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Activities after a Hip Replacement

If you are a candidate for hip replacement surgery, you probably anticipate that life after the surgery will be much like life before it, only without the pain. In many ways, you are correct. But change doesn’t happen overnight and your active participation in the healing process is necessary to ensure a successful outcome.

Although you will be able to resume most activities, you may have to change how you do them. For example, you will have to learn how to bend to avoid putting stress on your new hip. The following suggestions will help you adapt to your new joint and resume your daily activities safely.

Activities in the hospital

Joint replacement is major surgery and, for the first few days, you’ll probably want to take it easy. But it’s important that you start some activities immediately to counteract the effects of the anesthesia, encourage healing and help prevent blood clots from forming in your leg. Your doctor and a physical therapist will give you specific instructions on wound care, pain control, diet and exercise. Ask specifically about how much weight you can put on your operated leg.

Proper pain management is important in your early recovery. Although pain after surgery is quite variable and not entirely predictable, it can be controlled with medication. Initially, you will probably receive pain control medication through an intravenous (IV) connection so that you can regulate the amount of medication you need. Remember that it is easier to prevent pain than to control it. You don’t have to worry about becoming dependent on the medication; after a day or two, injections or pills will replace the IV.

In addition to pain medication, you will also have to take antibiotics and blood-thinning medication to help prevent blood clots from forming in the veins of your thighs and calves.

You may lose your appetite and feel nauseous or constipated for a couple of days. These are normal reactions. You may be fitted with a urinary catheter during surgery and be given stool softeners or laxatives to ease the constipation caused by the pain medication after surgery. You will be taught to do breathing exercises to prevent congestion from developing in your chest and lungs.

Usually a physical therapist will visit you on the day after your surgery and begin teaching you how to use your new joint. It is important that you get up and about as soon as possible after joint replacement surgery. Even as you lie in bed, you can "pedal" your feet and "pump" your ankles on a regular basis to promote blood flow in your legs. You may have to wear compression stockings and or a pneumatic sleeve to help keep blood flowing normally.

Discharge

Your hospital stay may last from 3 to 10 days, depending on how well you heal after surgery. You will need help at home for several weeks. If you do not have sufficient help at home, you may be temporarily transferred to a rehabilitation center. The following tips can make your homecoming more comfortable.

• In the kitchen (and in other rooms as well), place items you use regularly at arm level so you don’t have to reach up or bend down.
• Rearrange furniture so you can maneuver with a walker or crutches. You may temporarily change rooms (make the living room your bedroom, for example) to avoid using the stairs.
• Get a good chair, one that is firm and has a higher-than-average seat. This type of chair is safer and more comfortable than a low, soft-cushioned chair.
• Remove any throw or area rugs that could cause you to slip. Securely fasten electrical cords around the perimeter of the room.
• Install a shower chair, gripping bar and raised toilet in the bathroom.
• Use assistive devices such as a long-handled shoehorn, a long-handled sponge and a grabbing tool or reacher to avoid bending too far over. A footstool is useful for keeping your operated leg straight out in front of you when you sit. Wear a big-pocket shirt or soft shoulder bag for carrying things around.
• Set up a "recovery center" in your home, with the phone, television remote control, radio, facial tissues, wastebasket, pitcher and glass, reading materials and medications within reach.

Activities at home

• Keep the area clean and dry. A dressing will be applied in the hospital and should be changed as necessary. Ask for instructions on how to change the dressing if you are not sure.
• Sutures will be removed in 2 to 3 weeks and X-rays will be taken to ensure that the joint is healing properly. Until then, do not shower or bathe; instead, do a simple sponge bath.
• Notify your doctor if the wound appears red or begins to drain.
• Take your temperature twice daily and notify your doctor if it exceeds 100.5°F.
• Swelling is normal for the first 3 to 6 months after surgery. Elevate your leg slightly and apply an ice pack for 15 to 20 minutes at a time.
• Wound care: General guidelines for wound care include: Calf pain, chest pain or shortness of breath are signs of a possible blood clot. Notify your doctor immediately if you notice any of these symptoms.

Medication. Take all medications as directed. You will probably be given a blood thinner to prevent clots from forming in the veins of your calf and thigh, because these clots can be life-threatening. If a blood clot forms and then breaks free, it could travel to your lungs, resulting in a pulmonary embolism, a potentially fatal condition.

Because you have an artificial joint, it is especially important to prevent any bacterial infections from settling in your joint implant. You should get a medical alert card and take antibiotics whenever there is the possibility of a bacterial infection, such as when you have dental work. Be sure to notify your dentist that you have a joint implant and let your doctor know if your dentist schedules an extraction, periodontal work, dental implant, or root canal work.

Diet. By the time you go home from the hospital, you should be eating a normal diet. Your physician may recommend that you take iron and vitamin C supplements. Continue to drink plenty of fluids and avoid excessive intake of vitamin K while you are taking the blood thinner medication. Foods rich in vitamin K include broccoli, cauliflower, Brussels sprouts, liver, green beans, garbanzo beans, lentils, soybeans, soybean oil, spinach, kale, lettuce, turnip greens, cabbage and onions. Try to limit your coffee intake and avoid alcohol. You should continue to watch your weight to avoid putting more stress on the joint.

Resuming normal activities: Once you get home, you should continue to stay active. The key is not to overdo it! While you can expect some good days and some bad days, you should notice a gradual improvement over time. Generally, the following guidelines will apply:

• Weightbearing: Be sure to discuss weightbearing restrictions with your physician and physical therapist. Their recommendations will depend on the type of implant and other issues specific to your situation. Revision hip surgery (replacing a previously implanted prosthesis) may require an extended period of time without putting weight on the leg.

• Uncemented hip replacement: For the first 6 weeks, use crutches and do not put any weight on the leg. Then gradually begin to put weight on the leg, using a cane or walker. By 12 weeks, you can begin weightbearing. This protects the joint and gives the bone time to grow into the porous coating of the implant.
• Cemented or hybrid hip replacement: Using a cane or walker, you can put some weight on the leg immediately, but should continue to use an assistive device for 4 to 6 weeks.

• Driving: You can begin driving an automatic shift car in 6 to 8 weeks, provided you are no longer taking narcotic pain medication. If you have a stick shift car and your right hip was replaced, do not begin driving until 12 weeks. The physical therapist will show you how to slide in and out of the car safely. Placing a plastic bag on the seat can help.
• Sexual relations can be safely resumed 4 to 6 weeks after surgery.
• Sleeping positions: Sleep on your back with your legs slightly apart or on your side with a pillow between your knees. Be sure to use the pillow for at least 6 weeks, or until your doctor says you can do without it.
• Sitting: For at least the first 3 months, sit only in chairs that have arms. Do not sit on low chairs, low stools, or reclining chairs. Do not cross your legs. The physical therapist will show you how to sit and stand from a chair, keeping your operated leg out in front of you. Get up and move around on a regular basis, at least once every hour.
• Going up and down stairs: Stair climbing should be avoided if possible until healing is complete. If you must go up stairs,

• The unaffected leg should step up first.
• Then bring the affected leg up.
• Then bring your crutches or canes up.

To go down stairs, reverse the process.

• Put your crutches or canes on the lower step.
• Next, bring the affected leg forward.
• Finally step down on the unaffected leg.

• Return to work: Depending on the type of activities you perform, it may be 3to 6 months before you can return to work.
• Other activities: Walk as much as you like once your doctor gives you the go-ahead, but remember that walking is no substitute for your prescribed exercises. Swimming is also recommended; you can begin as soon as the sutures have been removed and the wound is healed, approximately 6 to 8 weeks after surgery. Acceptable activities include dancing, golfing (with spikeless shoes and a cart), and bicycling (on level surfaces). Avoid activities that put stress on the joint such as tennis or badminton, horseback riding, contact sports (football, baseball), squash or racquetball, jumping, badminton, or jogging. Do not do any heavy lifting (more than 40 pounds) or weight lifting.

Do’s and Don’ts

Your doctor and physical therapist will provide you with a list of do’s and don’ts to remember with your new hip. These precautions are necessary to prevent the new joint from dislocating and to ensure proper healing. Here are some of the most common precautions.

• Don’t cross your legs for at least 8 weeks.
• Don’t bring your knee up higher than your hip.
• Don’t lean forward while sitting or as you sit down.
• Don’t try to pick up something on the floor while you are sitting.
• Don’t turn your feet excessively inward or outward.
• Do keep the leg facing forward at all times.
• Do keep the operated leg in front as you sit or stand.
• Don’t reach down to pull up blankets when lying in bed.
• Don’t bend at the waist beyond 90 degrees.
• Don’t stand pigeon-toed.
• Do use a high kitchen or bar stool in the kitchen.
• Don’t use pain as a guide for what you may or may not do.
• Do use ice to reduce pain and swelling, but remember that ice will diminish sensation. Don’t apply ice directly to the skin; use an ice pack or wrap it in a damp towel.
• Do apply heat before exercising to assist with range of motion. Use a heating pad or hot, damp towel for 15 to 20 minutes.
• Do cut back on your exercises if your muscles begin to ache, but don’t stop doing them!

Anesthesia for Hip & Knee Surgery

At some point before your joint replacement surgery, your doctor will raise the issue of anesthesia. Many people will jokingly say, "Just put me out, Doc, and wake me when it’s over." But the selection of anesthesia is a major decision that could have a significant impact on your recovery. It deserves careful consideration and discussion with your surgeon and your anesthesiologist.

Several factors must be considered when selecting an anesthesia, including:

• Your past experiences and preferences—Have you ever had anesthesia before? What kind? Did you have a reaction to the anesthesia? What happened? How do other members of your family react to anesthesia?
• Your current health and physical condition—Do you smoke? Are you overweight? Do you drink or use "recreational" drugs? Are you being treated for any condition other than your joint replacement?
• Your reactions to medications—Do you have any allergies? Have you ever experienced bad side effects from a drug? Which drug? What kind of side effects? What medications, nutritional supplements, vitamins or herbal remedies are you currently taking?
• The risks involved—Risks vary, depending on your health and selection of anesthesia, but may include breathing difficulties, blood loss, and allergic reactions. Your surgeon and anesthesiologist will discuss specific risks with you.
• The skill and preferences of your surgical team

There are three broad categories of anesthesia—general, regional, and local. You are probably familiar with local anesthesia, the kind your dentist uses when repairing your teeth. Local anesthesia numbs only the specific area being treated. Most joint replacement surgeries use either general or regional anesthesia.

General anesthesia

General anesthesia affects your entire body. It acts on the brain and nervous system, leaving you in a deep sleep. Usually, it is given by injection or inhalation. When general anesthesia is used, the anesthesiologist will also place a breathing tube down your throat and administer oxygen to assist your breathing. General anesthesia is commonly used if you are having an extensive surgical procedure that takes a long time. There are several types of general anesthetics; your anesthesiologist will discuss specific selections with you.

As with any anesthesia, there are risks, which may be increased if you already have heart disease or a chronic lung condition. General anesthesia slows both your heartbeat and breathing rates, so your heart, blood pressure, breathing and temperature are constantly monitored during the surgery. It also causes your blood vessels to open wider (dilate), which can result in a heavier loss of blood during the surgery. You may want to consider donating blood in advance of your surgery. The tube inserted down your throat may give you a sore throat and hoarse voice for a few days. Headache, nausea and drowsiness are also common.

Regional anesthesia

Regional anesthesia focuses on numbing a specific area of the body, without affecting your brain or breathing. Because you remain conscious, you will be given sedatives to relax you and put you in a light sleep. The two types of regional anesthesia used most frequently in joint replacement surgery are spinal blocks and epidural blocks. For surgery below the hip, a combination block that targets the lumbar plexus and the sciatic nerve can numb only one leg.

In a spinal block, the anesthesia is injected into the fluid surrounding the spinal cord in the lower part of your back. This produces a rapid numbing effect that can last for hours, depending on the drug used. An epidural blockuses a small tube (catheter) inserted in your lower back to deliver large quantities of local anesthetics over a longer time period. The epidural block and the spinal block are administered in very similar in location. However, the epidural catheter is placed slightly closer to the skin and further from the spinal cord than the spinal block injection. There are several advantages to using a regional anesthesia during hip or knee replacement surgery. Studies have shown that there is less blood loss during the surgery, and fewer complications from blood clotting afterwards. Side effects from regional anesthesia include headaches, trouble urinating, and allergic reactions, which could be quite serious.

Pain relief after surgery

The goals of postoperative pain management are to enable you to do the required physical therapy and to minimize pain and stress. If a general or spinal anesthesia was used during your surgery, postoperative pain relief may be delivered intravenously. You will be able to control the flow of medication, within preset limits, as you feel the need for additional relief. This process is often referred to as patient-controlled anesthesia, or PCA.

If an epidural block was used during your surgery, the epidural catheter can be left in place and anesthesia continued afterwards to help control pain. You will also have control over the amount of pain medication you receive, within preset limits. You will be closely monitored to ensure that no complications such as excessive sedation or compartment syndrome, an excessive build-up of pressure within the muscles, develop. Your doctor may also prescribe other pain relievers, such as aspirin or ibuprofen, to help control pain after surgery. However, if you are also taking drugs to help prevent blood clots, your use of these pain relievers or any other medications that could further thin the blood will need to be monitored closely.

The proper use of pain relievers before, during, and after your surgery is an extremely important aspect of your treatment, can encourage healing, and can make your joint replacement a more satisfying experience. Take time to discuss the options with your doctor and to ask questions about things you don’t understand.

Bursitis of the Hip

Throughout the body, small sacs, sometimes filled with a little fluid, called bursae act as cushions between bones, tendons and muscles. Several bursae are located around the outer area of the hip, near the portion of the thighbone (femur) called the greater trochanter (tro-KAN-ter). The greater trochanter is a broad, flat area of bone that anchors several large muscles. An inflammation of one of the trochanteric bursa is a common cause of hip pain.

Causes of trochanteric (hip) bursitis

Possible causes of trochanteric bursitis include:

• Repetitive stress (overuse) injuries.
• Multiple minor traumatic injuries.
• Lumbar spine disease such as scoliosis.
• Leg-length inequalities.
• Rheumatoid arthritis.
• Lying on one side of the body for an extended period (perhaps due to another injury or illness).
• Excessive or prolonged pressure on the hip such as from standing too long.
• An acute traumatic incident such as a fall.
• Previous surgery or prosthetic implants in the hip.

Signs and symptoms

Trochanteric bursitis can affect anyone at any age, although it is more common in women and the middle-aged or elderly than in men or younger people. The main symptom is pain.

• Aching pain is usually focused on the outside of the upper thigh, just over the point of the hip.
• Pain may radiate down the outside of the thigh as far as the knee.
• Pain is worse when you lie down or roll over on the affected side.
• Climbing stairs, sitting or standing too long and walking may all be painful.
• Pain at night may make sleeping difficult.

Diagnostic tests

The primary diagnostic test is the physical examination. Specific pain centered in one area supports a possible diagnosis of trochanteric bursitis. The physician may request additional tests to eliminate other possible injuries or conditions.

An X-ray will show any bony abnormalities or spurs, calcium deposits or other problems within the joint that contribute to the bursitis. Bone scans and MRI (magnetic resonance imaging) may be needed if there is a possible fracture, tumor or tissue death (osteonecrosis) of the femoral head.

Treatment

If the bursitis is caused by overuse, the first step in treating it is rest. Simply giving the hip an opportunity to heal by taking some time off from the activity or by modifying your exercise regimen may be sufficient. Other conservative treatments include:

• Ice applications (apply for 15 to 20 minutes, two or three times a day; do not apply ice directly to the skin).
• Nonsteroidal anti-inflammatory drugs such as ibuprofen.
• Stretching exercises, especially for the lower back and hip muscles.
• Weight loss, to reduce pressure on the hip.
• Exercises to strengthen the muscles.
• Physical therapy.
• Using a cane to reduce pressure on the hip.
• Using a lift in your shoe if one leg is markedly different in length than the other.

If conservative treatment does not relieve the pain, your physician may recommend an injection of a corticosteroid preparation, which is usually successful in relieving symptoms. Surgery is rarely required. Because persistent pain may be an early sign of hip disease, an MRI may be recommended to diagnose this condition.

Preventing another painful episode

Three steps you can take to prevent hip bursitis from returning are:

1. Avoid prolonged standing or repetitive tasks that involve your hip muscles.
2. Exercise to strengthen and stretch the muscles in your hips and lower back.
3. Be sure to see your physician before beginning any exercise program, and to follow a planned program.

Deep Vein Thrombosis

Joint replacement surgery, especially in the lower extremities, is becoming more common. Orthopaedic surgeons performed a total of 309,000 hip arthroplasties and 340,000 knee arthroplasties in 1999. The vast majority of these surgeries are very successful, and patients go on to live fuller, more active lives without pain. But no operation is without risks. One of the major risks facing patients who undergo orthopaedic surgery in the lower extremities is a complication called deep vein thrombosis, a form of venous thromboembolic disease.

What is it?

Deep vein thrombosis (DVT) refers to the formation of a thrombus (blood clot) within a deep vein, commonly in the thigh or calf. This can have two serious consequences:

1. If the thrombus partially or completely blocks the flow of blood through the vein, blood begins to pool and build-up below the site. Chronic swelling and pain may develop. The valves in the blood vessels may be damaged, leading to venous hypertension. A person’s ability to live a full, active life may be impaired.

2. If the thrombus breaks free and travels through the veins, it can reach the lungs, where it is called a pulmonary embolism (PE). A pulmonary embolism is a potentially fatal condition that can kill within hours.

Both DVT and PE may be asymptomatic and difficult to detect. Thus, physicians focus on preventing their development by using mechanical or drug therapies. Without this preventive treatment, as many as 80 percent of orthopaedic surgical patients would develop DVT, and 10 percent to 20 percent would develop PE. Even with these preventative therapies, DVT and subsequent PE remain the most common cause for emergency readmission and death following joint replacement.

Contributing Factors

Although venous thromboembolic disease can develop after any major surgery, people who have orthopaedic surgery on the lower extremities are especially vulnerable. Three factors contribute to formation of clots in veins:

1. Stasis, or stagnant blood flow through veins. This increases the contact time between blood and vein wall irregularities. It also prevents naturally occurring anticoagulants from mixing in the blood. Prolonged bed rest or immobility promotes stasis.

2. Coagulation, which is encouraged by the presence of tissue debris, collagen or fats in the veins. Orthopaedic surgery often releases these materials into the blood system. During hip replacement surgery, reaming and preparing the bone to receive the prosthesis can also release chemical substances (antigens) that stimulate clot formation into the blood stream.

3. Damage to the vein walls, which can occur during surgery as the physician retracts, twists, folds or manipulates veins. This can also break intercellular bridges and release substances that promote blood clotting.

Other factors that may contribute to the formation of thrombi in the veins include: age, previous history of DVT or PE, metastatic malignancy, vein disease (such as varicose veins), smoking, estrogen usage or current pregnancy, obesity and genetic factors.

After hip surgery, thrombi often form in the veins of the thigh; these clots are more likely to lead to PE. After knee surgery, most thrombi occur in the calf; although less likely to lead to PE, these clots are more difficult to detect. Fewer than one third of patients with DVT present with the classic signs of calf discomfort, edema, distended veins, or foot pain.

Prevention

Prevention is a three-pronged approach designed to address the issues of stasis and coagulation. Usually, several therapies are used in combination. For example, a patient may be fitted with graded compression elastic stockings and an external compression device upon admittance to the hospital; movement and rehabilitation begin the first day after surgery and continue for several months; anticoagulant therapy may begin the night before surgery and continue after the patient is discharged.

1. Early movement/rehabilitation: With hospital stays averaging just four to seven days after an arthroplasty on the lower extremity, early movement is imperative as well as beneficial. Physical therapy, including joint range of motion, gait training and isotonic/isometric exercises, usually begins on the first day after the operation. Pain relievers administered intravenously also facilitate early mobilization.

2. Mechanical prophylaxes: Mechanical preventatives are usually used in combination with other therapies. They include:

• Lower extremity exercises such as simple leg lifts, elevating the foot of the bed, and active and passive ankle motion to increase blood flow through the femoral vein.

• Graded compression elastic stockings, which are more effective in preventing thrombi formation in the calf than in the thigh.

• Continuous passive motion, which is a logical treatment, but has not been proven effective in preventing the development of DVT.

• External pneumatic compression devices that apply pulsing pressures similar to those that occur during normal walking. They can help reduce the overall rate of DVT occurrence when used with other therapies, but they are difficult to apply and patient compliance is often a problem.

• In rare cases, a filter device may be inserted in the vein.

3. Pharmacologic prophylaxis: The use of anticoagulant pharmacologic agents includes an inherent risk of increased bleeding, which must be measured against their effectiveness in preventing clot formation. The most common anticoagulants are aspirin, warfarin and heparin.

• Aspirin is easy to administer, is low cost, has few bleeding complications, and doesn’t need to be monitored. However, it has not been proven more effective than other agents and may not be advisable for all patients. Studies have shown that aspirin has a greater protective effect for men than for women.

• Warfarin is the most commonly used agent for hip and knee replacement patients. Warfarin interferes with vitamin K metabolism in the liver to prevent formation of certain clotting factors. Because warfarin takes at least 36 hours to start working, and four to five days to reach its maximum effectiveness, it is usually started the day before surgery. Low doses are used because higher doses can cause episodes of bleeding, but the dose response is difficult to predict and warfarin must be administered through an outpatient clinic. Warfarin can cause fetal damage.

• Heparin is a naturally occurring substance that inhibits the clotting cascade. It can come in high (standard unfractionated heparin) or low (fractionated heparin) molecular weights. Recent emphasis has been on low molecular weight heparins (LMWH) because they are more predictable and effective, with fewer bleeding complications than standard unfractionated heparin. LMWH is effective after both hip and knee joint replacement surgeries, but there is a higher incidence of bleeding when it is used after knee replacement surgery. The most commonly used and researched LMWH are enoxaparin, ardeparin, dalteparin and fraxiparine. Heparin works much faster than warfarin, so it is often administered initially and followed by warfarin therapy, or administered as a single agent.

Diagnosis

Diagnosing DVT is difficult, and current diagnostic techniques have both advantages and disadvantages. The most commonly used diagnostic tests include venography, duplex or Doppler ultrasonography, magnetic resonance imaging (MRI), and cuff-impedence plethysmography.

Venography uses a radiographic material injected into a vein on the top of the foot. The material mixes with blood and flows toward the heart. An X-ray of the leg and pelvis will then show the calf and thigh veins and reveal any blockages.

Although venography is very accurate and can detect blockages in both the thigh and the calf, it is also costly and cannot be repeated often. In addition, the injected material may actually contribute to the creation of thrombi.

Duplex ultrasonography can also be very accurate in identifying clogged veins. Projected sound waves bounce off structures in the leg and create images that reveal abnormalities. The addition of color Doppler imaging improves accuracy. This test is noninvasive and painless, requires no radiation, can be repeated regularly and can reveal other causes for symptoms. It also costs substantially less than venography. However, it is technically demanding and requires a skilled, experienced operator to obtain the most accurate results. Ultrasonography is less sensitive in detecting thrombi in the calf and it has limited ability to directly image the deep veins of the pelvis.

Magnetic resonance imaging is particularly effective in diagnosing DVT in the pelvis, and as effective as venography in diagnosing DVT in the thigh. This technique is being increasingly used because it is noninvasive and allows simultaneous visualization of both legs. However, an MRI is expensive, not always readily available, and cannot be used if the patient has certain implants, such as a pacemaker. In addition, the patient can experience claustrophobia.

Cuff-impedance plethysmography uses blood pressure checks at different places in the leg to identify possible blockages. Although once used extensively, this procedure is no longer recommended as a diagnostic tool because of its high false-positive rate.

Postoperative Treatment

The risk of developing DVT extends for at least three months after joint replacement surgery. The risk is greatest two to five days after surgery; a second peak development period occurs about 10 days after surgery, after most patients have been discharged from the hospital. Recently, the Food and Drug Administration approved the use of the LWMH dalteparin sodium in a once-daily, 14-day dosing regimen to prevent DVT after hip surgery. A common postoperative regimen is five days of heparin followed by three months of warfarin therapy. However, the length of time that therapy should continue after surgery varies depending on the agent used and individual patient considerations.

Orthopaedic surgeons are continuing to research techniques, such as the use of regional anesthesia and intraoperative heparin, to reduce the risk of DVT formation. Studies have shown that using regional rather than general anesthesia can reduce the overall rate of DVT formation by up to 50 percent.

Research to identify those patients particularly at risk for DVT formation after surgery is also ongoing. Some risk factors such as weight and history have been identified. Based on these risk factors, some physicians use regular surveillance of patients, while others recommend using venography to identify those patients at risk for developing DVT. In general, orthopaedic surgeons would rather avoid extended outpatient prophylaxis for all patients, preferring to focus on those most at risk.

Treatment is the same for both asymptomatic and symptomatic venous thrombo-embolisms. If the clot is located in the femoropoliteal vein of the thigh, treatment consists of bed rest and five days of heparin therapy followed by three months of warfarin. A clot in the calf veins does not normally require heparin treatment; outpatient warfarin treatment for six to 12 weeks is sufficient. These treatment regimens are designed to prevent the occurrence of a fatal pulmonary embolism and reduce the morbidity associated with DVT.

Developmental Dislocation (Dysplasia) of the Hip (DDH)

Developmental dislocation of the hip (DDH) is an abnormal formation of the hip joint in which the ball at the top of the thighbone (femoral head) is not stable in the socket (acetabulum). Also, the ligaments of the hip joint may be loose and stretched. The degree of instability or looseness varies. A baby born with DDH may have the ball of his or her hip loosely in the socket, the looseness may worsen as the child grows and becomes more active, or the ball may be completely dislocated at birth.

Left untreated, DDH or hip dysplasia leads to pain and osteoarthritis by early adulthood. It may cause legs of different lengths or a "duck-like" walk and decreased agility. DDH has a familial tendency. It usually affects the left hip and is predominant in:

• Girls.
• First born children.
• Babies born in the breech position (especially with feet up by the shoulders). The American Academy of Pediatrics now recommends ultrasound screening of all female, breech babies.

Although hip dysplasia is usually noted in the newborn exam, treatment is easier and safer the earlier the diagnosis is made. Hips found normal at birth can be found abnormal later, but this is rare. Pediatricians screen for DDH at a newborn’s first exam and at every well-baby checkup thereafter. Otherwise, the condition may not be noticed until a child begins to walk – by which time treatment is more complicated and uncertain.

Signs of DDH

Although some dislocated hips show no signs, contact a doctor if your baby has:

• Legs of different lengths.
• Uneven thigh skin folds.
• Less mobility or flexibility on one side.

In children who have begun to walk, limping, toe walking and a waddling "duck-like" gait are also signs.

In addition to visual clues, doctors use careful physical examination tests to check for subtle signs of hip instability or dislocation in babies, such as listening and feeling for "clunks." Hip X-rays also may be helpful in older infants and children.

Treatment methods depend upon the child’s age.

Newborn: An unstable hip recognized at birth is treated with a soft, simple positioning device (Pavlik harness) for 1-2 months to keep the hip bone in its socket. This may help tighten ligaments and stimulate normal hip socket formation.

1-6 months: Treatment to reposition the hip ball in the socket uses a harness or similar device. The method is usually successful; if it is not, the joint may be positioned into place under anesthesia (closed reduction) and maintained with a body cast (spica).

6 months-2 years: Manipulation of the socket under anesthesia (closed reduction) is the major method of treatment. Open surgery may be necessary. Both require a body cast (spica).

After 2 years: Deformities may have become severe, making major open surgical intervention necessary to realign the hip. This is followed by a body cast (spica).

The child will need a body cast and/or brace to keep his or her hip bone in the joint while healing after operations. X-rays and other regular follow-up monitoring are needed after DDH treatment until the child’s growth is complete. Complications may include a small delay in the development of walking if he or she uses a cast. Positioning devices may cause skin irritation, and a difference in leg lengths may remain. Growth disturbance of the upper thigh rarely occurs.

If dysplasia is treated successfully – and the earlier the better -- children end up with normal hip joint function, have no further problems and go on to lead active lives.

Falls and Hip Fractures

Ninety percent of the 350,000 hip fractures that occur each year in the U.S. are the result of a fall. By the year 2050, there will be an estimated 650,000 hip fractures annually; nearly 1,800 hip fractures a day.

Women have two to three times as many hip fractures as men, and white, post-menopausal women have a 1 in 7 chance of hip fracture during a lifetime. The rate of hip fracture increases at age 50, doubling every five to six years. Nearly one-half of women who reach age 90 have suffered a hip fracture.

Increased risk The risk of hip fracture for women 5’8" or taller is twice that of women who are under 5’2." Studies show that women who have broken their arm in the past have an increased risk of breaking a hip. Among people age 50 and older who fall, women have two to three times as many hip fractures as men.

Hip fractures are very serious

• Only 25 percent of hip fracture patients will make a full recovery; 40 percent will require nursing home care; 50 percent will need a cane or walker; and 24 percent of those over age 50 will die within 12 months.
• Nearly one-in-four hip fracture patients will die within 12 months after the injury because of complications related to the injury and the recovery period.
• The cost of hip fracture care averages $33,000 per patient.
• There were 168,106 total hip replacements performed in the U.S. in 1999.

Hip Dislocation

The hip is a ball-and-socket joint, which gives it a great deal of stability and allows it to move freely. The round head of the thighbone (femur) fits inside a cup-shaped socket (acetabulum) in the hipbone (pelvis). It requires substantial force to pop the thighbone out of its socket. But that’s just what happens in a hip dislocation.

Motor vehicle accidents are the most common cause of hip dislocations, but wearing a seatbelt can reduce your risk substantially. A fall from a ladder or an industrial accident can also generate enough force to dislocate a hip. Someone with a dislocated hip will often have other injuries, including fractures in the pelvis and legs, back injuries or head injuries.

In nine out of ten hip dislocations, the head of the thighbone is pushed out and back (posterior dislocation). This leaves the hip in a fixed position, bent and twisted in towards the middle of the body. If the thighbone slips out and forward (anterior dislocation), the hip will be only slightly bent and the leg will twist out and away from the middle of the body. A hip dislocation is very painful; the patient is unable to move the leg and, if there is nerve damage, may not have any feeling in the foot or ankle area.

Diagnosis and treatment

A hip dislocation is an orthopaedic emergency. Call for help immediately. Do not try to move the injured person, but keep him or her warm with blankets.

Usually, a physician can diagnose the dislocation simply by looking at the position of the leg. X-rays will show whether there are any additional fractures in the hip or thighbone. If there are no other complications, the physician will administer an anesthetic or a sedative and manipulate the bones back into their proper position. If there are complications, the bones can be adjusted during surgery. Afterwards, the surgeon will request another set of X-rays and possibly a CT (computed tomography) scan to ensure that the bones are in the proper position.

It takes time – sometimes as long as two to three months - for the hip to heal after a dislocation. The orthopaedic surgeon may recommend traction for a short period, followed by controlled exercises using a continuous-passive-motion machine. The patient can probably begin walking with crutches when he or she is free of pain, and should continue to use a walking aid, such as a cane, until the limp disappears.

Consequences of a hip dislocation

A hip dislocation can have long-term consequences. As the thighbone is pushed out of its socket, it can disrupt blood vessels and nerve functioning. This can result in some tissue death. The protective cartilage covering the bone may also be damaged, increasing the risk of developing arthritis in the joint.

Hip Fracture

Hip fractures are a serious health problem common among elderly men and women who fall in their own homes. Each year there are more than 320,000 hospitalizations for hip fractures, including people of all ages who are injured in car crashes and other accidents. Only one in four patients recover completely.

A hip fracture is a break near the top of your thighbone (femur) where it angles into your hip socket. When you break your hip, it usually hurts too much to stand and your leg may turn outward or shorten. In most cases, you need hospitalization and surgery. Get to your doctor or emergency room right away.

Diagnosis

Your doctor will X-ray both of your hips to determine exactly where the bone broke and how far out of place the pieces have moved. If the fracture does not show up on X-rays, you might also get a MRI (magnetic resonance imaging) scan. Most hip fractures are one of two types:

• Femoral neck fractures are 1-2 inches from the joint.
• Intertrochanteric fractures are 3-4 inches from the joint.

Surgery and early mobilization

Modern treatment for a hip fracture aims to get you back on your feet again as soon as possible while your broken bone heals. (Treatment may vary for certain elderly people who were already bedridden, have other complicated medical conditions and are not in much pain.) Your doctor will reposition the fracture and hold it in place with an internal device.

• Femoral neck fracture: Pins (surgical screws) are used if you are younger and more active, or if your broken bone has not moved much out of place. If you are older and less active, you may need a high strength metal device that fits into your hip socket, replacing the head of your femur (hemiarthroplasty).
• Intertrochanteric fracture: A metallic device (compression screw and side plate) holds the broken bone in place while it lets the head of your femur move normally in your hip socket.

Your doctor will tell you when you should start standing and walking again after surgery. You will probably need crutches, a walker or other help. You may need to do physical therapy or rehabilitation exercises to get back to your normal level of activity.

Hip Implants

Total hip joint replacement (THR) is an orthopaedic success story, enabling hundreds of thousands of people to live fuller, more active lives. Using metal alloys, high-grade plastics and polymeric materials, orthopaedic surgeons can replace a painful, disfunctional joint with a highly functional, long-lasting prosthesis. Over the past half-century, there have been many advances in the design, construction and implantation of artificial hip joints, resulting in a high percentage of successful long-term outcomes.

Implant design

The hip joint is called a ball-and-socket joint because the spherical head of the thighbone (femur) moves inside the cup-shaped hollow socket (acetabulum) of the pelvis. To duplicate this action, a total hip replacement implant has three parts: the stem, which fits into the femur and provides stability; the ball, which replaces the spherical head of the femur and the cup, which replaces the worn-out hip socket. Each part comes in various sizes in order to accommodate various body sizes and types. In some designs, the stem and ball are one piece; other designs are modular, allowing for additional customization in fit. Several manufacturers make hip implants. The brand used by your doctor or hospital depends on many factors, including your needs (based on your age, weight, bone quality, activity level and health), the doctor’s experience and familiarity with the device, and the cost and performance record of the implant. These are issues you may wish to discuss with your doctor.

Implant construction

Many people credit Sir John Charnley, a British orthopaedist, with performing the first modern total hip replacement. His innovations included combining a metal stem and ball with a plastic shell and using a methacrylate cement, similar to the cement used by your dentist, to hold the devices in place.

Today, the stem portions of most hip implants are made of titanium- or cobalt/chromium-based alloys; they come in different shapes and degrees of roughness. Cobalt/chromium-based alloys or ceramic materials (aluminum oxide or zirconium oxide) are used in making the ball portions, which are polished smooth to allow easy rotation within the prosthetic socket. The acetabular socket can be made of metal, ultrahigh molecular weight polyethylene, or a combination of polyethylene backed by metal. All together, these components weigh between 14 and 18 ounces, depending on the size needed.

All the materials used in a total hip replacement have four characteristics in common:

• They are biocompatible; that is, they can function in the body without creating either a local or a systemic rejection response.
• They are resistant to corrosion, degradation and wear, so they will retain their strength and shape for a long time. Resistance to wear is particularly significant in maintaining proper joint function and preventing the further destruction of bone due to particulate debris generated as the implant parts move against each other.
• They have mechanical properties that duplicate the structures they are intended to replace; for example, they are strong enough to take weightbearing loads, flexible enough to bear stress without breaking and able to move smoothly against each other as required.
• They meet the highest standards of fabrication and quality control at a reasonable cost.

Implant insertion

During a THR, the surgeon will take a number of measurements to ensure proper prosthesis selection, limb length and hip rotation. After making the incision, the surgeon works between the large hip muscles to gain access to the joint. The femur is pushed out of the socket, exposing the joint cavity. The deteriorated femoral head is removed and the acetabulum is prepared by cleaning and enlarging with circular reamers of gradually increasing size. The new acetabular shell is implanted securely within the prepared hemispherical socket. The plastic inner portion of the implant is placed within the metal shell and fixed into place.

Next, the femur is prepared to receive the stem. The hollow center portion of the bone is cleaned and enlarged, creating a cavity that matches the shape of the implant stem. The top end of the femur is planed and smoothed so the stem can be inserted flush with the bone surface. If the ball is a separate piece, the proper size is selected and attached. Finally, the ball is seated within the cup so the joint is properly aligned and the incision is closed.

Hip replacements may be "cemented," "cementless" or "hybrid," depending on the type of fixation used to hold the implant in place. Although there are certain general guidelines, each case is individual and your surgeon will evaluate your situation carefully before making any decisions. Do not hesitate to ask what type of implant will be used in your situation and why that choice is appropriate for you.

Cemented THR

Over the past 40 years, there have been many improvements in both the materials and the methods used to hold the femoral and acetabular components in place. Today, the most commonly used bone cement is an acrylic polymer called polymethylmethacrylate (PMMA). A patient with a cemented total hip replacement can put full weight on the limb and walk without support almost immediately after surgery, resulting in a faster rehabilitation. Although cemented implants have a long and distinguished track record of success, they are not ideal for everyone.

Cemented fixation relies on a stable interface between the prosthesis and the cement and a solid mechanical bond between the cement and the bone. Today’s metal alloy stems rarely break but they can occasionally loosen. Two processes, one mechanical and one biological, can contribute to loosening.

1. In the femoral component, cracks (fatigue fractures) in the cement that occur over time can cause the prosthetic stem to loosen and become unstable. This is more often the case with patients who are very active or very heavy. The action of the metal ball against the polyethylene cup of the acetabular component creates polyethylene wear debris. The cement or polyethylene debris particles generated can then trigger a biologic response that further contributes to loosening of the implant and sometime to loss of bone around the implant.

2. The microscopic debris particles are absorbed by cells around the joint and initiate an inflammatory response from the body, which tries to remove them. This inflammatory response can also cause cells to remove bits of bone around the implant, a condition called osteolysis. As the bone weakens, the instability increases. Bone loss can occur around both the acetabulum and the femur, progressing from the edges of the implant.

Despite these recognized failure mechanisms, the bond between cement and bone is generally very durable and reliable. Cemented THR is more commonly recommended for patients over age 60, for patients with conditions such as rheumatoid arthritis and for younger patients with compromised health or poor bone quality and density. These patients are less likely to put stresses on the cement that could lead to fatigue fractures.

Cementless THR

In the 1980s, new implant designs were introduced to attach directly to bone without the use of cement. In general, these designs are larger and longer than those used with cement. They also have a surface topography that is conducive to attracting new bone growth. Most are textured or have a surface coating around much of the implant so that the new bone actually grows into the surface of the implant. Because they depend on new bone growth for stability, cementless implants require a longer healing time than cemented replacements.

The surgeon must be very precise in preparing the femur for a cementless impact. The implant channel must match the shape of the implant itself very closely. New bone growth cannot bridge gaps larger than 1mm to 2 mm. A 6- to 12-week period of protected weightbearing (using crutches or a walker) is needed to give the bone time to attach itself to the implant. This protected weightbearing helps to ensure there is no movement between the implant and bone so a durable connection can be established. Cementless femoral components tend to be much larger at the top, with more of a wedge-shape. This design enables the strong surface (cortex) of the bone and the dense, hard spongy (cancellous) bone just below it to provide support. The acetabular component of a cementless THR also has a coated or textured surface to encourage bone growth into the surface. Depending on the design, these components may also use screws through the cup or spikes, pegs, or fins around the rim to help hold the implant in place until the new bone forms. Usually these components have a metal outer shell and a polyethylene liner. The pelvis is prepared for a cementless acetabular component using a process similar to those employed in a cemented procedure. The intimate contact between the component and bone is crucial to permit bone ingrowth.

Initially, it was hoped that cementless THR would eliminate the problem of bone resorption or stem loosening caused by cement failure. Although certain cementless stem designs have excellent long-term outcomes, cementless stems can loosen if a strong bond between bone and stem is not achieved. Patients with large cementless stems may also experience a higher incidence of mild thigh pain. Likewise, polyethelene wear, particulate debris, and the resulting osteolysis remain problems in both cemented and uncemented designs. Improvements in the wear characteristics of newer polyethylene and the advent of hard bearings (metal-on-metal or ceramic) may help resolve some of these problems in the future.

Although some surgeons are now using cementless devices for all patients, cementless THR is most often recommended for younger (under 50 years of age), more active patients and patients with good bone quality where bone ingrowth into the components can be predictably achieved. . Individuals with juvenile inflammatory arthritis may also be candidates, even though the disease may restrict their activities.

Hybrid THR

A hybrid THR has one component, usually the acetabular socket, inserted without cement, and the other component, usually the femoral stem, inserted with cement. This technique was introduced in the early 1980s, so long-term results are just now being measured. A hybrid hip takes advantage of the excellent track records of cementless hip sockets and cemented stems.

Partial hip replacements

If only one part of the joint is damaged or diseased, a partial hip replacement may be recommended. In most cases, the acetabulum is left intact and the head of the femur is replaced, using a component similar to those employed in a total hip replacement. Another option uses a hemi-surface device, made of a cobalt/chromium alloy. This device resembles a half circle and fits over the head of the femur, thus sparing the bone of the femoral head. It is fixed to the femur with cement around the femoral head and has a short stem that passes into the femoral neck.

Longevity and outcomes

Hip replacement operations are highly successful in relieving pain and restoring movement. However, the ongoing problems with wear and particulate debris may eventually necessitate further surgery, including replacing the prosthesis (revision surgery). Men and patients who weight more than 165 pounds have higher rates of failure. The chance of a hip replacement lasting 20 years is about 80 percent.

Hip Strains

The large bones that make up the hip joint also serve as anchors for several muscles. Some of these muscles move down the thigh to the knee; others move across the abdomen or the buttocks. When overuse or injury stretches or tears the muscle fibers, the resulting injury is called a strain.

Most of the time, muscle strains in the hip area occur when a stretched muscle is forced to contract suddenly. A fall or direct blow to the muscle, overstretching and overuse can tear muscle fibers, resulting in a strain. The risk of muscle strain increases if you had a prior injury in the area, do not warm up properly before exercising or attempt to do too much too quickly. Strains may be mild, moderate or severe, depending on the extent of the injury.

Signs and symptoms

• Pain over the injured muscle is the most common symptom of a hip strain.
• Using the muscle aggravates the pain.
• Swelling may also be present, depending on the severity of the strain.
• There may be a loss of strength in the muscle.

Diagnosing the injury

Your physician will ask you about your activities just prior to feeling the pain, apply pressure to various muscles in the area and move your leg or hip in various directions. You may be asked to do certain exercises or stretch in specific ways to help determine which muscle is injured. An X-ray will be used to rule out the possibility of a stress fracture of the hip, which has similar symptoms, including pain in the groin area, with weightbearing. In most cases, no additional tests are needed to confirm the diagnosis.

Treatment

In general, treatment and rehabilitation are designed to relieve pain, restore range of motion, and restore strength, in that order. RICE (rest, ice, compression, elevation) is the standard protocol for mild to moderate muscle strains. Gently massage the area with ice to help decrease swelling. Take aspirin or ibuprofen to reduce swelling and ease pain. Compression shorts or a wrap bandage may also be helpful. If walking causes pain, limit weightbearing and consider using crutches for the first day or two after the injury.

After the first couple of days, you can use heat therapy, including hot soaks, heat lamps, or heating pads, as well. Avoid the activity that caused the strain for 10 to 14 days. During that time, you can rebuild muscle strength and endurance with stretching and strengthening exercises. If the pain returns, stop and go back to easier activities that do not cause pain. Severe muscle strains may require a longer rehabilitation time.

Preventing hip strains

Several techniques can help you avoid straining the muscles around the hip. The most important technique is to stretch properly before doing any kind of exercising. Stretch muscles slowly and hold the stretch instead of doing large numbers of rapid stretches. You can also reduce your risk of hip strains if you:

• Warm up before stretching; warming up first enables you to stretch more effectively.
• Participate in a conditioning program for muscle fitness and flexibility.
• Wear or use appropriate protective gear during sports.

Inflammatory Arthritis of the Hip

Arthritis literally means "inflammation of a joint." In some forms of arthritis, such as osteoarthritis, the inflammation arises because the smooth covering (articular cartilage) on the ends of bones wears away. In other forms of arthritis, such as rheumatoid arthritis, the joint lining becomes inflamed as part of a systemic disease. These diseases are considered the inflammatory arthritides.

The three most common types of inflammatory arthritis that affect the hip are:

• Rheumatoid arthritis (RA): RA is a systemic disease of the immune system that usually affects multiple joints on both sides of the body at the same time.
• Ankylosing spondylitis (AS): AS is a chronic inflammation of the spine and the sacroiliac joint (the point where the spine meets the pelvic bone) that can also cause inflammation in other joints.
• Systemic lupus erythematosus (SLE or lupus): SLE is an autoimmune disease in which the body harms its own healthy cells and tissues.

Signs and symptoms

The classic sign of arthritis is joint pain. Inflammatory arthritis of the hip is characterized by a dull, aching pain in the groin, outer thigh, or buttocks. Pain is usually worse in the morning and lessens with activity; however, vigorous activity can result in increased pain and stiffness. The pain may limit your movements or make walking difficult.

Diagnostic tests

During the physical examination, your physician may ask you to move your hip in various ways to see which motions are restricted or painful. Your physician will want to know if you walk with a limp, if one or both hips are painful, and if you experience pain in any other joints. X-rays and laboratory studies will be needed. The X-rays will show if there is any thinning or erosion in the bones, any loss of joint space or any excess fluid in the joint. Laboratory studies will show whether a rheumatoid factor or other antibodies are present.

Treatment

Treatment depends on the diagnosis. If you have an infection in the hip joint, it must be eliminated, either through the use of medications or through surgical draining. Nonoperative treatments may provide some relief with relatively few side effects or complications:

• Anti-inflammatory medications, such as aspirin or ibuprofen, may help reduce the inflammation.
• Corticosteroids are potent anti-inflammatories, part of a drug category known as symptom-modifying antirheumatic drugs, or SMARDs. They can be taken by mouth, by injection, or in creams applied to the skin.
• Methotrexate and sulfasalazine may be prescribed to help retard the progression of the disease. These medications are part of a drug category called DMARDs, or disease-modifying antirheumatic drugs. For example, tumor necrosis factor is one of the substances that seem to cause inflammation in people with arthritis. Newer drugs that work against this factor seem to have a positive effect on arthritis in some patients as well.
• Physical therapy may help you increase the range of motion and strengthening exercises may help maintain muscle tone. Swimming is a preferred exercise for people with AS.
• Assistive devices, such as a cane, walker, long shoehorn or reacher, may make it easier for you to do daily living activities.

If these treatments do not relieve the pain, surgery may be recommended. The type of surgery depends on several factors, including your age, the condition of the hip joint, the type of inflammatory arthritis you have, and the progression of the disease. Your orthopaedic surgeon will discuss the various options with you. Do not hesitate to ask why a specific procedure is being recommended and what outcome you can expect. Although complications are possible in any surgery, your orthopaedic surgeon will take steps to minimize the risks.

The most common surgical procedures performed for inflammatory arthritis of the hip include:

• Total hip replacement is often recommended for patients with RA or AS because it provides pain relief and improves motion.
• Bone grafts may help patients with SLE to build new bone cells to replace those affected by osteonecrosis. People with SLE have a higher incidence of this disease, which causes bone cells to die and weakens bone structure.
• Another option for patients with SLE and osteonecrosis is core decompression, which reduces bone marrow pressure and encourages blood flow.
• Synovectomy (removing part or all of the joint lining) may be effective if the disease is limited to the joint lining and has not affected the cartilage.

Live It Safe

More than 323,000 people are hospitalized for hip fractures each year.

The total cost in medical bills and lost income resulting from hip fractures is more than $12.6 billion a year or an average of $37,000 per hip fracture.

Because of the aging U.S. population, the number of hip fractures is expected to reach 650,000 by 2050. Ninety percent of hip fractures are among persons 65 and older. Women over age 65 have a 1-in-5 chance of having a hip fracture during their lifetime.

Hip fractures are caused by a variety of factors that weaken bone and, often, are caused by the impact from a fall. The common characteristics of persons who are vulnerable to hip fractures are:

• Age. The rate increases for people 65 and older.
• Gender. Women have two to three times as many hip fractures as men.
• Heredity. A family history of fractures in later life, particularly in Caucasians and Asians. A small-boned, slender body.
• Nutrition. A low calcium dietary intake or reduced ability to absorb calcium.
• Personal habits. Smoking or excessive alcohol use.
• Physical impairments. Physical frailty, arthritis, unsteady balance and poor eyesight.
• Mental impairments. Senility, dementia, e.g., Alzheimer's disease.
• Weakness or dizziness from side effects of medication.

About 24 percent of hip fracture patients over age 50 will die within 12 months after injury because of complications related to the injury and the recovery period.

Most hip fracture patients who previously lived independently will require assistance from their family or home care. About half will require canes or walkers for mobility when they return home. 53 percent of hip fracture patients 65 and older are discharged from hospitals to long-term care facilities. All hip fracture patients will require walking aids for several months after injury and nearly half will permanently require canes or walkers to move around their house or outdoors.

Osteoarthritis of the Hip

Like other joints that carry your weight, your hips may be at risk for "wear and tear" arthritis (osteoarthritis), the most common form of the disease. The smooth and glistening covering (articular cartilage) on the ends of your bones that helps your hip joint glide may wear thin. Your first sign may be a bit of discomfort and stiffness in your groin, buttock or thigh when you wake up in the morning. The pain flares when you’re active and gets better when you rest.

If you don’t get treatment for osteoarthritis of the hip, the condition keeps getting worse until resting no longer relieves your pain. The hip joint gets stiff and inflamed. Bone spurs might build up at the edges of the joint. When the cartilage wears away completely, bones rub directly against each other. This makes it very painful for you to move. You may lose the ability to rotate, flex or extend your hip. If you become less active to avoid the pain the muscles controlling your joint get weak, and you may start to limp.

About 30 million Americans have osteoarthritis. You’re more likely to get it if you have a family history of the disease. You’re also at risk if you are elderly, obese or have an injury that puts stress on your hip cartilage. You can get osteoarthritis if you don’t have any risk factors. See your doctor as soon as possible if you think you may have it.

Evaluation

While you cannot reverse the effects of osteoarthritis, early nonsurgical treatment may help you avoid a lot of pain and disability and slow progression of the disease. Surgery can help you if your condition is already severe. You doctor will determine how much the disease has progressed. Describe your symptoms and when they began. Your doctor may rotate, flex and extend your hips to check for pain. He or she may want you to walk or stand on one leg to see how your hips line up. Both hips will probably be X-rayed to check if hip joint space has changed, and if you have developed bone spurs or other abnormalities.

Nonsurgical treatment

If you have early stages of osteoarthritis of the hip, the first treatment may be:

• Rest your hip from overuse.
• Follow a physical therapy program of gentle, regular exercise like swimming, water aerobics or cycling to keep your joint functioning and improve its strength and range of motion.
• Use nonsteroidal anti-inflammatory medications like ibuprofen for pain.
• Get enough sleep each night.

You may need to lose weight if you are overweight. As the disease progresses, you may need to use a cane.

Total hip replacement surgery

If you have later stages of osteoarthritis, your hip joint hurts when you rest at night and/or your hip is severely deformed, your doctor may recommend total hip replacement surgery (arthroplasty). You will get a two-piece ball and socket replacement for your hip joint. This will cure your pain and improve your ability to walk. You may need crutches or a walker for awhile after surgery. Rehabilitation is important to restore your hip’s flexibility and work your muscles back into shape.

Osteonecrosis of the Hip

Osteonecrosis of the hip is a disabling condition that can lead to your hip joint collapsing. The condition may start with few signs or warnings. If you have osteonecrosis of the hip, your blood vessels gradually cut off nourishment to the top of the thighbone (femur) where it fits in the hip socket. Without blood, the head of your femur dies and collapses. This can make it painful to move your hip, and you may develop arthritis and a limp. Cartilage in your hip’s socket may also break down. You will probably get the same problems in your other hip eventually.

Diagnosis and treatment

It is estimated that doctors see about 10,000-20,000 new cases of osteonecrosis (ON) each year. No one knows exactly what causes it. See your doctor if you start feeling a dull ache or throbbing pain to the side of your hip in the groin or buttock and you have osteonecrosis risk factors including:

• Age 20-50 years.
• Hip dislocation or fracture.
• Alcoholism.
• Corticosteroid use.
• Glandular problems and diseases including rheumatoid arthritis, sickle cell disease, myeloproliferative disorders, Gaucher’s disease, chronic pancreatis, Crohn’s disease, Caisson’s disease or systemic lupus erythematosus.

Your doctor may flex and rotate your hips to check for pain. Your hips may be X-rayed and possibly scanned by MRI (magnetic resonance imaging) to see if bone marrow is dying or dead, and how much the head of your femur may have collapsed.

• If you have ON and the head of your femur is not yet collapsed, certain medical procedures (i.e.: decompression and bone grafting) may help your body build new blood vessels and bone cells to replace the dead ones.
• If ON has already collapsed your hip, total hip replacement surgery (arthroplasty) may eliminate your pain and give you better hip mobility. A ball and socket replaces your hip joint. Your thighbone is fitted with the ball piece, which takes the place of the head of your femur. Your hip socket is fitted with the socket piece (cup).

Prevent Falls!

Falls are the leading cause of injuries to older people in the U.S. Each year, more than 11 million senior citizens fall--that’s one of every three people over 65. Treatment of the injuries and complications associated with falls costs the U.S. more than $20.2 billion annually.

The number of falls and the severity of injury increase with age. While some risk factors for falls, such as heredity and age, cannot be changed, several risk factors can be eliminated or reduced. The American Academy of Orthopaedic Surgeons has developed guidelines to help you avoid falls.

• Get an annual physical and eye examination, particularly an evaluation of cardiac and blood pressure problems.
• Maintain a diet with adequate dietary calcium and vitamin D.
• Participate in an exercise program for agility, strength, balance and coordination.
• Eliminate all tripping hazards in your home and install grab bars, handrails and other safety devices.
• Wear properly-fitting shoes with nonskid soles.
• Tie your shoe laces.
• Replace slippers that have stretched out of shape and are too loose.
• Use a long-handled shoehorn if you have trouble putting on your shoes.
• Avoid high heels and shoes with smooth, slick soles.
• Do not smoke.
• Avoid excessive alcohol intake.
• Keep an up-to-date list of all medications and provide it to all doctors with whom you consult.
• Check with your doctor(s) about the side effects of your medicines and over-the-counter drugs. Fatigue or confusion increases your risk of falling.
• Make sure all medications are clearly labeled and stored in a well-lit area according to instructions.
• Take medications on schedule with a full glass of water, unless otherwise instructed.
• Never walk in your stocking feet.
• Women who cannot find wide-enough athletic shoes for proper fit should shop in the men’s shoe department because men’s shoes are made wider.

What are the medical risk factors for a fall?

• Impaired musculoskeletal function, gait abnormality, osteoporosis.
• Cardiac arrhythmias (irregular heartbeat), blood pressure fluctuation.
• Depression, Alzheimer's disease and senility.
• Arthritis, hip weakness or imbalance.
• Neurologic conditions, stroke, Parkinson's disease, multiple sclerosis.
• Urinary and bladder dysfunction.
• Vision or hearing loss.
• Cancer that affects bones.

Falls can occur anytime, anyplace and to anyone while doing everyday activities such as climbing stairs or getting out of the bathtub. Research shows that simple safety modifications at home—where 60 percent of seniors' falls occur—can substantially cut the risk of falling. Protect yourself with these simple changes in furniture arrangement, housekeeping and lighting to prevent falls.

Bedroom

• Place a lamp, telephone and flashlight near your bed.
• Sleep on a bed that is easy to get into and out of.
• Replace satiny sheets and comforter with products made of nonslippery material, i.e. wool, cotton.
• Arrange clothes in your closet so that they are easy-to-reach.
• Install a night-light along the route between your bedroom and the bathroom.
• Keep clutter off the bedroom floor.

Living areas

• Arrange furniture so you have a clear pathway between rooms.
• Keep low-rise coffee tables, magazine racks, footrests and plants out of the path of traffic.
• Install easy-access light switches at entrances to rooms so you won’t have to walk into a darkened room in order to turn on the light. Glow-in-the-dark switches may be helpful.
• Walk only in well-lighted rooms, stairs and halls.
• Do not store boxes near doorways or in hallways.
• Remove newspapers and all clutter from pathways.
• Keep electric, appliance and telephone cords out of walkways, but don’t put cords under a rug.
• Don’t run extension cords across pathways; rearrange furniture.
• Secure loose area rugs with double-faced tape, tacks, or slip-resistant backing.
• Don’t sit in a chair or on a sofa that is so low it is difficult to stand up.
• Repair loose wooden floorboards right away.
• Remove door sills higher than 1/2".

Kitchen

• Remove throw rugs.
• Clean up immediately any liquids, grease, or food spilled on the floor.
• Store food, dishes, and cooking equipment within easy reach.
• Don’t stand on chairs or boxes to reach upper cabinets.
• Use nonskid floor wax.

Stairs and steps

• Keep stairs clear of packages, boxes or clutter.
• Light switches should be at the top and bottom of the stairs. Or consider installing motion-detector lights which turn on automatically.
• Provide enough light to see each stair and the top and bottom landings.
• Keep flashlights nearby in case of a power outage.
• Remove loose area rugs from the bottom or top of stairs.
• Replace patterned, dark or deep-pile carpeting with a solid color, which will show the edges of steps more clearly.
• Put non-slip treads on each bare-wood step.
• Install handrails on both sides of the stairway. Each should be 30 inches above the stairs and extend the full length of the stairs.
• Repair loose stairway carpeting or wooden boards immediately.

Bathroom

• Place a slip-resistant rug adjacent to the bathtub for safe exit and entry.
• Mount a liquid soap dispenser on the bathtub/shower wall.
• Install grab bars on the bathroom walls.
• Keep a night-light in the bathroom.
• Use a rubber mat or place nonskid adhesive textured strips on the tub.
• Replace glass shower enclosures with non-shattering material.
• Stabilize yourself on the toilet by using either a raised seat or a special toilet seat with armrests.
• Use a sturdy, plastic seat in the bathtub if you cannot lower yourself to the floor of the tub or if you are unsteady.

Preventing Hip Fractures

In 1999, there were more than 320,000 hospitalizations for hip fractures.

The total cost in medical bills and lost income resulting from hip fractures is more than $12.6 billion a year or an average of $37,000 per hip fracture.

Because of the aging U.S. population, the number of hip fractures is expected to reach about 650,000 by 2050.

More than 90 percent of hospitalizations for hip fractures are persons 65 and older. Women have a 1 in 7 chance of having a hip fracture during their lifetime. Men have a 1 in 17 chance.

The aging Baby Boomer who may be caring for a parent with a broken hip also is in danger because the incidence of hip fractures starts to increase at age 45.

Hip fractures are caused by a variety of factors that weaken bone and, often, are caused by the impact from a fall. The common characteristics of persons who are vulnerable to hip fractures are:

• Age. The rate increases for people 65 and older.
• Gender. Women have two to three times as many hip fractures as men.
• Heredity. A family history of fractures in later life, particularly in Caucasians and Asians. A small-boned, slender body.
• Nutrition. A low calcium dietary intake or reduced ability to absorb calcium.
• Personal habits. Smoking or excessive alcohol use.
• Physical impairments. Physical frailty, arthritis, unsteady balance and poor eyesight.
• Mental impairments. Senility, dementia, e.g., Alzheimer's disease.
• Weakness or dizziness from side effects of medication.

Women (men) are 8 percent (18 percent) more likely to die within 1 year following a hip fracture than other women (men) their age.

Most hip fracture patients who previously lived independently will require assistance from their family or home care. About half will require canes or walkers for mobility when they return home. 53 percent of hip fracture patients 65 and older are discharged from hospitals to long-term care facilities. All hip fracture patients will require walking aids for several months after injury and nearly half will permanently require canes or walkers to move around their house or outdoors.

Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) is the most common hip disorder among young teenagers. Your child’s symptoms may come on suddenly, or they may build up over time. Often the first pain is in the knee or thigh. The sooner your child gets treatment, the better off he or she will be.

SCFE happens when the cartilage plate (epiphysis) at the top of your child’s thighbone (femur) slips out of place. In a growing child, the plate is what controls the way the top of the thighbone grows. It’s also a pivotal part of the hip’s ball and socket joint, so slippage of the epiphysis may severely deform your child. Problems may include:

• He or she can’t turn the hip inward.
• His or her foot turns outward.
• His or her leg is measurably shorter.
• He or she suffers too much pain to stand on it.

Children aged 10-18 are at risk for SCFE, particularly African-American boys, and all children who are overweight or athletic. More than one-third of the time, children with SCFE in one hip develop the same condition in the other hip.

It’s important to recognize SCFE early and get the treatment your child needs right away. Surgery is less complicated and the outcome is better the sooner you get it done. If you don’t treat SCFE, your child’s deformities will get worse, and arthritis may set in.

Surgery involves stabilizing your child’s hip with pins to stop the SCFE from getting any worse. The pins help the growth plate fuse into place and become stable. Your doctor may also want to pin your child’s other hip to prevent it from developing the same problem.

Snapping Hip

When you walk, get up from a chair or swing your leg around, do you feel or hear a "snapping" sensation in your hip? Snapping hip is usually painless and harmless, although the sensation can be annoying. Young athletes and dancers frequently experience snapping hip.

Causes of snapping hip

The snapping sensation results from the movement of a muscle or tendon (the tough, fibrous tissue that connects muscle to bone) over a bony structure. In the hip, the most common site is at the outer side where a band of connective tissue (the iliotibial band) passes over the broad, flat portion of the thighbone known as the greater trochanter (tro-KAN-ter).

When the hip is straight, the band is behind the trochanter. When the hip bends, the band moves over the trochanter so that it is in front of it. The band is always tight, like a stretched rubber band. Because the trochanter juts out slightly, the movement of the band across it creates the snap you hear. Eventually, this could lead to hip bursitis. Bursitis is thickening and inflammation of the bursa, a fluid-filled sac that allows the muscle to move smoothly over bone.

Another tendon that could cause a snapping hip runs from the inside of the thighbone up through the pelvis. As you bend the hip, the tendon shifts across the head of the thighbone; when you straighten the hip, the tendon moves back to the side of the thighbone. This back-and-forth motion across the head of the thighbone causes the snapping.

A tear in the cartilage or some bone debris in the hip joint can also cause a snapping or clicking sensation. This type of snapping hip usually causes pain and may be disabling. A loose piece of cartilage can cause the hip to catch or lock up.

Diagnosis

Most people don’t bother seeing a doctor unless they’re feeling some pain. The doctor will first want to determine the exact cause of the snapping. You may be asked where it hurts, what kinds of activities bring on the snapping, whether you can demonstrate the snapping or if you’ve experienced any trauma to the hip area. You may also be asked to stand and move your hip in various directions to reproduce the snapping. The physician may even be able to feel the tendon moving as you bend or extend your hip.

X-rays are typically normal, but may be requested along with other tests so that the doctor can rule out any problems with the bones or joint.

Treatment

• If your snapping hip is painless, no treatment is needed.
• If it bothers you, reduce your activity levels and apply ice.
• Stretching exercises prescribed by your physician or a physical therapist can help.
• Nonsteroidal anti-inflammatory drugs, such as aspirin or ibuprofen, may reduce discomfort.
• If you’ve developed hip bursitis, your physician may recommend an injection of a corticosteroid to reduce inflammation.
• Modify your sport or exercise activities to avoid repetitive movement of the hip. For example, reduce time spent on a bicycle; swim using your arms only.
• In the very rare cases that do not respond to conservative treatment, surgery may be recommended. The type of surgery will depend on the cause of the snapping hip.

Total Hip Replacement

Whether you have just begun exploring treatment options or have already decided with your orthopaedic surgeon to undergo hip replacement surgery, this booklet will help you understand the benefits and limitations of this orthopaedic treatment. You'll learn how a normal hip works and the causes of hip pain, what to expect from hip replacement surgery and what exercises and activities will help restore your mobility and strength and enable you to return to everyday activities.

If your hip has been damaged by arthritis, a fracture or other conditions, common activities such as walking or getting in and out of a chair may be painful and difficult. You may even feel uncomfortable while resting.

If medications, changes in your everyday activities, and the use of walking aids such as a cane are not helpful, you may want to consider hip replacement surgery. By replacing your diseased hip joint with an artificial joint, hip replacement surgery can relieve your pain and help you get back to enjoying normal, everyday activities.

First performed in 1960, hip replacement surgery is one of the most important surgical advances of this century. Since then, improvements in joint replacement surgical techniques and technology have greatly increased the effectiveness of this surgery. Today, more than 168,000 total hip replacements are performed each year in the United States. Similar surgical procedures are performed on other joints, including the knee, shoulder, and elbow.

Total Hip Replacement Exercise Guide

Regular exercises to restore your normal hip motion and strength and a gradual return to everyday activities are important for your full recovery. Your orthopaedic surgeon and physical therapist may recommend that you exercise 20 to 30 minutes 2 or 3 times a day during your early recovery. They may suggest some of the following exercises. This can help you better understand your exercise and activity program.

Early Postoperative Exercises

These exercises are important for increasing circulation to your legs and feet to prevent blood clots. They also are important to strengthen muscles and to improve your hip movement. You may begin these exercises in the recovery room shortly after surgery. It may feel uncomfortable at first but these exercises will speed your recovery and reduce your postoperative pain. These exercises should be done as you lie on your back with your legs spread slightly apart.

Ankle Pumps - Slowly push your foot up and down. Do this exercise several times as often as every 5 or 10 minutes. This exercise can begin immediately after surgery and continue until you are fully recovered.

Ankle Rotations - Move your ankle inward toward your other foot and then outward away from your other foot. Repeat 5 times in each direction 3 or 4 times a day.

Repeat the following three exercises 10 times 3 or 4 times a day