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Q. A year ago I had a total
hip replacement done. Last week I was out gardening
on my hands and knees and it dislocated. I thought I
was all healed. What
happened?
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Q. A year ago I had a
total hip replacement. I did all my exercises and
I'm almost back to normal. There is one problem. It
feels like that leg is longer than my other leg. Is
this possible or am I just imagining it?
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Q. About a year ago I
had a total hip replacement. My hip pain is much
better but now I'm starting to have pain along the
front of my groin and thigh. Could this be from the
new joint?
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Q. According to the
X-rays and my doctor's measurements one of my legs
is longer than the other. I'm about 9 months
post-hip replacement. I'm having some pain and a
little trouble walking normally but it's not too
bad. What kinds of problems might occur with this
later?
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Q. After a new hip
replacement I started having back pain that I never
had before. My doctor thinks it might be that one
leg is longer than the other. The plan is to wait
and see what happens. Does this mean the doctor just
doesn't know what to do about it?
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Q. After getting a
total hip replacement I ended up with nerve damage.
It's very disappointing to have to always use a cane
and drag my leg around. How often does this happen?
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Q. As a result of a
severe case of hip dysplasia, at age 28, I had a hip
joint resurfacing procedure done. So far, it's
lasted five years. What are my chances I'll be able
to keep this implant for the rest of my life?
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Q. Both my parents
have had total hip replacements. Both have had to
have a second operation on the same hip. Is this a
common thing or just a coincidence?
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Q. Dad is in the
hospital with a hip fracture. This is a first for
our family. What can we do to help him maintain his
independent lifestyle once he's home?
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Q. Do you think
dementia should prevent my father from having a
total hip replacement? He is still in good health
and otherwise mobile. But we are worried he'll get
up and walk on it when he shouldn't.
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Q. I am going in to
have hip replacement surgery. How soon can I get
back to the things I enjoy?
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Q. I got heterotropic
ossification after a total hip replacement. I'm
still recovering from the hip surgery. What's the
treatment for this new problem?
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Q. I had a hip joint
replacement last month and got a nasty infection in
the joint. Does this come from the operating room?
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Q. I had a total hip
joint replacement last month. The physical therapist
got me up and walking on the day after the
operation. Is this typical?
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Q. I have a brand new
ceramic hip replacement and it squeaks when I walk.
What in the world causes this? Will it go away?
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Q. I have heard that
it isn't good to have a hip replacement when you are
too young. Why is that? You would think that a
younger person is healthier for surgery.
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Q. I heard that most
hip fractures are in women over 65. Can you explain
why this happens?
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Q. I've been dealing
with an arthritic hip for years. Now it's affecting
my sleep. I heard that having a total hip
replacement could help me sleep better. How does
that work? |
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Answers
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Q. A year ago I had a total hip
replacement done. Last week I was out gardening on
my hands and knees and it dislocated. I thought I
was all healed. What happened?
Many factors can play a part in hip
dislocation after replacement. For example, which
side of your hip is the scar located? Any position
you get in that can push the hip in that direction
has the potential to cause a dislocation.
When you are on your hands and knees,
you have your body weight against that hip. If you
twist or angle your body against the hip, injury can
occur. Your weight and bone density are also
important factors. Being overweight means that much
more pressure through the hip. Having osteoporosis
(brittle bones) or decreased bone density makes it
harder for the bone to grow around the new implant
and hold it in place. Bone or muscle weakness can
also lead to injury.
Most patients are given positioning
precautions for the first 12 weeks post-op. In
theory at 12 months you should be free to assume any
position possible. In practice, sometimes our
theories (and hips) don't hold up.
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Q. A year ago I had a total hip
replacement. I did all my exercises and I'm almost
back to normal. There is one problem. It feels like
that leg is longer than my other leg. Is this
possible or am I just imagining it?
You may be quite right. In a small
number of patients after total hip replacement the
leg either is longer or seems longer. An X-ray and
exam are needed to find out for sure.
If the leg is truly longer than the
other one, the doctor will see this on X-ray.
Sometimes this can happen because of the implant.
Usually the patient has pain along the outside of
the hip or around the incision. The pelvis drops on
the short side to make up the difference. A shoe
lift may be all that's needed.
If the legs are truly equal in length
on X-ray then the problem is considered called a
functionalleg length difference. This means the soft
tissues around the hip are tight or off-balance
pulling the leg up or down. In these cases physical
therapy may be helpful. An aggressive program of
stretching and/or strengthening may restore limb
length and function.
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Q. About a year ago I had a total hip
replacement. My hip pain is much better but now I'm
starting to have pain along the front of my groin
and thigh. Could this be from the new joint?
There are many possible causes for
thigh pain. The joint replacement is certainly one.
But both systemic and musculoskeletal problems can
refer pain to the anterior thigh. For example,
throbbing pain can be a sign of a vascular problem.
Atherosclerosis in the blood vessels of your legs
can limit the blood supply causing pain.
Other systemic causes of anterior
thigh pain include kidney stones, tumours, abscess,
diabetes, and chronic use of alcohol. Less often,
thigh pain may be the first symptom of an inguinal
hernia.
On the musculoskeletal side, spinal
stenosis (narrowing of the spinal canal) can cause
anterior thigh pain. So can fractures or stress
reactions from osteoporosis, sacroiliac joint
problems, and nerve compression.
A medical doctor will need to examine
you to diagnose the cause. An X-ray will be taken to
check the status of your implant. The type of pain
and its location will help the physician find the
cause.
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Q. According to the X-rays and my
doctor's measurements one of my legs is longer than
the other. I'm about 9 months post-hip replacement.
I'm having some pain and a little trouble walking
normally but it's not too bad. What kinds of
problems might occur with this later?
Most patients like you with a minor
leg length difference after a total hip replacement
have very few (if any) symptoms. Even a moderate
difference (up to three centimetres or 1 inch) is
very manageable.
When there's a severe difference
(more than three centimetres) symptoms such as
limping, pain, numbness, and loss of balance can
occur. In older adults there's even an increase in
the amount of oxygen it takes to walk or do daily
tasks using the legs. Changes in lung and heart
function start to occur with a two to three
centimeter leg length difference.
In the long run a leg length
difference can cause the new hip to wear out sooner.
Uneven ground reaction forces through the legs to
the hips put added stress on the joint and
surrounding soft tissues.
Sometimes something as simple as a
shoe insert is all that's needed. You can use up to
three-eighths of an inch inside the shoe without
changing the shoe or the walking dynamics. Ask your
doctor to measure your legs to find out how much
correction is needed.
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Q. After a new hip replacement I
started having back pain that I never had before. My
doctor thinks it might be that one leg is longer
than the other. The plan is to wait and see what
happens. Does this mean the doctor just doesn't know
what to do about it?
Actually it tells us your doctor
knows a lot about what happens next. In the months
after a hip replacement you'll be busy with healing,
rehab, and recovery. That's not the best time to do
something about a possible leg length difference.
About three to six months after
surgery you should start to see a relaxation of the
hip and leg muscles. Some doctors won't even allow
the patient to use a shoe insert or shoe lift until
a full six months has passed.
Make sure your physical therapist
knows this is a problem. The PT can often help bring
about a change through stretching and/or
strengthening exercises. Ask your doctor again what
can be done if there's still a problem at your
six-month check-up.
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Q. After getting a total hip
replacement I ended up with nerve damage. It's very
disappointing to have to always use a cane and drag
my leg around. How often does this happen?
Motor nerve palsy after total hip
replacement (THR) is relatively rare. Studies report
one to four percent of the cases end up this way.
There is some evidence to suggest it's happening
more often than it used to.
A recent study from the Mayo clinic
thinks this may be related to the newer uncemented
implants. Implant without cement requires more
forceful pounding on the bone during the operation.
The stress may put extra strain on the nearby
nerves.
One other possible cause of the more
recent rise in nerve palsies after THR may be the
amount of leg lengthening that takes place. There
aren't any studies to show just how far the leg can
be lengthened without problems occurring. The Mayo
study showed nerve palsies with more than 3.8 cm of
length added.
They suggested the nerve palsy can
occur with a change in nerve length or by scar
tissue forming in the area. Scarring can keep the
nerve from gliding and moving even a little bit so
that even minor amounts of lengthening become a
problem.
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Q. As a result of a severe case of
hip dysplasia, at age 28, I had a hip joint
resurfacing procedure done. So far, it's lasted five
years. What are my chances I'll be able to keep this
implant for the rest of my life?
Long-term studies of hip joint
resurfacing have not been reported yet. There's been
one study of a small number of patients (20) who had
a failed hip resurfacing. They all had a second
operation to convert to a total hip replacement and
did quite well.
The patients who needed conversion
surgery either had a femoral neck fracture or
loosening of the femoral component. Fortunately,
this doesn't happen very often. But that means we
don't have much to report from research studies yet.
Based on results of total hip
replacements, most implants are expected to last at
least 10 to 15 years. With today's improved
materials and surgery techniques, there's some hope
that many patients will actually get longer use than
that.
At age 28, if you live another 50
years, it's likely that at some point you will have
to convert to a total hip replacement. Wear rates
are somewhat dependent on how active you are.
Although it's advised to stay active, too much
activity (for example training for and running
marathons) can reduce the life of your implant.
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Q. Both my parents have had total hip
replacements. Both have had to have a second
operation on the same hip. Is this a common thing or
just a coincidence?
Reoperations after total hip
replacement (THR) are not uncommon. The most common
reasons for reoperation are loosening of the
implant, repeated dislocation, or bone fracture
around the implant.
Most patients report minor trauma
before bone fracture. Spontaneous fracture (no known
cause) is more likely after revision surgery.
Revisions are done to repair or replace the primary
(first) THR.
Other reasons for reoperation can
include nonunion of the fracture or refracture.
Sometimes infection or fracture of the implant can
occur.
Researchers are collecting data to
help sort out who is at risk for implant failure or
reoperation. One way to do this is to create a
national patient registry. For example in Sweden,
anytime someone has a total hip replacement, the
surgeon must report information about the case to
the Swedish National Hip Arthroplasty Register.
This registry has three separate
databases. Each one collects slightly different bits
of information. This allows researchers to group
data together for easier analysis. Information can
be used to identify who has a reoperation, fracture
or refracture, or other complications.
Patient selection, implant choice,
and experience of the surgeon all seem to be
important factors in THR surgery. Your parents'
situation could be the result of one of these
factors -- or it could indeed be just a coincidence.
We still don't always know how to tell exactly what
caused the problem in order to prevent it.
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Q. Dad is in the hospital with a hip
fracture. This is a first for our family. What can
we do to help him maintain his independent lifestyle
once he's home?
Many older adults who survive a hip
fracture are left with problems they didn't have
before the fracture. For example, they may have to
use a walker or cane to get around. Walking and
managing stairs can be major disabilities now.
Dressing and undressing can be difficult. And some
patients are unable to get back to their regular
community or social activities. Recovery can take up
to two years.
Most patients receive physical
therapy while in the hospital. But PT after
discharge isn't always ordered or provided. Yet
studies show that patients with this injury who have
PT after going home are less likely to be re-hospitalized.
They are also less likely to die from complications
of this condition.
The therapist will help the patient
regain motion, balance, and strength needed to
resume normal activities of daily living. These
skills are also needed to get back to regular social
activities. Breathing exercises and aerobic
conditioning may help prevent problems such as
pneumonia that can cause rehospitalization and even
death.
After a few weeks of PT, many
patients can be set up on a supervised home program
they can follow on their own. The therapist will
also help identify safety concerns in the home
environment. Anything you can do to make sure safety
feature are installed (e.g., lighting, tub bars)
will go a long way to prevent future falls and
subsequent fractures.
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Q. Do you think dementia should
prevent my father from having a total hip
replacement? He is still in good health and
otherwise mobile. But we are worried he'll get up
and walk on it when he shouldn't.
Quality of life is an important issue
at any age and in any circumstance. The presence of
Alzheimer's, dementia, or other neurologic problem
must be considered but isn't a reason to withhold
treatment.
In the case of hip replacements, an
assessment of need should be done. An orthopaedic
surgeon is the best one to consult for this. There
may be other less invasive treatments that can make
a difference. Physical therapy to help restore
motion and strength can help. If they haven't been
tried yet, cortisone injections and/or
anti-inflammatory medications may provide some
effective relief.
And if it turns out that surgery
really is the best option, the surgeon will modify
treatment to take the cognitive condition of the
patient into account. For example, there are
minimally invasive surgical techniques that can be
used to take the old joint out and put the new
implant in. The postoperative protocol allows for
early weight-bearing. There are fewer restrictions
on movements and positions.
The type of implant used can be
chosen based on the patient's specific needs. A
larger femoral head component helps reduce the risk
of dislocation. Cementing the prosthesis in place
also makes for a more stable joint. Preventing
complications is a key factor in cases like this.
Having a team approach with family, patient, and
health care providers will go a long way to provide
a good result.
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Q. I am going in to have hip
replacement surgery. How soon can I get back to the
things I enjoy?
The answer usually is "as soon as you
are ready." However, this depends on the activities
you have in mind. Some activities, like high-impact
sports and recreation, are not recommended after hip
replacement surgery. Other activities, like walking,
swimming, and cycling, can usually be started once
your pain is controlled and your strength improves.
It is generally just a matter of getting warmed up
and used to doing those kinds of activities again.
You should begin these activities in a gradual,
guided manner to avoid injury and complications. Be
sure to ask your doctor if you have questions about
the activities you'd like to do.
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Q. I got heterotropic ossification
after a total hip replacement. I'm still recovering
from the hip surgery. What's the treatment for this
new problem?
Heterotopic ossification (HO) or the
overgrowth of bone is not uncommon after any trauma
to the hip area. Total hip replacement tops the
list. Doctors hope to find ways to tell who might
get HO and how to prevent it. This would be much
better than trying to treat it after it occurs.
Right now, radiation therapy can be
used to treat HO. Patients are
understandablyconcerned about the possible side
effects of radiation. Also the cost of this
treatment can add up. Another option is the use of
nonsteroidal anti-inflammatory drugs (NSAIDs).
There are many different kinds of
NSAIDs. Researchers are trying to find out which
one(s) work best. The newer NSAIDs have fewer side
effects on the gut, a common problem with aspirin
and other anti-inflammatory drugs. These newer
NSAIDs are called COX-1 and COX-2 inhibitors.
It's not clear how COX-1 and 2
inhibitors work to prevent HO. Maybe they suppress
bone formation by stopping early stages of
inflammation that occur with bone growth. Or maybe
there's a direct effect of the inhibitors on the
base cells that form bone cells.
In some cases surgery is needed to
cut the bone fragments out. This can damage the
nearby muscle tissue and must be done carefully.
Even with the best surgeon, problems can occur.
Treatment often depends on how severe the problem is
and how much it's bothering the patient. Check with
your doctor about your case and see what's advised.
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Q. I had a hip joint replacement last
month and got a nasty infection in the joint. Does
this come from the operating room?
The infection rate after a joint
replacement is very low (less than 2 per cent).
Modern operating rooms have a special laminar
airflow system that has reduced the infection rate.
The source of infection after an
operation isn’t easy to trace. It’s possible, though
unlikely, that the tools used in the operation
weren’t sterile. Sometimes, staff in the operating
room don’t use completely sterile methods. This can
result in an infection.
There can be a wide range of patient
factors that can lead to such an infection. For
example, anyone with diabetes or a weak immune
system is just more susceptible to infection. A
history of alcohol or drug abuse puts a patient at
increased risk of infection.
Bacteria from another infection can
invade the joint. This could be from a bladder or
kidney infection. Often, the cause remains unknown.
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Q. I had a total hip joint
replacement last month. The physical therapist got
me up and walking on the day after the operation. Is
this typical?
Doctors make this decision based on
many factors. These include the reasons for the
joint replacement, the type of joint implant used,
and the amount of damage to the joint. For example,
a severely arthritic joint may be treated
differently from a broken hip.
Each doctor has a schedule of what
activities can be done after an operation and when
to start each one. This is called a protocol.
Putting weight on the new hip joint on the first day
after the operation is not unusual. In fact, studies
show that early motion helps prevent blood clots and
other problems.
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Q. I have a brand new ceramic hip
replacement and it squeaks when I walk. What in the
world causes this? Will it go away?
Total hip replacements come in two
parts. There's the cup to replace the acetabulum
(socket) and the round head at the top of the femur
(thigh bone) and femoral neck. These component parts
can be made out of a variety of different materials.
Ceramic was first introduced about 30
years. It wears well but tends to fracture.
Improvements in materials and design have increased
its popularity again in the last few years.
Ceramic-on-ceramic implants have the lowest wear
rate but squeaking can be a problem.
Surgeons aren't quite sure yet what
might be causing this to happen. Not all patients
are affected. And sometimes it goes away on its own.
Studies so far suggest there may be two main reasons
for this squeaking.
The first is a lack of lubrication in
the joint. This is called dry joint. But what causes
the dryness is still unknown. There are many
theories so far. It could be the liner inside the
socket is mismatched in size. Or ceramic particles
may chip off the implant and rub inside the joint.
Most likely there are either many
possible causes or several factors that occur at the
same time resulting in squeaking. A solution to the
problem hasn't been discovered yet. Once researchers
pinpoint the cause, then surgeons can find ways to
avoid or eliminate the problem.
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Q. I have heard that it isn't good to
have a hip replacement when you are too young. Why
is that? You would think that a younger person is
healthier for surgery.
The age at which a hip replacement,
or arthroplasty is ideally performed has not so much
to do with the age of the patient in terms of
health, but in terms of how well the artificial
joint would stand up to the amount of time and use
that a younger person would require.
Most younger people demand more from
their hip joints than do most seniors. A younger
person may want to continue to be able to ski, for
example or to travel and frequently walk long
distances. Researchers are working on developing
stronger, more robust artificial joints, but the
concern lies with having to replace the joint later
on as the younger patients age.
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Q. I heard that most hip fractures
are in women over 65. Can you explain why this
happens?
Two major factors account for the
number of hip fractures in older adults, especially
women over age 65. The first is osteoarthritis of
the joints -- wear and tear on the joints that seems
to be part of the aging process for many adults. The
second is osteoporosis (brittle bones), which often
occurs as a result of menopause for women.
Osteoporosis can also affect men in this age group.
Loss of balance and falls are a major
cause of hip fractures. There are many risk factors
for falls for both men and women. Muscle weakness
and decreased reaction time when the balance is
challenged are part of the problem. Medications that
cause dizziness or dehydration can also contribute
to falls.
Sometimes simple household situations
can cause problems. For example slippery floors,
throw rugs, animals under foot, or stairs without
handrails can lead to falls. Problems with vision
and hearing so common in older age can add to the
risk. Use of alcohol or other substances is another
risk factor.
Doctors, nurses, and physical
therapists are working together to teach older
adults about the dangers and risks that can lead to
falls and hip fractures. Osteoporosis prevention for
men and women begins with nutrition and exercise
early in life. Staying active and doing specific
balance exercises can also make a difference.
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Q. I've been dealing with an
arthritic hip for years. Now it's affecting my
sleep. I heard that having a total hip replacement
could help me sleep better. How does that work?
Arthritis sufferers are known to have
poor sleep patterns caused by pain. Conditions such
as osteoarthritis are a common source of hip pain in
the older adult.
A study in New Zealand showed that
sleep is improved after hip joint replacement. All
patients had painful symptoms from arthritis that
woke them up at night. Less hip pain after the
operation meant better sleep. If the patients were
awakened from sleep, it was for some other reason
than from hip pain.
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