Naples Orthopedic Surgeon - Dr. Robert J. Zehr » hip replacement surgery

What to do about noisy, dislocating hip replacement

admin — Fri, 04 Nov 2011 10:01:20 +0000

I have an unusual situation. I’m only 23 years old, but because of severe hip dysplasia, I had to have a hip replacement. Because of my age, the ceramic-on-ceramic type implant was recommended. I’m nine months post-op and have two problems. First, the hip squeaks and clicks. Second, it also dislocates. I’m going to be seeking advice from several orthopedic surgeons in my area, but I wanted to also ask your group what to do.

Hip dysplasia is a condition in which there is a disruption in the normal relationship between the head of the femur (thigh bone) and the acetabulum (hip socket). Usually, the acetabulum is too shallow or sloping rather than a normal cup shape. It cannot hold the femoral head in place. Hip subluxation (partial dislocation) and even full dislocation can occur.The condition can be present at birth or develop in the early months to years of life. Conservative (nonoperative) care is possible when this condition is identified early in life. But sometimes, it’s not possible to keep the femoral head in good contact with the acetabulum. Then surgery may be required.

Hip replacement is usually not the first procedure used for this problem. An open reduction is a surgical procedure used most often in children two years old or older when hip dysplasia has not been corrected. During this operation, the surgeon removes any abnormal tissues that are keeping the femoral head from fitting inside the acetabulum and cuts any tight ligaments in the joint capsule around the hip joint. The surgeon may perform a tenotomy during the surgery to cut the tightly contracted tendons or muscles in the hip area. This relaxes the tight structures around the hip joint and allows the hip to be placed in the socket.

Other more advanced procedures may be required. An operation called derotational osteotomy may be needed. In this surgical procedure, the femur is cut and rotated to make it easier to keep the femoral head inside the acetabulum. When this procedure is done, the soft tissues loosen up and the forces of the muscles tend to keep the femoral head reduced. But when all else fails, a hip replacement may be the only way to correct the problem. Ceramic-on-ceramic bearings are used most often on young, active patients but complications such as squeaking or other noises are possible. For a while, it was thought that the ceramic implants had a very low rate of noise-making (less than one per cent). But a recent study showed that when specifically asked about this problem, up to 10 per cent of the patients who were surveyed reported noises. Squeaking was the most common, but there were reports of grinding, popping, and snapping.

Some patients aren’t bothered by the noises — or at least not enough to have a second (revision) operation. But with chronic dislocations, it may be necessary to swap out the ceramic-on-ceramic implant for one that has metal-on-polyethylene (plastic) or even a ceramic-on-polyethylene interface. The surgeon who has been following you will probably be the best one to advise you. Given your age and the diagnosis of hip dysplasia, there are likely other complicating factors to be considered.

For more information on this subject, call The Zehr Center for Orthopaedics at 239-596-0100 or visit www.zehrcenter.com. The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of a visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.

How soon can I swim after a hip replacement?

admin — Wed, 02 Nov 2011 10:00:03 +0000

I was always a swimmer through grade school, high school, and college. I probably should have kept it up because now I need a hip replacement. The exercise would have been good for me. Oh well. What do the experts say about swimming after a hip replacement? How soon can I start?

With the recent effort to reduce the length of hospital stays, physical therapists are exploring the most effective ways to treat orthopedic patients. The standard rehab program after hip or knee joint replacement includes a mix of exercises to improve circulation and to prevent blood clots and other complications. Other goals include improving motion, strength, and function (especially walking).

Aquatic therapy after hip replacement may fill the bill nicely. Aquatic (pool) therapy is defined as physical therapy that is performed in the water. There are good reasons to consider using aquatic therapy after joint replacement. Aquatic therapy uses the resistance of water instead of weights. With the reduced load provided by the buoyancy of the water, certain exercises (e.g., squats, step ups, walking without a cane or walker) can be started sooner in water than on land. Circulation is also improved leading to faster tissue healing and reduced swelling.

A recent study from Australia looked at the benefit of aquatic therapy in the early days after joint replacement. Physical therapists randomly placed patients getting a hip or knee replacement into one of three different treatment groups. The goal was to find out what kind of treatment is best in the early days after orthopedic surgery. Everyone in the study either had a hip or knee replacement. They each received the standard postoperative hospital care by a physical therapist for the first three days after the operation. After that, the patients were randomly assigned to one of three groups. Group one continued with the standard care. This included circulation and deep breathing exercises, transfer practice, gait (walking) training, and practice going up and down stairs. Stretching and strengthening exercises were also done daily. Group two received a nonspecific water therapy session each day they were in the hospital. Group three had one standard physical therapy treatment each day and attended aquatic therapy everyday while in the hospital. The only reported difference among groups in this study was hip abductor muscle strength. Hip abductor strength is important for trunk and hip stability and normal a gait (walking) pattern. Patients in the specific aquatic therapy program had the greatest improvement in strength. When all other variables were compared among the groups, the aquatic group had the best short-term improvements. At the end of six months, there was no difference in outcomes from one group to the next. There were overall trends that seemed to support the idea that aquatic therapy was slightly more beneficial than either land-based or nonspecific water-based exercises.

You may be able to start swimming early on after your surgery. But you’ll need to check with your surgeon. Some rehab programs have an aquatic program specifically geared toward postoperative orthopedic patients. Keying into specific muscle groups needing strengthening after each type of surgery may be to the patient’s advantage. It might be best to go through a rehab-specific program before just resuming swimming laps. That way you’ll get the best of both worlds — the pleasure of getting back in the pool while performing exercises just for your new situation.

How long should it take to recover from total hip replacement?

admin — Mon, 17 Oct 2011 10:30:04 +0000

I had a total hip replacement about 9 months ago. I had it in my head that I’d be back to normal after about six months. But that isn’t the case at all. What went wrong?

Studies do show that the average patient makes rapid gains in recovery after a hip replacement in the first three to six months following the procedure. Patients are encouraged to keep up their exercise program after that for at least another six months (if not longer).

It appears that it takes some people as long as two years to fully regain strength, motion, and function. It’s not entirely clear why there are such differences. Many factors may come into play. For example, the type of procedure performed has something to do with it. More invasive procedures that require the surgeon to cut through major hip muscles can delay restoration of normal movement patterns.

Implant placement is an important key. The implant must be put in place with the correct angle and rotation. If the center of rotation is off, the muscles can’t function normally. Hip stability, load on the hip, and biomechanics are all affected in different ways by these variables. Sometimes the patient ends up with a leg length difference. The implant may sink down into the bone too much making the operated leg shorter than the other leg. In other cases, the component parts make the leg longer than the other side. Either of these situations can impact recovery.

There’s also some question about how long the rehab program should extend. The standard time is two to three months. There’s some evidence that this just isn’t long enough. But it’s not clear yet what the ideal time frame may be. Some experts who study human movement and posture have also suggested that a different rehab protocol may be needed. It’s clear that the hip abductor muscles are key here. These muscles move the leg away from the body. They also stabilize the hip when you stand on one leg. Both functions are equally

What happens if a hip replacement dislocates?

admin — Thu, 06 Oct 2011 11:00:35 +0000

My mother fell and dislocated her new hip replacement. They took her back into surgery and put the joint back in place. She’ll be going to a step-down transition unit. What should we expect for a prognosis? Will it hold? What happens if it doesn’t?

Dislocation is every patient’s fear after getting a new hip replacement. The surgeons call it instability. No matter what name you give it, the problem is troublesome for the patient and a complex challenge for the surgeon. Conservative (nonoperative) care is usually tried first. Once the hip is back in the socket, a brace may be applied and the patient is sent to physical therapy.

Not all surgeons use bracing in these situations. If they do, the brace used is called an abduction brace. It holds the hips apart and in a neutral position (not turned in or rotated out). The physical therapist will help your mother learn how to move safely while strengthening the muscles around the hip.

A special focus of treatment is to restore normal joint proprioception (sense of joint position) and kinesthesia (awareness of movement). Balance training is also very important. Before discharging her to home, the therapist will interview the family to find out what kind of changes need to be made at home. For example, throw rugs will have to be removed, additional lighting (especially for at night) may be needed, grab bars installed in and around the bathroom, and so on.

If a conservative approach doesn’t work and the hip dislocates again and again, then surgery may be needed. The surgeon may have to tighten up loose tissue and restore a balance to soft-tissue tension on all sides of the hip joint. If the implant is improperly positioned, it must be removed and realigned. The surgeon may need to replace the femoral head with a larger one. The goal is to prevent a recurrent (second) hip dislocation.

The good news is that only 10 per cent of patients who dislocate the hip after receiving a total hip replacement will dislocate it a second time. Your surgeon and the rehab team will help you navigate through this difficult time. Don’t hesitate to bring up your concerns and questions. They have knowledge of your mother’s health and hip condition that they can draw on to provide you with answers.

Hip resurfacing vs. hip replacement

admin — Tue, 04 Oct 2011 11:00:38 +0000

I’m looking into the possibility of having a hip joint resurfacing procedure done instead of a total hip replacement. I’ve heard all about the positives of this operation from my surgeon. Could you fill me in on any down sides there might be?

Hip resurfacing arthroplasty is a type of hip replacement that replaces the arthritic surface of the joint but removes far less bone than the traditional total hip replacement. Because the hip resurfacing removes less bone, it may be preferable for younger patients that are expected to need a second, or revision, hip replacement surgery as they grow older and wear out the original artificial hip replacement.

You are asking, how well do they work? And what are the potential problems or complications? Using data from the 1000s of hips done outside of the United States along with studies done in the states, it’s clear that the overall revision rate is still higher for resurfacing than for standard total hip replacements. But the rate is still small enough to make it worth having the procedure for the many patients who aren’t ready yet for a complete total hip replacement.

The most common complications are femoral neck fracture, implant dislocation, and metal ion hypersensitivity. Because the component parts of the implant are metal, tiny pieces of metal ions flake off and get trapped inside the joint forming a tumor-like cyst or entering the blood stream. This could become a problem for anyone with metal hypersensitivity.

Studies show that women are more likely to have a failed resurfacing procedure. So are patients who’ve had a previous hip surgery or anyone who has osteonecrosis (loss of blood supply to the top of the femur or thighbone causing death of bone cells). And anyone with inflammatory arthritis or developmental dysplasia of the hip is at increased risk for implant failure.

Joint resurfacing is a stop-gap measure for patients with painful arthritic conditions. By preserving as much bone as possible, it buys them some time before converting to a total hip replacement. This plan allows younger patients to remain active and put off the inevitable hip replacement.

Fast-track program for hip replacement

admin — Fri, 30 Sep 2011 11:00:12 +0000

Have you ever heard of a fast-track program for total hip replacements? That’s what my father is on, and we are just wondering what it means.

Patients and surgeons are both interested in a speedy, painless recovery from surgery after a total hip replacement. To reach that goal, surgeons have introduced something called a minimally-invasive surgery (MIS). Minimally invasive surgery refers to any operation where the surgeon changes how long or how deep the cut is made into the tissue. With some minimally invasive approaches, the surgeon can avoid cutting into most of the muscles around the hip that are normally removed from the bone during the standard hip replacement surgery. The hope is that with less trauma to the soft tissues (especially the muscles around the hip), the patient will be able to recover that much faster.

There are also some efforts to speed up the rehab or postoperative recovery process. A program called the fast-track has been designed to accomplish this. Several studies have shown that patients who are on the fast-track after surgery get better faster. The fast-track means they get a patient-controlled pump to manage their pain. They start rehab sooner, and the therapist provides a more aggressive program. In studies so far, patients in the fast-track groups are discharged sooner, can walk better, and are more satisfied than patients following the standard rehab protocol. This is true no matter what type of incision or approach was used to do the surgery.

Not everyone can participate in a fast-track program. Patients are selected based on general health, motivation, and compliance level. Complications after surgery such as infection, dislocation, or fracture can put an end to someone’s fast-track status. But for those who are able to complete the program, the results have been very impressive.

Patient wants tiny incision

admin — Wed, 28 Sep 2011 11:00:11 +0000

I’m going to have a total hip replacement next week with the new minimally invasive surgery. The surgeon has explained how this is to my advantage, but mostly, I’m just interested in having a tiny incision. Am I going to be sorry I didn’t have the standard type of incision? Will my vanity come around and bite me in the butt, so-to-speak?

You’re not alone in your concern about form over function. Even if the minimally-invasive approach doesn’t yield better functional outcomes, patients like how it looks. A shorter incision just looks better, and patients are asking for that. Patients also want an implant that will last as long as possible. And that factor is more important to them than the length of the scar or how long they are in the hospital.

There are many advantages to a minimally-invasive approach. And we’re not talking about just a shorter incision line. Minimally invasive refers to the fact that the group of muscles usually cut to remove the old hip joint aren’t touched. The gluteus maximus (buttock) muscle is split to get to the hip joint, but the length of the split is much shorter. The incision into the joint capsule is also smaller and repaired without any negative effects.

Studies are ongoing to assess the results of minimally-invasive surgeries. There are mixed reviews as to outcomes. In some studies, the operating time is shorter and there’s less blood loss. In others, the operation is complex and may take more time if the surgeon hasn’t done quite a few of them. But the long-term results (a year or more later) don’t really show much of an advantage of the minimally invasive approach over the standard incision. Walking distance, walking speed, and muscle strength appear to even out between the two surgical approaches. There are still plenty of factors to consider when comparing the two approaches. Patient education, preoperative counseling, analgesia, and rehabilitation programs may be the real keys to recovery. While the surgical approach might make a difference, there’s at least enough preliminary information to suggest that the postoperative treatment process may be equally (if not more) important.

Pain on inside of hip could be arthritis

admin — Thu, 22 Sep 2011 11:00:03 +0000

I have a deep pain in my groin that my doctor diagnosed as a hip problem – arthritis. I always thought if you had hip pain, it was on the outside?

Hip pain from problems like osteoarthritis does often show up in the inner thigh or groin area, more so than the outside. This is because of the anatomy of the joint and where the ball of the femur, the thigh bone, fits into the socket of hip joint. It’s in the inner part of the hip that the motion takes place that allows you to move your leg inward and outward again.

Soccer player chooses surgery for snapping hip syndrome

admin — Tue, 20 Sep 2011 11:00:09 +0000

After a very long and unsuccessful attempt at treating my snapping hip syndrome, I finally decided to have surgery to release the hip tendons on both sides. I’m hoping to be through rehab by the time soccer season starts again. How long does it take to get my full strength and motion back?

Some athletes are bothered by a painful snapping at the hip when moving the leg from a flexed to an extended position. There can be a variety of reasons why this happens. Some occur outside the joint such as when a tendon rubs over a bony prominence. Others are caused by something going on inside the joint. It could be a tear in the labrum (rim of cartilage around the hip socket) or a loose fragment inside the joint. The most common cause is the iliopsoas tendon rubbing over a bony bump called the iliopectineal eminence. Many times there is also a fraying or a tear of the labrum contributing to the problem.

Whatever the cause, treatment is needed to help the athlete get back into action. At first, conservative care with rest, stretching exercises, and antiinflammatory drugs is advised. A nonoperative approach should be tried for at least six months. Sometimes a steroid injection with a numbing agent into the iliopsoas bursa helps. When none of these approaches reduces or relieves painful snapping symptoms, then surgery may be advised. The surgeon can partially or fully cut the iliopsoas tendon away from the bone. The tendon retracts and reattaches to the nearby soft tissue.

Recovery and rehab takes at least 10 to 12 weeks. At first, you won’t be able to bend the hip. This makes you unstable when trying to walk or use coordinated movements of the legs. This new symptom will last two to four weeks until the tendon reattaches and heals in its new location. You’ll be given some simple exercises to do at first. You will probably work with a physical therapist who will supervise how much weight you put on the leg(s), how to use crutches or canes, and a progression of leg control exercises. Eventually stretching exercises will be included, then coordination exercises, and finally, sport-specific movements. When you can control your motion, have 90 per cent strength, and can handle impact activities, then you will be released to return to the soccer field.

What is a cervical hip fracture?

admin — Wed, 14 Sep 2011 11:00:42 +0000

Have you ever heard of a cervical hip fracture? What is that? I thought the cervical bones were in the neck, not in the hip.

There are many types of hip fractures, usually named for their location. A basic understanding of the hip anatomy will help visualize where the fractures occur.

The hip joint is one of the true ball-and-socket joints of the body. The hip socket is called the acetabulum. It forms a deep cup that surrounds the ball of the upper thighbone, or femoral head. The femoral head is attached to the rest of the femur by a short section of bone called the femoral neck. A bony bump on the outside of the femur just below the femoral neck is called the greater trochanter. A smaller bony bump on the femur called the lesser trochanter is located on a diagonal from the greater trochanter.

These two bumps on the femur are where some of the hip muscles attach. A cervical hip fracture refers to the fact that the break is inside the joint itself. Either the top of the femur (called a subcapital fracture) or the acetabulum (hip socket) have a break. Another term for the location of these fractures is intracapsular or cervical.

When the break affects the hip, but is not right inside the hip, the fracture is referred to as an extracapsular hip fracture. The fracture may occur in the neck of the femur (femoral neck fracture), between the two trochanters (intertrochanteric fracture), or in the main shaft of the femur just below the lesser trochanter and may extend down the shaft of the femur. This last type of hip fracture is called a subtrochanteric fracture.