Hip Conditions

AVASCULAR NECROSIS

WHAT IS AVASCULAR NECROSIS?

Avascular necrosis, also known as osteonecrosis, is a disorder in which the bone does not receive enough blood, resulting in small breaks that can eventually cause it to collapse.

CAUSES OF AVASCULAR NECROSIS

Insufficient blood flow to a bone may occur as a result of a fracture or dislocation, excessive alcohol use, extended use of corticosteroids, or certain diseases that impede blood flow, such as sickle cell anemia, diabetes, lupus, Gaucher disease and HIV. Medications taken for osteoporosis or bone cancer, called bisphosphonates and radiation therapy also increase the risk of a patient developing avascular necrosis. The condition can occur in numerous joints, but it most commonly affects the hip.

WHAT ARE THE SYMPTOMS OF AVASCULAR NECROSIS?

In the early stages of avascular necrosis, patients may be asymptomatic. As the disease progresses, patients typically experience pain and a diminished range of motion in the affected area. In addition to occurring in the hip, this disorder can affect the knee or shoulder, feet, ankles, spine, jaw or wrists.

The pain from avascular necrosis may begin as mild discomfort, experienced only when joint is weight-bearing. Over time, however, the pain will become more severe and the patient may experience pain even when at rest. The pain associated with avascular necrosis of the hip may radiate into the thigh, buttock or groin. It is not unusual for some patients to experience bilateral pain from the condition, such as in both hips or both knees.

HOW IS AVASCULAR NECROSIS DIAGNOSED?

In order to diagnose avascular necrosis, a thorough review of the patient’s medical history and a full physical examination of the patient are necessary. Because joint pain can be caused by a variety of conditions, imaging tests are normally administered as well, such as X-rays, MRI, CT or bone scans.

AVASCULAR NECROSIS TREATMENT OPTIONS

There are several treatments available for avascular necrosis. Some are designed to reduce inflammation and relieve pain and some are recommended as a means of improving the patient’s condition or preventing further bone deterioration. Rest, at times including the use of crutches, is usually the first treatment prescribed, followed by one or more of the others listed below.

MEDICATIONS

Patients with avascular necrosis may be advised to take:

Over-the-counter anti-inflammatories
Medications normally prescribed for osteoporosis
Cholesterol-lowering drugs
Anti-coagulants (blood thinners)

The last two on this list may be of help in keeping blockages that interfere with blood circulation from occurring and so assist the bones in receiving proper nourishment.

PHYSICAL REHABILITATION

Physical therapy may be useful during the early stages of avascular necrosis. Such rehabilitation efforts may include exercises to maintain range of motion and electrical stimulation of the affected area.

SURGICAL PROCEDURES

Most patients don’t have symptoms of avascular necrosis until the condition is well-advanced, at which point surgery may be necessary. Procedures performed to help patients with avascular necrosis include:

Core decompression
Bone transplant
Joint replacement

Of these three surgical procedures, joint replacement is the most complex operation, usually requiring the lengthiest rehabilitation. It is also the procedure most likely to provide a permanent solution to the problem.

While patients with mild, early stage avascular necrosis may be helped by noninvasive treatments, for most patients the disorder requires surgical intervention.

HIP FRACTURES

A hip fracture is a break in the upper part of the thigh bone (femur) where the bone angles toward the hip joint. The hip is a “ball-and-socket” joint where the “ball” at the top of the thigh bone (femur) fits inside the “socket” of the pelvis (acetabulum). It allows the upper leg to bend and rotate. Most hip fractures are caused by falls or an injury from direct impact to the side of the hip. Hip fractures are more common in elderly adults as a result of osteoporosis or bones that have weakened over time. In addition to advanced age, factors such as certain medications, chronic medical conditions, or a history of heavy tobacco and alcohol use, may weaken bones and make individuals more susceptible to hip fractures.

SYMPTOMS OF A HIP FRACTURE

Immediately after a hip has fracture, the individual may find it difficult to stand and may experience the following symptoms:

Severe pain in the hip and groin
Bruising
Swelling
Inability to put any weight on the leg

The leg may appear shortened or turn outward on the side of the injured hip.

DIAGNOSIS OF A HIP FRACTURE

A hip fracture is diagnosed after a physical examination of the hip and leg as well as imaging tests that may include X-rays, CT scans or MRI scans. Imaging tests allow the physician to identify the exact location of the fracture and determine the severity of the broken bone.

TREATMENT OF A HIP FRACTURE

Treatment for a hip fracture often involves surgery. The surgical procedures may vary depending on the severity of the fracture, but may include:

Surgery to insert screws and rods to hold the bone together
Total hip replacement
Partial hip replacement

Hip replacement surgeries involve replacing part of the femur bone or hip socket with prosthetic devices. After surgery, a physical therapy program is created to help the individual regain flexibility, increase range of motion and strengthen the hip and leg.

In rare cases, stable hip fractures may be treated through prolonged immobilization and bed rest. However, these instances are uncommon, and this form of treatment is usually only considered when the patient is too ill to undergo surgery.

HIP ARTHROSCOPY

Hip arthroscopy is a minimally invasive procedure used to diagnose and treat a wide range of conditions affecting the hip joint. This procedure can be used to confirm the diagnosis of various imaging procedures, such as X-rays and MRIs, as it provides a three-dimensional, real-time image of the affected area. If damage or abnormalities are detected during the arthroscopy, repairs can often be made during the same procedure.

REASONS FOR HIP ARTHROSCOPY

Hip arthroscopies can be performed for a number of reasons, to definitively diagnose or repair of the following conditions:

Osteoarthritis
Joint cartilage (labral) tears
Loose pieces of bone or cartilage, or bone spurs
Snapping hip syndrome

CANDIDATES FOR HIP ARTHROSCOPY

Arthroscopy is considered an ideal treatment option for many conditions affecting the hip, since it offers smaller incisions, shorter recovery times and less scarring. Patients can often return home the same day as their procedure and resume their regular activities in just a few weeks, while enjoying less pain, greater range of motion and restored joint function.

While arthroscopy offers many advantages over conventional hip surgery, it is not right for all patients, especially those with conditions affecting hard-to-visualize areas. In such cases, traditional surgery may be more appropriate.

HIP ARTHROSCOPY PROCEDURE

During the hip arthroscopy procedure, the surgeon makes a small incision near the affected area of the hip and inserts an arthroscope, a long flexible tube with a camera and a tiny light on the end. This device displays magnified images of the inside of the hip joint on a video monitor for the surgeon to view in real time. During this diagnostic part of the procedure, the hip is examined for any signs of tearing, damage or degeneration to the ligaments, cartilage and other internal structures.

If damage is detected, it can often be repaired during the same procedure by creating a few more small incisions through which tiny surgical instruments are inserted. These instruments allow the surgeon to replace damaged cartilage, join together torn ends, remove loose bodies or realign the joint to minimize pain and inflammation. Once the repair has been performed, the tools and arthroscope are removed and the incisions are sutured closed. A dressing will be applied to the area, which will later be replaced with smaller bandages as the incisions heal.

RECOVERY FROM HIP ARTHROSCOPY

After the hip arthroscopy procedure, patients may experience pain, swelling and bruising at the incision sites for several days. Pain medication and the application of ice are advised in order to manage this pain and reduce inflammation. Most patients will be encouraged to get up and walk around as soon as possible, but will need to use crutches or a walker for 7 to 10 days as healing takes place.

In order to restore function and strength to the hip joint, patients will need to undergo a customized physical rehabilitation program after surgery, designed to meet their individual goals. Physical rehabilitation may include weight-bearing exercises, hip mobilization techniques, flexibility exercises and other activities that target the various muscles of the region: the quadriceps, the hamstrings, the gluteals, the abductors and adductors. The length of the rehabilitation regimen varies according the patient’s specific condition and rate of healing. Most patients are able to return to full physical activity after several weeks, but other may require up to 12 weeks to fully recover.

RISKS OF HIP ARTHROSCOPY

While hip arthroscopy is considered safer and more efficient than conventional hip procedures, there are still certain risks associated with any type of surgery. Some of these risks may include:

Infection
Nerve or blood vessel damage
Tissue damage
Prolonged pain
Blood clots

Patients should discuss these and other risks with the doctor before undergoing hip arthroscopy.

HIP IMPINGEMENT

Osteoplasty is an effective method of treatment for certain forms of femoroacetabular impingement (FAI), an abnormality in the way the ball of the femur and the acetabulum (hip socket) fit together. FAI is a fairly common condition that affects more men than women. An improper shape of the ball and socket creates excess friction in the joint and may cause a significant amount of pain. Over time, hip impingement can tear or wear down the hip cartilage, causing pain, swelling, stiffness and loss of mobility. There also may be a sensation of catching or popping within the hip.

An osteoplasty is a type of surgery performed on the hip joint for the purpose of altering the rim of the socket and/or the ball that sits within the joint. It is a successful technique for improving the function of the joint and promoting a fuller range of movement. Osteoplasty is ideally performed at an early stage of hip problems. This procedure helps resolve pain and other symptoms while preserving the natural structures of the joint, preventing the need for a more extensive hip replacement.

BENEFITS OF OSTEOPLASTY FOR HIP IMPINGEMENT

The Osteoplasty procedure is ideal for younger patients who do not have arthritis. The benefits of this procedure may include:

Relief of painful symptoms and discomfort
Reduced risk of developing osteoarthritis
Improved range of motion in the hip

Older patients with degenerative hip disease may benefit more from a total hip arthroplasty

THE OSTEOPLASTY PROCEDURE

The osteoplasty procedure generally takes several hours to complete, depending on the extent of the work that is required. It may be performed arthroscopically, and the surgeon will insert a small camera in one incision and specialized surgical tools in the others. In other cases, an open procedure may be necessary, accessing the joint through one long incision near the hip. After anesthesia is administered and the incision has been made, the surgeon removes a section of bone from the femoral neck and reshapes it to increase the amount of clearance that exists within the hip socket. If necessary, bone will be removed from the rim of the socket as well. The goal of the procedure is to trim the bones enough to prevent the impingement from occurring.

RECOVERY FROM THE OSTEOPLASTY PROCEDURE

After an osteoplasty procedure, patients may remain in the hospital overnight. Typically, an assistive device such as crutches or a cane will be necessary for the first several weeks post-surgery to prevent patients from overstressing the hip joint while walking. Physical therapy can be very beneficial in regaining strength and flexibility in the hip as well as obtaining a greater range of motion. Most patients can return to relatively sedentary jobs after approximately 2 weeks. However, sports and other activities may be restricted for up to 6 months following the surgery.

RISKS OF THE OSTEOPLASTY PROCEDURE

Osteoplasty is generally considered a safe procedure, but all forms of surgery carry some risk. Although rare, the risks typically associated with osteoplasty may include infection, formation of blood clots and avascular necrosis due to an interruption of blood flow to the femur.

HIP REPLACEMENT

Our hips bear much of the load of the human body. And when you have a damaged or deteriorating hip, some of the most seemingly simple movements can become an exercise in torture. Walking around the block or getting up from a chair can involve shooting pain. Sleeping on your bad hip becomes almost impossible.

When the pain and lack of mobility really starts to impact your life, it’s time to consider hip replacement with the team at Ortho Montana. Our patients have great success with these surgeries, enabling them to get back on their feet and back to normal.

WHAT IS A HIP REPLACEMENT?

The hips are involved in all of our movements when we are upright, and a damaged hip can make many of life’s simple pleasures, things like walking on the beach, excruciatingly painful, if not at the time then hours afterward. Things you may have taken for granted your entire life, such as getting out of a chair, now are painful. Sleep can be difficult, as your bad hip is loaded when on your side. The damage is usually simply a result of long-term use. This can be especially true if you’ve participated in activities or sports with a lot of impact, such as running or gymnastics. You’ve likely damaged the cartilage in the hip socket or maybe the cartilage has mostly worn away.

The goal becomes simply stopping the pain. People opt for cortisone injections or hip resurfacing procedures that “clean out” the torn or frayed cartilage. They stop participating in certain sports or activities they love.

But when the pain continues, as it will when the damage is within the hip socket, it could be time to consider a total hip replacement with the experienced team at Ortho Montana. Hip replacement is one of the most successful operations performed in the medical world. As we age as a population, the need is growing all the time. Hip replacement can make a real difference in the life of the patient, in effect allowing the person to return to a pain-free life once again.

Hip replacement involves addressing both the bone and the socket. The damaged ball of the thigh bone is replaced with a metal ball; the socket is ground clean of damage and a metal socket is inserted into it for the new metal ball to pivot within.

CONDITIONS THAT LEAD TO HIP REPLACEMENT

The most common cause of chronic hip pain and damage is arthritis, in this case, osteoarthritis, rheumatoid arthritis, and traumatic arthritis.

Osteoarthritis — As we age, basically everyone has some degree of this “wear-and-tear” arthritis. In the hips, osteoarthritis damages the slick cartilage that covers the ends of the femur and the inside of the hip socket.
Rheumatoid arthritis — Rheumatoid arthritis creates inflammation that erodes cartilage and bone in the hips.
Post-traumatic arthritis — If you’ve had a serious hip injury or fracture, the cartilage could have been damaged, leading to pain and stiffness over time.
Osteonecrosis — Sometimes a hip dislocation or fracture can limit the blood supply to the femoral head, which causes the surface of the bone to collapse. If you were a fan of football/baseball legend Bo Jackson, this was his cause for immediate hip replacement.
Childhood hip disease — In rare cases, children have hips that didn’t develop normally. Even if the hips were successfully treated during childhood, these conditions will often lead to arthritis later in life.

HOW WILL I KNOW IF I NEED A HIP REPLACEMENT?

There is no “this is the day” threshold with hip replacement. The question usually comes down to how much your damaged hip is impacting your daily life. There isn’t a typical age threshold, but most of our Ortho Montana hip replacement patients are between the ages of 50 and 80.

People considering hip replacement surgery usually have been dealing with the pain for a long time, possibly decades. The question is — how badly is the pain affecting your life? Our entire team helps walk you through the decision to move forward with replacement. These are some of the common issues people have when considering hip replacement:

Hip pain is limiting activities such as walking or bending.
Hip pain is impacting sleep.
Hip pain continues even when resting.
There is stiffness in the hip that limits movement.
Other avenues to address the pain have not been effective — physical therapy, band-aid procedures such as hip resurfacing, cortisone injections, and other options are not stopping the pain.

BENEFITS OF HIP REPLACEMENT SURGERY

What is the benefit of being able to walk around the block without pain? What’s the benefit of being able to return to sports you love, such as snow skiing, without pain? And who wouldn’t welcome actually sleeping on your bad hip?

These are quality of life issues. When people postpone these surgeries they are basically postponing living life, and that’s a shame because these surgeries are so successful.

WHAT IS THE AVERAGE AGE FOR HIP REPLACEMENT?

As mentioned above, there isn’t a predominant age or point where a person needs hip replacement. At Ortho Montana we’ve had teenagers with juvenile arthritis have hip replacement. Still, it is generally a condition of advancing age. If you were to average out this procedure, you would see patients between the ages of 40 and 80.

PREPARING FOR HIP REPLACEMENT SURGERY

Once you’ve made the decision to go ahead with hip replacement, it will be very helpful to do a few things prior to the procedure.

Do your research — Become knowledgeable about what to expect. Ask all the questions you have of your doctor. Know what to expect.
Plan for work — You’ll have to miss some work, so plan accordingly.
Become stronger — If you are stronger at the time of your surgery, you’ll fare better in recovery. Lose some weight, if you need to. Get stronger in your upper body, which will make crutches and walkers easier to manage.
Meet with your physical therapist — We’ll line you up with a physical therapist for your recovery. He or she will give you a series of exercises that are key to your recovery. It helps if you understand them and are comfortable with how to do them prior to your surgery.
Get a feel for your crutches or walker — We’ll let you borrow crutches so you can get comfortable with them prior to your surgery.
Bring in reinforcements — This is not time to be the Lone Ranger; recovering from hip replacement requires help. It can be family or a friend. If you don’t have a network, you may want to stay in a rehab center after your procedure.
Get your home ready — You’ll want to sleep downstairs if your bedroom is upstairs. Prepare your recovery area where you’ll spend most of your time. Get your computer, remote controls, books, phone charger, pillows, blankets. Keep everything within arm’s reach. Go around the house and remove any things you could trip over, such as throw rugs.

HOW IS A TOTAL HIP REPLACEMENT DONE?

The procedure begins with an incision on the upper outer thigh to allow access to the bones of the hip joint. Next, damaged cartilage and bone are removed from the acetabulum, the cup-shaped hollow in the pelvic bone. The damage was the result of bone on bone contact as the cartilage was worn down and frayed. A tool called a reamer removes any cartilage and bone spurs and prepares the socket for the placement of the acetabular component (the cup that will accept the artificial femur ball). The acetabular component consists of two parts, an outer metal cup that will fit directly into the socket and an inner plastic part that will accept the ball of the thighbone. The outside portion of the metal cup is usually rough to allow the patient’s bone to grow into the exterior, making it a part of the hip socket.

Now it’s time to address the femur. First, the ball-shaped head is removed and the femur is prepared for the placement of the stem portion of the component. Once the stem is inserted into the femur a metal ball is attached to the end. This ball precisely fits into the plastic socket, mimicking the similar arrangement in the natural hip.

After this is done, the surgeon checks the range of motion and closes the incision.

HIP REPLACEMENT RECOVERY

The first part of your recovery isn’t necessarily about your new hip; it’s about preventing blood clots. To address this, you may be encouraged to sit up and even walk with crutches on the same day as your surgery. This surprises patients, but it really helps prevent potential clots. You’ll also likely wear a compression stocking to exert pressure on your leg; this keeps blood from pooling in the leg veins, reducing the chances of a clot forming. You’ll also be on blood-thinning medication.

Usually, on your first day, you will meet with your physical therapist who will walk you through minor exercises you can do immediately, along with the longer-term plan for your rehabilitation.

Once you leave the hospital and return home, being diligent about your exercises will be critical to a successful recovery. You will likely be able to return to most normal light activities in your life within three to six weeks after your surgery. Total return to normal with your new hip will take about six months.

HOW SOON AFTER MY SURGERY WILL I HAVE RELIEF FROM MY HIP PAIN?

Your pain that was the cause of needing replacement surgery will be gone. For instance, the torn cartilage in the joint has been replaced. Your pain now is simply involved with your recovery and your body adapting to the new prostheses.

HOW LONG BEFORE I CAN WALK NORMALLY AFTER HIP REPLACEMENT?

It depends what you deem “normal,” but most patients can begin to walk without the aid of crutches or a walker at a point from 2 to 6 weeks after surgery. You probably wouldn’t consider this “normal” walking at this point, but you won’t need support. By 10-12 weeks, you should be able to walk without anyone knowing you’re using a new hip to do so. That’s pretty amazing when you think about it.

WHAT WILL THE SCARRING BE LIKE AFTER THIS SURGERY?

This is major surgery and you will have a scar. The scar length will be dictated by the approach used. Here are some general numbers. With an anterior approach, the incision runs down the front of the thigh starting at the pelvic bone and will be approximately 3-6 inches. With a posterior hip replacement, the incision tends to be behind the hip, down the outer buttocks. If this can be done with a minimally invasive technique, the incision will be from 3-5 inches. If a traditional posterior method is used, the scar will be longer, from 8-10 inches. It will fade with time, but there will be a scar. Still, considering you’ll be pain-free, most patients are thrilled with the tradeoff of a scar.

RISKS OF HIP REPLACEMENT SURGERY

As with any surgery, there is a risk of infection and blood clots. Infections can be especially difficult, as something like an infection in a tooth can spread bacteria that then lodge around your prostheses.

Here are other risks.

Leg-length inequality — Sometimes after a hip replacement, one leg may be longer than the other. While the surgeon makes every effort to keep your leg lengths equal, sometimes it may be necessary to shorten or lengthen the leg slightly in order to maximize the stability and biomechanics of the hip. A shoe lift can rectify this down the road.
Dislocation — Dislocation of the hip joint is not common, but the greatest risk of it occurring is during the first few weeks after your surgery while the tissues are healing and strengthening.
Loosening and wear — Over time, the hip prosthesis may wear out or loosen. This can simply be the result of everyday impacts from normal activity, but you can exacerbate the process with high-impact activity. Tissue may also grow between the components and the bone, leading to loosening.
Metal sensitivity — As you live with your artificial hip, tiny bits of the surface of the new hip joint wear off as the ball and socket pieces rub against each other. Some people are sensitive to this metal.

SNAPPING HIP

WHAT IS SNAPPING HIP SYNDROME?

Snapping hip syndrome, or “dancer’s hip” is a condition commonly affecting athletes and dancers. It involves a snapping sensation, often accompanied by a popping sound during movement. The snapping sensation occurs as a muscle or tendon in the area moves over a bony structure. While the syndrome, for many, is only an annoyance, for individuals with a very active lifestyle or occupation it may lead to pain, weakness and disability.

WHAT CAUSES SNAPPING HIP SYNDROME?

Most commonly, the problem occurs in a band of connective tissue that passes over large jutting bone of the thigh, the trochanter. This band is known as the iliotibial band. Two other bands can cause snapping hip syndrome: the iliopsoas, which connects to the inner upper thigh and the rectus femoris, which stretches from the inner thigh through the pelvis. Less frequently, snapping hip syndrome can be the result of torn cartilage or bone in the hip joint, known as a labral tear. Which injury is causing the problem is determined through physical examination and X-rays.

SNAPPING HIP SYNDROME TREATMENT

When snapping hip syndrome does not involve pain, no treatment is required. For patients who experience mild pain, home remedies, such as over-the-counter pain medications and applications of ice to the affected area, may suffice. It may also be necessary to modify activity level. If pain is severe or persistent, medical consultation is needed.

Treatment of snapping hip syndrome may include physical rehabilitation and/or corticosteroid injections. Physical therapy most often consists of exercises to strengthen and stretch muscles, especially the quadriceps, and to align the hip joint. Corticosteroid injections serve to reduce inflammation and relieve pain. In rare cases, when snapping hip syndrome does not respond to other treatments, surgical repair may be necessary.