motion when compared with a total hip replacement.

The authors advise that success with MOMHR depends on pre-operative planning. For the best results, the surgeon should create a template for each patient. The template is a clear plastic pattern used to determine the right size component to use. This is an essential step in preparation for hip reconstruction.

Is it safe to have a total hip replacement (THR) if you are obese or older than 75 years of age? This review shows that the answer is yes for each unique group. But there are some risks and special factors the surgeon must consider.

Patients whose body mass index (BMI) is greater than 30 kg/m2 are classified as obese. They may be at increased risk for complications from anesthesia and poor wound healing. The presence of sleep apnea, diabetes, and high blood pressure are additional risk factors for poor outcome. And the durability and surface of the implant may not last as long.

The number of adults who remain active in their older years is on the rise. Therefore, the need for THR is increasing in this age group. There are concerns about blood clots, poor rehab, and falls linked with hip dislocation among the elderly. There are even more risk factors for older adults with dementia or Alzheimer’s.

Studies show that careful management is needed for both the obese and the elderly patient. A multidisciplinary (team) approach is needed. Rates of infection and poor wound healing may be higher in the obese group. Mental confusion and decline in cognitive function are problems after surgery for the aging patient.

The surgeon can expect that both groups will need more help during the rehab phase. Patients and their families should be told that improved function may be less than hoped for or anticipated. Bariatric surgery for weight loss in obese patients before THR does not appear to decrease complications.

In this case report, a 73-year-old woman with Gorham’s disease is described. Gorham’s disease is also known as the vanishing or disappearing bone disease or the phantom bone disease.

It is a massive destruction or osteolysis of bone. The condition may have a genetic basis but this has not been proven yet. Usually only one bone is affected. However, the process can spread to nearby soft tissues and adjacent bones.

The bones affected most often are in the pelvis, shoulder, or jaw. Ribs, spine, and skull can also be involved. This patient had severe and constant left hip pain. Her left leg was one centimeter shorter than the right. She had a significant loss of motion and limped when walking.

Surgery to replace the hip joint was planned. An X-ray showed massive osteolysis so the operation was cancelled. Further testing with CT scans and MRIs helped identify the disease.

Her condition was made worse by an infection that developed while she was in the hospital. IV and oral antibiotics were used to take care of the infection. Bone osteolysis continued to progress. Once the infection was under control, then the hip replacement was rescheduled.

At the time of operation, the surgeons saw degeneration of the hip muscles. One muscle was even partially torn. The hip capsule was thickened. The head of the femur (thigh bone) was completely destroyed.

The total hip replacement (THR) was a success. Everything healed well and her function was restored. She could walk normally and did not have any pain. Final X-rays shows no further signs of osteolysis.

In this article, Dr. Iorio from the Lahey Clinic in Massachusetts reviews treatment options for displaced fractures of the femoral neck. The femoral neck is the bridge of bone between the long shaft of the femur (thigh bone) and the round head at the top that fits into the hip socket.

A displaced fracture means the bones on either side of the break have shifted. In order for good healing to occur, the fracture lines must be lined up or the bones replaced. Surgery is needed to accomplish repair or reconstruction.

Repairing the break is referred to as reduction with internal fixation. Metal plates, screws, nails and/or wires are used to fix or hold the bones in place until they knit together. In the case of reconstruction, a total hip replacement (THR) is done.

The choice of treatment depends on several factors. Age and general health are two main considerations. Young, healthy, active adults with good bone stock are usually treated with reduction repair. The best choice may not be so easy to determine for older adults.

There are many factors to consider. Was the patient able to walk before the fracture? Would a repair or reconstruction be more likely to get the patient back up on his or her feet? Cost for each method of management must be considered. Does the patient have the mental ability to follow directions and complete a rehab program?

Once the decision is made regarding reduction or replacement, the surgeon faces another series of decisions. What kind of surgical technique should be used? What kind of internal fixation would give the most stable hip? If a THR is going to be done, should it be with or without cement? What type of implant would be best?

The author advises a THR for most displaced femoral neck fractures in the elderly. For those who are good candidates, the THR gives the best chance for regaining function and maintaining independence. In the long run, THR is more cost effective compared with reduction surgery.

Patients who have dementia, confusion, or other mental handicaps should have a hemiarthroplasty. In such cases, just the femoral head and neck are replaced. The acetabulum (hip socket) is not replaced.

Osteonecrosis of the hip, a condition in which the bone tissue in the hip dies, affects mainly young, active patients. Its origin is unknown, making it more difficult to treat. The authors of this study undertook a research of the literature to find previously completed studies that investigated the causes and treatments for osteonecrosis of the hip.

The researchers reviewed the article for etiology (origin of the disease), pathophysiology (changes associated with the injury), evaluations, and both surgical and non-surgical treatments. The researchers found that although no distinct cause for osteonecrosis of the hip has been found, some factors appeared to be involved in the development. Among those were consumption of alcohol, high doses of corticosteroids, and abnormal clotting of the blood (coagulation, as well as some genetic factors.

For evaluations, physicians have been relying on magnetic resonance imaging (MRI), which has a 99 percent accuracy rate in detecting osteonecrosis of the femoral (thigh bone) head. The researchers noted that using MRI for diagnosis is helpful in following the progress of the disorder. They noted that the high fat content of the bone, detected by MRI may have a connection with the corticosteroids that is thought may induce some osteonecrosis. Testing also allows the physicians to classify the hip deterioration by severity.

When assessing treatments for osteonecrosis of the hip, the researchers found a desire to use pharmaceutical agents (medications) to treat first, not only as treatment but as prevention for patients who are thought to be at a higher risk of developing the disorder, such as those on high doses of steroids. These medications include alendronate, a medication given for osteoporosis, or thinning bones, enoxaparin, a medication given to thin the blood and reduce clotting time, and iloprost, a medication given to patients with a disease called pulmonary arterial hypertension. Both alendronate and iloprost showed promise but need further testing in order to prove their efficacy in treating osteonecrosis of the hip.

Some physicians have tried to treat the disorder with extracorporeal shockwave and pulsed electromagnetic field therapy. The short-term findings were promising but longer term trials are needed.

Surgery is the option when other treatments are not viable or do not work. The surgeons try to spare the femoral head but, at times, must do a total hip arthroplasty, a hip replacement. Other more novel treatments have also been tried. These include a process called a bone morphogenetic protein enhanced bone graft, which is aimed at preventing the disease from progressing.

The authors conclude that more testing must be done in order to gain a better understanding of the best treatments for osteonecrosis of the hip. They recommend that core decompression, with or without bone graft is likely the best method for lesions that have not yet collapsed, with replacements being performed for those that have collapsed. MRI for staging is a useful tool and allows physicians to stage and monitor the patients’ progress.

Legg-Calve Perthes disease, a disease where the femoral head, or the top of the thigh bone, softens and breaks down, occurs most often in children between 4 and 8 years old, but leaves damage in the hip that results in problems in adulthood.

Total hip arthroplasties, or replacements, (THAs) use the femur (thigh bone) to help stabilize the implant. However, this can be difficult if the part of the bone has been damaged by Perthes disease. For this reason, the authors of this study wanted to see if total hip resurfacing, a procedure that only replaces part of the hip, and reshapes and caps the head of the femur instead, would be a better option for these patients.

Hip resurfacing is being done more often among people under 55 years old who need hip replacements. The advantages include they are harder to dislocate and they don’t require as much word done on the remaining bone as a full replacement. This gives surgeons more to work with if additional hip surgeries are needed as the patients get older.

The records of 18 patients were examined for this study. One patient had both hips resurfaced, for a total of 19 hips to be reviewed. Following the surgery, all patients were allowed to stand and participate in physiotherapy, although weight bearing was only at 50 percent until 6 weeks after the surgery. Hip progress was assessed before surgery and then at 6 weeks, 6 months, and 1 year after the procedure, and annually thereafter. The physicians used the Harris hip score (0 to 100, with 100 being the best), and x-rays. Patients did self-evaluations with the Short Form-12 Health Survey that assessed the mental component and physical summary, also at the time of the doctor assessments. In order to compare the treatment group with others who had THAs, the authors did a literature search to identify similar patients and to review their outcomes.

The results of the hip resurfacing were positive. Before the surgery, the Harris hip score ranged from 16 to 68. Although 1 patient did not do well, for the rest of the patients, this score rose to 53 to 98 following surgery. The patient who did not do well went on to have a THA. The researchers found that the patients’ range of motion of the hip improved from 70 degrees to 140 degrees before surgery to 115 degrees to 140 degrees after surgery.

One of the problems experienced by these patients is the shortening of one leg. The average shorter leg was shorter by 11.3 millimeters before the surgery. This improved to 6.7 mm after the surgery.

The authors concluded that although there was no true control group due to the unavailability of such a group, the study’s findings indicated that through the follow-up period, the hip resurfacing was a success for this patient group. They pointed out that due to the possible increased damage to the femur among patients who had Perthes disease, this approach allows for a stronger result than a THA.

Although hip resurfacing has been available for a few decades, the high failure rate caused the procedure to be fall out of favor with many surgeons. However, with new techniques and understanding of the procedure following a meeting of specialists, the procedure is now considered an option for select patients.

The authors of this study wanted to evaluate if these changes improved patient outcomes and reduced complications. To do this, researchers compared the hip resurfacing results of 292 hips before the meeting and 724 after. The outcome of the meeting was a better understanding of the reasons for resurfacing failures, improved techniques, and how to choose the most ideal patients for the procedure.

The patients were evaluated before the surgery and immediately afterwards, between 1 to 6 weeks later. They were assessed again at 6 and 12 months after surgery, and then annually thereafter unless complications required treatment.

The researchers used the Harris hip score to evaluate the status of each hip – a score of 100 is the best score possible. Among the patients who had the surgery before the meeting, the average HHS was 93.1; for those after the meeting, it was 93.4. Breaking this down, among the patients in the before-meeting group, 74.7 percent were rated excellent, 12 percent rated good, 5.5 percent rated fair, and 3.8 percent rated poor. Four percent were not available. Among the after-meeting patients, 74,7 percent were rated excellent, 10.6 percent rated good, 3.9 percent rated Fair, and 3.7 percent rated poor. Just over 7 percent were missing.

The authors noted that patients in the before-meeting group had more revisions than the after-meeting group (13.4 percent vs. 2 percent, respectively). The before-meeting group also experienced more femoral fractures (7.2 percent vs. 0.8 percent), and more loosening (3.4 percent vs. 0.6 percent). This trend continued with pulmonary embolism (clot to the lungs), with the before-meeting group at 1 percent, the after-meeting group at 0.6 percent; the deep vein thrombosis (blood clots in the veins) rate was 2.7 percent in the before-meeting group and 2.2 percent in the after, and with death, 1.4 percent of the patients in the before group died and only 0.6 percent in the after group.

Looking at the results, the authors concluded that, despite the limitation of the short follow-up period, they demonstrated that the metal-on-metal hip resurfacing appears to be promising following the meeting with recommended procedure improvements.

Range of motion, how well a joint moves about naturally, has been a significant measure in the success of knee arthroplasties, or replacements. However, the same attention has not been paid to total hip arthroplasties (THAs).

The authors of this study sought to understand if there is a correlation between a patient’s ability to move the hip with a good range of motion will provide a prognosis regarding the success or failure of the THA.

The researchers analyzed the hip range of motion of 1383 patients who had a total of 1517 THAs. Alongside using the Harris hip score, the researchers also evaluated the patients’ ability to walk a distance, climb stairs, put on socks and shoes, and sit in a chair, as well as looking for pain, a limp, or the use of a device for support.

Among the patients, whose average age was 69 years, the average body mass index was 28.2 kg/m2. There were more females (57.9 percent) than males. As the evaluations were done, the hips were assigned a function group: high was the ability of the hip to flex more than 115 degrees, turn in the hip 25 degrees or more, and flexion contraction of 20 degrees or less. An average rating was motion of 90 degrees to 114 degrees, turning the hip inward 16 degrees to 24 degrees, and flexion contraction of less than 20 degrees. The low motion group were hips that had a flexion of less than 90 degrees, inward rotation of less than 15 degrees, and a flexion contraction of 20 degrees or higher. Thirty five percent fell into the high group, 51 percent into the average, and 14 percent in the poor.

The findings were correlated with the Harrison hip scores and the researchers found that the numbers associated. The authors thus concluded that using range of motion following a hip replacement is useful in determining prognosis following THA.

For patients who have undergone an uncemented total hip arthroplasty (replacement), rehabilitation includes limited/partial weight bearing on the affected hip for a period of six to 12 weeks to reduce the risk of the stem of the implant moving, resulting in the bone not being able to settle and to solidly hold the implant.

This approach has not been backed up through studies. The authors of this study wanted to see if it was possible for patients to begin earlier weight bearing without affecting the implants’ stability. To do this, the researchers enrolled 43 patients who received an uncemented CLS hip stem arthroplasty; however, one patient died two weeks after surgery due to a pulmonary embolism (clot to the lung), so results were based on 42 patients.

The researchers evaluated the patients’ bone density in most of the patients; two patients could not be measured. All patients, average age 54.5 years, had osteoarthritis of the hip and weighed no more than 100 kg. After surgery, the patients were randomized, 21 per group, to unrestricted weight bearing (UWB) or partial weight bearing (PWB). Although patients were allowed to have paracetamol and morphine for pain, as needed, nonsteroidal anti-inflammatory drugs (NSAIDs) were not given for the first week after surgery. Patients also received heparin, to reduce the risk of blood clots, and antibiotics to reduce the risk of postoperative infections.

The patients in the UWB group underwent intensive physiotherapy for the first three months after surgery, which included full weight bearing in addition to flexion and strength exercises. They also trained in the water for the first four to six weeks, and cycling on an ergometer bicycle was added at seven weeks.

The patients in the PWB group began with crutches, limiting their weigh bearing on the affected hip, while the UWB group patients only used crutches if they felt they needed them. The PWB group followed instructions that “focused on cautious training,” allowing full weight bearing only after three months.

For evaluation, the weight bearing was evaluated before surgery at 1 week after surgery, and again at three, six, and 12 months after surgery. Clinical evaluations were done before surgery and at one week, and then again at one, three, 12, and 24 months. The findings were based on the 42 patients, two of whom had surgery on the other hip during the study period. One patient in the UWB group had revision surgery due to loosening, at 1.5 years after the initial surgery. The researchers found no significant differences between the two groups of patients and the ability of the implant to become fixed. The authors wrote, “We combined early full weight bearing with a vigorous physiotherapy program including loaded exercises and ergometer cycling. However, this very active regimen did not significantly affect the measured parameters, compared with our current rehabilitation program with PWD for three months.”

Authors of a small study have found that hip arthroscopies can be an effective and safe tool for managing hip disorders. The advantages of arthroscopy include the minimal invasiveness of the procedure compared with surgery, short rehabilitation period following the procedure, and reduced interference for future surgical intervention. However, a good understanding of the appropriate patient group for whom arthroscopies would be a benefit is important.

Researchers reviewed the records of 35 patients (average age 32 years, ranging from 11 to 55 years) who underwent hip arthroscopy between April 2004 and November 2006. Each patient was followed up for at least six weeks following the procedure. For seven patients, diagnosis prior to the procedure was idiopathic (unknown cause) painful hip. Six of these patients had debris removed from the hip during the arthroscopy and one was diagnosed with intra-articular osteochondroma. When comparing the arthroscopy findings with the imaging tests done prior to the procedure on the remaining patients, 11 had a consistent diagnosis. The remaining patients had their diagnosis changed. For example, in five hips, a lesion that was seen by imaging, was not seen by arthroscopy. The authors of this study point out that in a previous study, the author found that these lesions were commonly overestimated through imaging tests.

Following the procedure, the patients underwent similar rehabilitation programs (full weight bearing with crutches as tolerated and simple range-of-motion exercises) following same-day discharge for 90 percent of the patients.

The authors conclude with the following observations:

– Patient selection is important in order to optimize the chance of successful outcome
– Although either general or spinal anesthetic may be used, it is vital that the muscles be as relaxed as is possible for the procedure
– Reasons not to perform a hip arthroscopy include a systemic illness, superficial infection, arthrofibrosis or ankylosis, non-progressing avascular necrosis, and morbid obesity.

The researchers also found that patients older than 55 years who had advanced degenerative arthritis did not do as well with the procedure as did the younger patients or those without the arthritis.

In this paper, two cases of hip arthrokatadysis first reported in 1929 are reprinted. Arthrokatadysis is a sinking-in of the hip socket (acetabulum). The patient with this condition presents with hip pain and loss of motion.

The underlying cause of this problem remains unknown. In the first case, a 37-year-old homemaker developed symptoms after the birth of her first child. There was a history of phlebitis (blood clots) linked with her pregnancy.

She reported burning pain in the hip joint area and a gradual loss of motion. Muscle wasting was observed at the time of the medical exam. The affected leg was one-fourth of an inch shorter than the uninvolved side. X-rays did show subsidence (sinking) of the acetabulum into the pelvis. The hip was not dislocated.

Dr. Richard A. Brand, who reviewed these cases with today’s knowledge and information, offered the following opinion. The arthrokatadysis may have occurred as a result of a disturbance in the vascular supply to the hip.

Since there was a history of blood clots, it’s possible that the acetabulum did not get the nutrition it needed. Softening and sinking of the bone resulted.

In the second case, a 43-year-old woman had symptoms in both hips. X-rays showed hip dislocation on both side (worse on the left). Dr. Brand suggested the bilateral presentation points to a systemic cause. Lab tests were negative, but there may have been a glandular problem of some type.

This condition and these cases were presented with an invitation for other similar cases to be reported and studied. Finding the cause of the problem may help identify the best treatment approach. Previous management with rest, casting, manipulation, and physical therapy have not been proven effective.

In the last 10 years, surgeons have developed a new method to treat painful and disabling hip arthritis. Hip resurfacing arthroplasty is a type of hip replacement that replaces the arthritic surface of the joint. This method removes much less bone than the traditional total hip replacement.

In this article, Dr. T.P. Schmalzried from the Joint Replacement Institute in Los Angeles, California reports on second generation resurfacing procedures. Second generation refers to an improved line of implant devices.

Improved materials, cement, and techniques have taken care of many of the problems with the first generation resurfacing implants. The components are more durable now. They can be held in place without cement. There is a thinner metal-on-metal design. This makes it possible to save even more bone than with the first generation of resurfacing joint replacements.

Cementless fixation has reduced the risk of implant loosening. Replacing ceramic and polyethylene materials with metal has improved fracture rates. Using metal bearings has also decreased the squeaking that can occur with ceramic-on-ceramic implants.

More and more adults in their forties and fifties are seeking hip joint replacements. They don’t want to be limited by the pain of hip arthritis. At the same time, they want to remain physically active. Hip joint resurfacing may be a good option for this group.

Careful patient selection is still the key to a good result. Men 55 years of age or younger have the best results. This is especially true if they have good bone stock, good biomechanics, and limited degeneration of the femoral head.

The outcomes of hip resurfacing are improved when there are no bone spurs increasing the risk of fracture at the head-neck junction. Postmenopausal women with low bone mass have the highest risk of hip fracture. Even with the new generation of implants, they are not always good candidates for hip joint resurfacing. Advancing age compounds these risk factors.

Subtrochanteric femoral fractures are rare. When they do occur, they require careful diagnosis and treatment. Failure to recognize this fracture pattern can lead to problems with surgical repair.

Subtrochanteric femoral fractures involve the area or zone between the lesser trochanter and the place where the middle third of the femur (thigh bone) meets the upper portion of the bone. The lesser trochanter is a cone-shaped bump at the base of the femoral neck. Several hip and thigh muscles attach to this area of bone.

In this article, an orthopedic trauma surgeon describes the system used to classify these fractures. Evaluation and initial treatment are discussed. Even with X-rays, it may not be easy to identify a subtrochanteric fracture correctly. Sometimes the diagnosis takes place in the operating room.

The author offers detailed instruction in the stabilization of these fractures. The placement of internal fixation with plates, screws, or nails is demonstrated with drawings and X-rays.

With careful surgical repair, the patient shouldn’t need bone grafts. Compression plates apply indirect reduction and stabilize the fracture during healing. Union rates of 90 per cent or better have been reported using this method without bone graft.

Deep vein thrombosis (DVT) or blood clots are a major concern with this type of fracture pattern. The surgeon must pay attention to this potential problem even before surgery. Pneumatic compression along with blood thinners may be needed before and after surgery. Patients must be monitored carefully for any signs and symptoms of DVTs.

Femoral neck fracture is a unique complication after total hip joint resurfacing. In this study, surgeons explore the incidence (how often this happens) and the risk factors for this type of fracture.

Five hundred and fifty (550) patients received a metal-on-metal total hip resurfacing from one surgeon. Femoral neck fractures were much more common in the first group of patients to have this procedure. At first, the incidence of femoral neck fracture was 2.5 per cent. This rate went down to 0.4 per cent by the end of the study.

Surgical technique and learning how to do the procedure probably accounted for the early complications seen in this study. After analyzing the data, the authors also noted that women and obese patients had the highest incidence of fractures.

Women, especially postmenopausal women, are more likely to have decreased bone density. Poor bone stock at the femoral neck can lead to fractures. Surgeons who do enough of these operations develop the skill and technique needed to avoid errors leading to fractures.

The authors note that joint hip resurfacing should not be done on a casual basis. The surgeon must be trained for this method and use it routinely.

Selecting the right patient is also important. Body mass index (BMI) should be less than 35. Normal BMI is a range between 20 and 25. Overweight is between 25 and 30. Obese is defined as a BMI between 30 and 40.

Joint resurfacing is a more difficult operation to perform than a total joint replacement. With joint resurfacing, more of the bone is saved. The femoral head is not cut off like in the total joint replacement. This makes it more difficult for the surgeon to see the acetabulum (socket) during the operation.

With the right training, education, and patient selection, hip joint resurfacing is a very successful procedure. More than 90 per cent of patients who receive resurfacing have an excellent outcome up to five years later. More long-term studies are being done to find out the long-term results.

Sometimes it’s necessary to remove part of the femur (thigh bone) during a total hip replacement. This procedure is called a trochanteric osteotomy. It allows the surgeon better access to the hip joint. The piece of bone that is removed will be wired back in place.

In this article, orthopedic surgeons review the various wiring methods used to reattach the bone. Advantages and disadvantages of each one are discussed. Recommendations are made for the type of wire and knots to use for the best results.

There are three fixation systems used to reattach the trochanter to the femur. These include wires, cables, and cable grip systems. Each type of device is discussed in detail. The results of studies using each method are summarized.

The wire or cable must be able to keep the bone fragment in place until union takes place. At the same time, it must hold up under compressive, shear, and load forces.

For example, muscles that move the hip apply more than four times the patient’s body weight on the hip. This type of force occurs anytime a person goes up stairs or gets up out of a chair. Even with fixation, muscle contraction be strong enough to pull the bone segment away from the femur.

The authors suggest using 16-gauge wire with a square knot or knot twist. This provides the best strength for fixation to hold the bone in place and prevent migration. At the same time, this wiring method has a lower rate of breakage.

Nonunion is most often the result of limited experience of the surgeon and technical errors. Placement and tightening of the wire are key factors. To prevent breakage of the fixation device, surgeons give patients special instructions to follow. Certain movements such as active hip abduction (moving the leg away from the body) must be avoided.

Finally, patient selection is important to the success of the operation. Previous hip surgery and the presence of other hip or spine conditions are risk factors for a poor outcome. The surgeon must always choose the patient and the choice of fixation device carefully.

Materials used in hip replacement implants have varied over time. Ceramic femoral heads were popular in the late 1980s. Zirconia ceramic was favored at one time because of its resistance to crack formation. If a crack did occur, the zirconia could expand to stop the crack from getting worse. The crack would be sealed in place.

In this study, researchers tested zirconia heads removed due to failure. All implants included were the same size and type to make comparisons equal.

The zirconia heads were scanned with a special microscope. Tests were done to measure surface roughness. Fracture toughness was calculated. The content of the material was also analyzed.

The authors report a direct link between length of time the implant was in the body and breakdown of the surface. Over time, fracture toughness decreased and surface roughness increased. Wear and tear was worse in implants with an irregular surface. There was no link between patient age, weight, or level of activity as a cause of implant failure.

Aging-induced wear seems to affect only the outer layer of the zirconia heads. The surface changes seen in this study did not affect the entire femoral head. Surgeons should be aware that zirconia ceramic may not hold up over time. The risk of implant fracture and uneven wear increases over time.

Ceramic materials have been used in total hip replacements for more than 30 years now. Improved materials and design have increased the popularity of this type of implant. But in a small number of patients, squeaking can occur.

In this article, surgeons from the Colorado Joint Replacement Center report on this problem. They review the studies done so far and report on the cause and how often this happens. Photographs and diagrams of the problem implant are included.

No one knows for sure what causes the hip to squeak with ceramic-on-ceramic implants. Special moving X-ray studies using fluoroscopy have helped identify some problems. Squeaking implants removed from patients have also been studied.

One type of implant seems to be involved most often: Trident by Stryker Orthopaedics. The extended rim on the socket side of the implant seems to be causing pinching of the femoral head and neck.

Other possible causes of hip squeaking may include decreased lubrication in the joint and a mismatch of the implant parts. The cause of a dry joint is unknown. To avoid mismatched components, the authors advise surgeons not to mix and match component parts from different manufacturers.

The squeaking is annoying but not usually painful. Sometimes it goes away on its own. This may happen if a small amount of polishing occurs on the ceramic surface. When the problem doesn’t go away, surgery can be done to revise the implant. This isn’t usually necessary.

Hopefully, continued improvements in design, materials, and positioning of the implant will take care of this problem in the near future.