Hip

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Hip

Conditions

Avascular Necrosis (Osteonecrosis)

Avascular necrosis (AVN), better known as osteonecrosis, of the femoral head, is a disease that causes death of bone.

There are only four "Ficat" stages. Stage 1 has a normal x-ray, but some other diagnostic test is positive (e.g., bone scan, MRI). Stage 2 has changes on plain x-ray but no sign of collapse. Stage 3 has a positive x-ray and signs of collapse (e.g., crescent sign), which is a crescent-shaped chondral lucency ( the fracture of AVN) seen on the plain x-ray. Stage 4 has a positive x-ray and signs of degenerative changes (e.g., osteoarthritis).

In the earliest stages of osteonecrosis plain x-rays are often normal. A magnetic resonance image (MRI) is the key that allows us to detect AVN at its earliest stages.

Will it get worse?

The natural history of osteonecrosis is linked to the size of the necrotic segment. Very small lesions (involvement of less than 15% of the femoral head) may resolve without any further treatment. On the other hand, lesions involving greater than 50% of the femoral head progress to collapse, and ultimately require in total hip arthroplasty.

Does Avascular Necrosis cause pain?

AVN may be present without any pain whatsoever. There may be early hip pain but unfortunately, pain often develops only once the osteonecrosis has progressed quite far. At that time the pain is caused by fragmentation and collapse of the femoral head.

How often is the other hip affected?

Verification of the status of the opposite hip is very important as part of the evaluation of osteonecrosis, because studies have shown that often the contralateral hip is asymptomatic and has a normal x-ray, and even more importantly in cases of non-traumatic osteonecrosis, the incidence of bilaterality is up to 80%.

Degenerative Joint Disease (Osteoarthritis)

Osteoarthritis or Degenerative Joint Disease is the most common type of arthritis that occurs most commonly in hips, knees, ankles, and foot joints. Osteoarthritis is also known as "wear and tear arthritis" since the cartilage simply wears out. When cartilage wears away, bone rubs on bone causing severe pain and disability. The most frequent reas on for osteoarthritis is genetic, since the durability of each individual's cartilage is based on genetics. If your parents have arthritis, you may also be at risk of suffering from degenerative joint disease.

Symptoms

Pain is the most frequent symptom for patients with osteoarthritis. The pain is usually described as being in the groin or thigh for degenerative joint disease of the hip. Degenerative joint disease of the knee most often results in pain in the knee joint. The pain is frequently associated with activity and relieved by rest. It may occur at night and, in severe cases, prevent sleep. Patients also complain of stiffness and often limp when they walk.

Femoroacetabular Impingement

Evidence is emerging that subtle abnormalities around the hip, resulting in femoroacetabular impingement (FAI), may be a contributing factor in some instances to osteoarthritis in the young patient. FAI is the abnormal contact or friction between the femoral neck/head (ball) and the acetabular margin (socket), causing tearing of the labrum and avulsion of the underlying cartilage region, continued deterioration, and eventual onset of arthritis. Nonsurgical treatment typically fails to control symptoms.

Hip Loose Bodies

The hip is described as a ball and socket joint. The ball of the femur sits deep inside the socket of the pelvic bone called the acetabulum. Several structures including the capsule, ligaments, and tendons hold these bones together. Sports injuries or trauma may move the ball too much one way or another causing small pieces of bone or cartilage to shear off. These small pieces are called "loose bodies.", and it is appropriate to think of these bodies as debris in the joint. These loose bodies may also be caused by degeneration to the hip joint as happens in many forms of arthritis. These loose bodies may stay in one place or may migrate within the joint. They can often cause pain and stiffness when they are pinched or caught between two moving structures. This pain or motion loss is seen in the groin where the true hip joint lies. Often, they may spontaneously move causing relief from the pain. However, as they are often constantly in motion, they may move to again cause pain in the same area or another area of the hip.

Inflammatory Arthritis

Swelling and heat (inflammation) of the joint lining called synovium causes a release of enzymes which soften and eventually destroy the cartilage. Rheumatoid arthritis, Lupus and psoriatic arthritis are inflammatory in nature.

Labral Tear

The labrum is a pad of fibrocartilage deep in the hip joint. The hip is a ball-in-socket joint with the ball from the thigh bone (femur) and the socket from the pelvis (acetabulum). The labrum is a pad of cartilage that lies between the femoral head (ball) and the acetabulum (socket). It acts as a stabilizer and a shock absorber in the hip. Labral tears are common in athletes. When tears in the labrum occur, patients can experience pain deep in the hip joint. There are many different causes for tears. When a labral tear is symptomatic and patients have failed non-surgical measures such as physical therapy, activity modification and medication, it may be repaired arthroscopically.

Snapping Hip

There are three types of snapping hip: internal (iliopsoas tendon or hip flexor), intra-articular (loose bodies), and external (IT band). In most patients the snapping is merely an annoyance, but it can lead to pain and dysfunction, especially with athletic activities. When non-surgical measures have failed, these conditions can be treated arthroscopically.

Synovitis

The synovium is the lining of our joints. When it gets irritated it can get inflamed (synovitis) and cause hip pain. The synovitis is typically secondary to an intrinsic hip problem (labral tear, FAI, arthritis) but may be due to a primary disease of the synovium (inflammatory arthritis). When indicated, the synovium can be resected arthroscopically.

Procedures

Anterior Approach Total Hip Replacement

When is it Time to Think About Surgery?

You may need hip replacement surgery if you are experiencing pain or loss of motion in your hip joint. These symptoms may be caused by degenerative arthritis (osteoarthritis), rheumatoid arthritis, or avascular necrosis. Hip arthritis can be caused by injury to the joint, long-term steroid use, alcoholism or systemic diseases. When pain interferes with daily activities such as walking, climbing stairs or getting out of a chair, it’s usually time to consider having surgery.

About the Surgery

Total hip replacement involves replacing damaged cartilage in your hip joint with smooth artificial surfaces. This is done by replacing the upper end of the thigh bone (femur) with a metal ball, and resurfacing the hip socket in the pelvic bone with a metal shell and liner. A 4" incision is made on the outside of the hip, which is closed with staples or sutures.

The anterior approach for total hip replacement is a tissue-sparing alternative to traditional hip replacement surgery that provides the potential for less pain, faster recovery, and improved mobility because the muscle tissues are spared during the surgical procedure. The technique allows the surgeon to work between your muscles and tissues without detaching them from either the hip or thighbones – sparing the tissue from trauma.

Keeping the muscles intact may also help to prevent dislocations. The surgeon uses one small incision on the front (anterior) of your hip as opposed to the side or back. Since the incision is in front, you’ll avoid pain of sitting on the incision site.

Preparing for Surgery

You should be examined by your family doctor to ensure you are healthy enough for the planned surgery. You will be encouraged to stop smoking before surgery to prevent lung complications or delayed healing. Pre-admission testing (lab work, EKG, chest x-ray) and attendance at a “joint camp” will also be scheduled to further help you prepare for surgery. Anti-inflammatory medications, aspirin, and blood thinning medications should be discontinued one week before your surgery. These medications affect your blood clotting factors and could increase your risk of blood loss during surgery.

You will be given a prescription for a blood thinner such as Coumadin to take before surgery, or Xeralto or Lovenox to take after surgery, in order to prevent blood clots during the healing process.

What to Expect After Surgery

You will wake up in the recovery room after surgery with an IV for antibiotics and fluid replacement that will be continued for 24-48 hours. You may receive medication through an IV-regulated pump to control your pain. Depending on your doctor, you may also have a urinary catheter for 24 hours and compression stockings or a compression pump on your legs.

Physical therapy will begin the day after your surgery and you will be instructed on how to walk with the use of a walker. You may also be allowed to bear weight as tolerated on the affected hip. There are no specific range of motion limitations with anterior approach total hip arthroplasty.

Complications and Risks of Surgery

Blood clots: You are encouraged to get up and move frequently as well as take your prescription blood thinner to help prevent clotting. Symptoms of clotting include pain, swelling or redness of your calf or thigh and shortness of breath. Call the office immediately if you develop any of these symptoms.

Infection: Infection is rare, but can occur following surgery. You are at higher risk of infection if you have diabetes, rheumatoid arthritis, chronic liver or kidney disease, or if you are taking steroids. Symptoms include fevor or chills, drainage, redness, a foul smell or increased pain at the surgical site. Call the office immediately if any of these symptoms occur.

Blood loss: It is possible that you will need a blood transfusion following surgery. Your doctor will evaluate you daily to determine if there is a need for a transfusion.

Hip dislocation: It’s rare, but a dislocation may occur. This happens when your new “ball socket” is no longer in your hip joint. If you feel you have dislocated your hip and are not able to walk, you must go to the emergency room to have a doctor move the hip back into place.

Nerve damage: Damage to your surrounding hip nerves is rare, but can occur. Symptoms include the inability to lift your affected foot, numbness or tingling of the leg. Although these symptoms get better over time and may go away completely, you should still be evaluated by your doctor.

Anesthesia complications: Respiratory failure, shock, cardiac arrest, and death are always possible during surgery. Patients with long-term liver, kidney, heart or lung disease are at a higher risk.

Bone fracture: Although it is rare, a fracture could occur during surgery while fixating the femur implant. If a fracture occurs during your surgery, the doctor will correct the problem with additional cabling and the use of a longer implant. If you develop thigh pain after surgery, alert your doctor so further x-rays can be done to rule out a fracture.

Difference in leg length: When your implant is attached, it may leave you with a small difference in leg lengths. This can be corrected with shoe inserts if this difference persists over six months.

Pneumonia: Lung congestion is possible while you are recovering from surgery and are not as active. Coughing and deep breathing are encouraged to help you expand your lungs and clear any congestion.

Constipation: Bowel movements slow down with less activity and the use of pain medications. You will be encouraged to use stool softeners after you are discharged to promote regular bowel movements and prevent constipation.

Urinary tract infection: Infection to your urinary tract can occur if you have a catheter in place following surgery. Symptoms include burning and frequent urination, as well as blood in your urine. Fever and weakness may also occur. Report any of these signs to your doctor. This type of infection is a major source of joint infection and should be treated with antibiotics quickly.

Recovery Period

The average recovery period for hip replacement is 2-3 months. Most patients are back to work in 2 months if their job is sedentary, and 3 months if they have a labor-intensive job. Exercise such as running, skiing, or contact sports are discouraged following hip replacement surgery. Activities like swimming, walking and biking are encouraged to promote hip strength and overall fitness.

Treating and Preventing Infection

Notify your family doctor if you develop any suspected infection so you can be placed on an antibiotic to prevent the spread of infection to your hip joint. Infections such as ear infections, ingrown toenails, bladder infections, sinus infections, and sore throats should be reported immediately. Make sure your doctors know you have had a joint replacement so you can be pre-medicated with an antibiotic before any dental work, or bladder/bowel surgery.

Total Hip Replacement Surgery

When is it Time to Think About Surgery?

You may need hip replacement surgery if you are experiencing pain or loss of motion in your hip joint. These symptoms may be caused by degenerative arthritis (osteoarthritis), rheumatoid arthritis, or avascular necrosis. Hip arthritis can be caused by injury to the joint, long-term steroid use, alcoholism or systemic diseases. When pain interferes with daily activities such as walking, climbing stairs or getting out of a chair, it’s usually time to consider having surgery.

About the Surgery

Total hip replacement involves replacing damaged cartilage in your hip joint with smooth artificial surfaces. This is done by replacing the upper end of the thigh bone (femur) with a metal ball, and resurfacing the hip socket in the pelvic bone with a metal shell and liner. A 6-8 inch incision is made on the outside of the hip, which is closed with staples or adhesive.

Preparing for Surgery

You should be examined by your family doctor to ensure you are healthy enough for the planned surgery. You will be encouraged to stop smoking before surgery to prevent lung complications or delayed healing. Pre-admission testing (lab work, EKG, chest x-ray) and attendance at a “joint camp” will also be scheduled to further help you prepare for surgery. Anti-inflammatory medications, aspirin, and blood thinning medications should be discontinued one week before your surgery. These medications affect your blood clotting factors and could increase your risk of blood loss during surgery.

What to Expect After Surgery

You will wake up in the recovery room after surgery with an IV for antibiotics and fluid replacement that will be continued for 24 hours. You may receive medication through an IV-regulated pump to control your pain.

Physical therapy will begin the day after your surgery and you will be instructed on how to walk with the use of a walker. You may also be allowed to bear weight as tolerated on the affected hip, but you will have “hip precautions” that you will need to follow for lifetime.

Hip precautions:

  • Do not sit with legs crossed.
  • Do not sit on low chairs, beds, tubs, or toilets.
  • Do not raise your knee higher than your hip.
  • Do not bend over more than 90 degrees (do not put on your own shoes).
  • Do not lean forward while you are sitting or as you stand up.

You may be given a prescription for a blood thinner such as Coumadin, Xarelto, Lovenox, or Aspirin to take after surgery, in order to prevent blood clots during the healing process.

Complications and Risks of Surgery

Blood clots: You are encouraged to get up and move frequently as well as take your prescription blood thinner to help prevent clotting. Symptoms of clotting include pain, swelling or redness of your calf or thigh and shortness of breath. Call the office immediately if you develop any of these symptoms.

Infection: Infection is rare, but can occur following surgery. You are at higher risk of infection if you have diabetes, rheumatoid arthritis, chronic liver or kidney disease, or if you are taking steroids. Symptoms include fever or chills, drainage, redness, a foul smell or increased pain at the surgical site. Call the office immediately if any of these symptoms occur.

Blood loss: It is possible that you will need a blood transfusion following surgery. Your doctor will evaluate you daily to determine if there is a need for a transfusion.

Hip dislocation: It’s rare, but a dislocation may occur. This happens when your new “ball socket” is no longer in your hip joint. If you feel you have dislocated your hip and are not able to walk, you must go to the emergency room to have a doctor move the hip back into place.

Nerve damage: Damage to your surrounding hip nerves is rare, but can occur. Symptoms include the inability to lift your affected foot, numbness or tingling of the leg. Although these symptoms get better over time and may go away completely, you should still be evaluated by your doctor.

Anesthesia complications: Respiratory failure, shock, cardiac arrest, and death are always possible during surgery. Patients with long-term liver, kidney, heart or lung disease are at a higher risk.

Bone fracture: Although it is rare, a fracture could occur during surgery while fixating the femur implant. If a fracture occurs during your surgery, the doctor will correct the problem with additional cabling and the use of a longer implant. If you develop thigh pain after surgery, alert your doctor so further x-rays can be done to rule out a fracture.

Difference in leg length: When your implant is attached, it may leave you with a small difference in leg lengths. This can be corrected with shoe inserts if this difference persists over six months.

Pneumonia: Lung congestion is possible while you are recovering from surgery and are not as active. Coughing and deep breathing are encouraged to help you expand your lungs and clear any congestion.

Constipation: Bowel movements slow down with less activity and the use of pain medications. You will be encouraged to use stool softeners after you are discharged to promote regular bowel movements and prevent constipation.

Urinary tract infection: Infection to your urinary tract can occur after having surgery. Symptoms include burning and frequent urination, as well as blood in your urine. Fever and weakness may also occur. Report any of these signs to your doctor. This type of infection is a major source of joint infection and should be treated with antibiotics quickly.

Recovery Period

The average recovery period for hip replacement is 2-3 months. Most patients are back to work in 2 months if their job is sedentary, and 3 months if they have a labor-intensive job. Exercise such as running, skiing, or contact sports are discouraged following hip replacement surgery. Activities like swimming, walking and biking are encouraged to promote hip strength and overall fitness.

Treating and Preventing Infection

Notify your family doctor if you develop any suspected infection so you can be placed on an antibiotic to prevent the spread of infection to your hip joint. Infections such as ear infections, ingrown toenails, bladder infections, sinus infections, and sore throats should be reported immediately. Make sure your doctors know you have had a joint replacement so you can be pre-medicated with an antibiotic before any dental work, or bladder/bowel surgery.

Hip Arthroscopy

When is it Time to Think About Surgery?

Your hip is the joint where your thigh bone meets your pelvis. It is called a ball-and-socket joint, because the ball-like top of your thigh bone (femur) fits into a cup-like area (acetabulum) within your pelvis, much like a baseball fits into a glove. The labrum is a rim of soft tissue or fibrocartilage that surrounds the acetabulum (hip socket). The labrum adds to the stability of the hip by deepening the socket and protecting the joint surface.

Normally, the ball glides smoothly within the socket, but a problem with the ball or socket rim can interfere with smooth motion. This problem can cause femoroacetabular impingement also referred to as hip impingement.

The main symptoms are stiffness in the groin or front of the thigh and/or a loss of your hip's full range of motion. At first, you may only feel pain when you move the hip near its limits. As the condition progresses, however, you may feel pain with more subtle activities, such as sitting for a long time or walking up a hill. Pain that occurs at night or when walking on flat ground suggests that the cartilage cushioning the ball and socket has begun to break down and wear away, a condition known as osteoarthritis.

Treatment for hip impingement starts with conservative measures such as rest, activity modification, physical therapy and the use of anti-inflammatory medications. Diagnosis and need for surgery will be based on the description of your symptoms, a physical exam, response to conservative treatments, and the findings of imaging tests such as an x-ray, MRI or CT scan. Hip arthroscopy can be used for the diagnosis of unexplained hip pain or commonly for the treatment of hip impingement and its associated conditions such as labral tears and cartilage abnormalities.

About the Surgery

Hip arthroscopy refers to the viewing of the interior of the hip joint through an arthroscope using 2-4 very small incisions, each approximately ½” in length. The procedure is performed under general anesthesia as an outpatient. The procedure can take 2-3 hours. The arthroscope allows the physician to see inside the hip joint, diagnose and possibly correct any conditions he may find. If the affected hip has minimal cartilage damage, the surgeon may use tools to reshape the ball and/or the outside edge of the socket that is catching on the thigh bone. Conditions such as labral tears require a more extensive technique allowing the labrum to be reattached to the acetabulum (socket).

Once you are awake and taking fluids, the IV will be removed and you will be allowed to go home.

Preparing for Surgery

You will have pre-admission testing done before your surgery to ensure that you are healthy enough for the planned procedure. Testing may include lab work, an EKG and a chest x-ray. Medications that increase your risk for bleeding should be stopped prior to surgery. Your medication list will be reviewed with one of our nurses and you will be advised as to which medications need to be stopped and when. Prescription blood thinners can only be stopped under the approval of the physician who is prescribing them for you. Our nurse will provide you with a prescription for crutches or a walker for use after surgery, please bring either crutches or a walker with you the day of surgery.

What to Expect After Surgery/Recovery Period

Corrective repairs that may have been performed during the arthroscopy would require you to be non-weight bearing for 3 weeks following the procedure. This would require strict use of crutches or a walker for 3 weeks to allow the repairs to heal. Your physician will advise you about your weight bearing status before you go home.

If you have a labor intensive job that includes heavy lifting, squatting or running, you may have restrictions for up to 3 months after your surgery.

It is normal to experience mild swelling around the hip, pain around the incisions or stiffness of hip after arthroscopic surgery.

Physical therapy typically starts 1-2 weeks after surgery and will continue for several months.

Complications and Risks of Surgery

Blood clots: Symptoms of clotting include pain, swelling or redness of your calf or thigh. Call the office immediately if you develop any of these symptoms or go to the emergency room if it is a weekend. If you experience sudden and severe shortness of breath, go to the emergency room or call 911. Walk every hour during the daytime. Patients who are immobile for prolonged periods of time are at a higher risk of blood clots.

Infection: Infection is rare, but can occur following surgery. You are at a higher risk of infection if you have diabetes, rheumatoid arthritis, chronic liver or kidney disease or if you are taking steroids. Symptoms include fever or chills, foul smelling drainage, increasing redness or increasing pain at the incision sites. Call the office immediately if any of the symptoms occur, or go to the emergency room if it is a weekend.

Anesthesia: Respiratory failure, shock, cardiac arrest and death are always possible during surgery. Patients with long-term kidney, heart, liver or lung disease are at a higher risk. Nausea and vomiting from anesthesia is not uncommon. Coughing/deep breathing exercises and drinking plenty of fluids help to remove the anesthesia gases from your system.

Nerve damage: Damage to the nerves surrounding your hip are rare but can occur. Notify your surgeon if numbness or tingling is prolonged or worsens after surgery.

Bleeding: Trauma to the arteries and veins surrounding your hip is rare, but may occur. It is common for some bruising and swelling around the hip after surgery. Bright red bloody drainage from the incisions that cannot be stopped with compression, should be reported to our office or go to the emergency room if it is a weekend.

Persistent pain: Not all hip pain can be addressed with surgery, it is possible that you will not be completely pain free after surgery.

Nurses are available to answer medical related questions from 8:00am – 4:45pm Monday-Friday. If you have a medical related question before surgery or a concern following surgery, please do not hesitate to call the nurse. She can be reached by calling the main office number and following the prompts to speak with the phone nurse.

Hip Arthroscopy Post-op Instructions

Your surgical dressing can be removed 48 hours after surgery and you may shower. Please do not take a bath or go into a pool or hot tub. Do not apply lotion or neosporin to your incisions. Please allow incisions to air dry well after showering and cover the incisions with bandaids if they are draining. Please be sure to call our office the day after surgery to schedule a follow-up appointment with your physician if one was not scheduled prior to surgery.

You will be provided with a prescription for pain medication before you go home. Please call the prescription line at our office for any pain medication refills 2 business days before your medication is gone.

After surgery you will need to avoid any deep flexion of the hip, squatting, heavy lifting, running, or any strenuous activities until instructed by your physician.

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