Torbay Hip Surgeon

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Frequently Asked Questions - Hip

 

 

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Questions

 

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?

 

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?

 

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?

 

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?

 

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?

 

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?

 

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?

 

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?

 

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?

 

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.

 

Q. I am going in to have hip replacement surgery. How soon can I get back to the things I enjoy?

 

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?

 

Q. I had a hip joint replacement last month and got a nasty infection in the joint. Does this come from the operating room?

 

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?

 

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?

 

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.

 

Q. I heard that most hip fractures are in women over 65. Can you explain why this happens?

 

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?

 

 

 

Answers

 

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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