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Hip

Activities after a Hip Replacement

Description

After a hip replacement, you may expect your lifestyle after the surgery to be a lot like the way it was before, but without the pain. In many ways, you are right, but it will take time. You need to be a partner in the healing process to ensure a successful outcome.

You will be able to resume most activities; however, you may have to change how you do them. For example, you will have to learn new ways of bending down that keep your new hip safe. The suggestions you find here will help you enjoy your new hip while you safely resume your daily routines.

Activities in the hospital

Hip replacement is major surgery and, for the first few days, you'll want to take it easy. However, it's important that you start some activities immediately to deal with the effects of the anesthetic, help the healing and keep blood clots from forming in your leg veins. Your doctor and physical and occupational therapists can give you specific instructions on wound care, pain control, diet and exercise. Ask how much weight you can put on your affected leg.

Pain management is important in your early recovery. Although pain after surgery is quite variable and not entirely predictable, it does need to be controlled with medication. Initially, you may get pain medication through an IV (intravenous) tube that you can control to get the amount of medication you need. It is easier to prevent pain than to control it and you don't have to worry about becoming addicted to the medication; after a day or two, injections or pills will replace the IV.

Besides the pain medication, you will also need antibiotics and blood-thinners to help prevent blood clots from forming in the veins of your thigh and calf.

You may lose your appetite and feel nauseous or constipated for a couple of days. These are ordinary reactions. You may have a urinary catheter inserted 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 keep your chest and lungs clear.

A physical therapist will visit you, usually on the day after your surgery, and teach you how to use your new joint. It is important that you get up and about as soon as possible after hip replacement surgery. Even in bed, you can "pedal" your feet and "pump" your ankles regularly to keep blood flowing in your legs. You may have to wear elastic stockings and/or a pneumatic sleeve to help keep blood flowing freely.

Discharge

Your hospital stay may last from 3 to 10 days, until you can perform certain skills you'll need to use at home. If you go straight home, you will need help at home for several weeks. If going straight home is too difficult, you may need to spend some time at a rehabilitation center.

The following tips can make your homecoming easier.

• In the kitchen (and in other rooms as well), place items you use frequently within reach so you don't have to reach up or bend down.
• Rearrange furniture so you can get about on a walker or crutches. You may want to change rooms (make the living room your bedroom, for example) to stay off 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 rugs or area rugs that could cause you to slip. Securely fasten electrical cords around the perimeter of the room.
• Install a shower chair, grab 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. Wear a big-pocket shirt or soft shoulder bag for carrying things.
• Set up a "recovery center" in your home, with a phone, television remote control, radio, facial tissues, wastebasket, pitcher and glass, reading materials and medications within easy reach.

Activities at home

• Keep the skin clean and dry. The dressing applied in the hospital should be changed as necessary. Ask for instructions on how to change the dressing if you are not sure.
• If you have stitches that need to be removed, your surgeon will give you specific instructions about the incision and when you can bathe. X-rays will be taken later to ensure that the joint is healing properly.
• 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, a few times a day.
• Calf pain, chest pain and 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 life-threatening clots from forming in the veins of your calf and thigh. 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. The AAOS and the American Dental Association have prepared guidelines that say when you should get antibiotics to prevent joint infection if you must have dental work. You'll find a link to these guidelines at the end of this article.

Diet: By the time you leave the hospital, you should be eating your normal diet. Your physician may recommend that you take iron and vitamin 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 intake of coffee and alcohol. You should watch your weight to avoid putting more stress on the joint.

Resuming normal activities: Once you get home, you should 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:

Weight bearing: Be sure to discuss weight bearing with your physician and physical therapist. Their recommendations will depend on the type of implant and other factors in your situation. Revision hip surgery (replacing an artificial joint that fails) may require you to wait a longer time without putting weight on the leg.

• Uncemented hip replacement: Your surgeon will give you specific instructions about the use of crutches or a walker and when you can put weight on the leg. By 8 weeks, you should be weight bearing with only a little support. 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 some support for 4 to 6 weeks to help the muscles recover.

Driving: You can begin driving an automatic shift car in 4 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 your doctor says you can. 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.

Sex: Some form of sexual relations can be safely resumed 4 to 6 weeks after surgery. Ask your doctor if you need more information.

Sleeping positions: Sleep on your back with your legs slightly apart or on your side with an abduction pillow, a regular pillow between your knees or a knee immobilizer at night. Be sure to use the pillow for at least 6 weeks, or until your doctor says you can do without it. Sleeping on your stomach should be all right.

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 at the knees. The physical therapist will show you how to sit and stand from a chair, keeping your affected 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 limited if possible until healing is far enough along. If you must go up stairs:

• The unaffected leg should step up first.
• Then bring the affected leg up to the same step.
• 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 down to that step.
• Finally step down with the unaffected leg.

Return to work: Depending on the type of activities you perform, it may be as long as 3 to 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. Walking with a pair of trekking poles is helpful and adds as much as 40 percent to the exercise you get when you walk. 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. Using a pair of training fins may make swimming a more enjoyable and effective exercise. Acceptable activities include dancing, golfing (with spikeless shoes and a cart) and bicycling (on level surfaces). Avoid activities that involve impact stress on the joint such as tennis or badminton, contact sports (football, baseball), squash or racquetball, jumping, or jogging. Lifting weights is not a problem, but carrying heavy, awkward objects that cause you to stagger is not wise, especially if you must go up and down stairs or slopes. Plan ahead to have a cart, dolly or hand-truck available.

Do's and Don'ts

Do's and don'ts (precautions) vary depending upon the surgeon's approach. 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 will help 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 at the knees 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 when you bend down.
• Do keep the leg facing forward.
• Do keep the affected 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 kneel on the knee on the unoperated leg (the good side).
• Do kneel on the knee on the operated leg (the bad side).
• 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!

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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 block uses 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.

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Burning Thigh Pain (Meralgia paresthetica)

The nerves in your body bring information to the brain about the environment (sensory nerves) and messages from the brain to activate muscles (motor nerves). To do this, nerves must pass over, under, around and through your joints, bones, and muscles. Usually, there is enough room to permit easy passage. But swelling, trauma, or pressure can narrow these openings and squeeze the nerve. When that happens, pain, paralysis, or other dysfunction may result.

A painful, burning sensation on the outer side of the thigh may mean that one of the large sensory nerves (lateral femoral cutaneous nerve) to your legs is being compressed. This condition is known as meralgia paresthetica (me-ral'-gee-a par-es-thet'-i-ka).

Signs and Symptoms

• Pain on the outer side of the thigh, occasionally extending to the outer side of the knee
• A burning sensation, tingling, or numbness in the same area
• Occasionally, aching in the groin area or pain spreading across the buttocks
• Usually only on one side of the body
• Usually more sensitive to light touch than to firm pressure

Diagnosis

During a physical examination, your physician will ask about recent surgeries, injury to the hip, or repetitive activities that could irritate the nerve. He or she will also check for any sensory differences between the affected leg and your other leg. To verify the site of the burning pain, the physician will put some pressure on the nerve to reproduce the sensation. You may need both an abdominal and a pelvic examination to exclude any problems in those areas.

X-rays will help identify any bone abnormalities that might be putting pressure on the nerve. If your physician suspects that a growth such as a tumor is the source of the pressure, you may need to get an MRI or CT (computed tomography) scan. In rare cases, a nerve conduction study may be advised.

Restrictive clothing and weight gain are two common reasons for pressure on a nerve. Your physician may ask if you wear a heavy tool belt at work or if you consistently wear a tight corset or girdle. He or she may recommend a weight loss program.

Treatment

Treatments will vary, depending on the source of the pressure. It may take time for the burning pain to stop and, in some cases, numbness will persist despite treatment. The goal is to remove the cause of the compression. This may mean resting from an aggravating activity, losing weight, wearing loose clothing, or using a toolbox instead of wearing a tool belt. In more severe cases, your physician may give you an injection of a corticosteroid preparation to reduce inflammation. This generally relieves the symptoms for some time. In rare cases, surgery is needed to release the nerve.

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Developmental Dislocation (Dysplasia) of the Hip (DDH)

Description

Developmental dislocation of the hip (DDH) is an abnormal formation of the hip joint. 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. It is important to note the ball may not always be out of the socket at birth.

Hip dysplasia is often 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. A child's hip may not be dislocated at birth, which means the condition may not be noticed until a child begins to walk, by which time treatment is more complicated and uncertain.

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. 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. However, even with appropriate treatment, especially in the child who is 2 years or older, hip deformity and osteoarthritis may develop later in life.

Risk Factors / Prevention

DDH has a familial tendency. It can be present in either hip and in any individual. 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 after birth to show if DDH is present.

Symptoms

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 Options

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 one or two 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.

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Falls and Hip Fractures

Ninety percent of the more than 352,000 hip fractures in the U.S. each year 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 $26,912 per patient.

There were 220,000 total hip replacements performed in the U.S. in 2003 (Source: National Center for Health Statistics; Centers for Disease Control and Prevention; 2003 National Hospital Discharge Survey).

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Fracture of the Pelvis

The pelvis is a ring-like structure of bones at the lower end of the trunk. The two sides of the pelvis are actually three bones (ilium, ischium, and pubis) that grow together as people age. Strong connective tissues (ligaments) join the pelvis to the large triangular bone (sacrum) at the base of the spine. This creates a bowl-like cavity below the rib cage. On each side, there is a hollow cup (acetabulum) that serves as the socket for the hip joint.

Many digestive and reproductive organs are located within the pelvic ring. Large nerves and blood vessels to the legs pass through it. The pelvis serves as an attachment point for muscles that reach down into the legs and up into the trunk of the body. A pelvic fracture is often associated with substantial bleeding, sensory and motor dysfunction, and other injuries.

How it happens

Growing teens, especially those involved in sports, are one group of people at risk for a particular type of pelvic fracture. Many "pulled muscles" may actually be undetected avulsion fractures of the pelvis. These fractures usually occur with sudden muscle contractions. A small piece of bone from the top of the hipbone is torn away by the muscle. This is a very stable type of fracture. It does not involve the entire pelvic ring or injure internal organs.

Another group at risk for pelvic fractures is elderly people with osteoporosis. An individual may fracture the pelvis during a fall, such as when getting out of the bathtub or descending stairs. These injuries usually do not damage the structural integrity of the pelvic ring, but may fracture an individual bone.

However, most pelvic fractures involve high-energy forces, such as those generated in a motor vehicle accident, crush accident or fall. Depending on the direction and degree of the force, these injuries can be life-threatening.

Diagnosis

A broken pelvis is painful, often swollen and bruised. The individual may try to keep the hip or knee bent in a specific position to avoid aggravating the pain. If the fracture is due to trauma, there may also be injuries to the head, chest or legs. There is usually considerable bleeding, which can lead to shock. Summon emergency assistance. The injuries must be stabilized and the individual taken to a trauma center for definitive care. All pelvic fractures require X-rays, usually from different angles, to show the degree of displacement to the bones. A computed tomography (CT) scan may be ordered to define the extent of other injuries. The physician will also examine the blood vessels and nerves to the legs to see if they have been injured.

Treatment

Stable fractures such as the avulsion fracture experienced by an athlete will normally heal without surgery. The physician may prescribe a painkiller (analgesic). The patient will have to use crutches or a walker, and will have to avoid putting weight on the hip until the bones heal. Because mobility may be limited for several months, the physician may also prescribe a blood-thinner to reduce the risk of blood clots forming in the veins of the legs.

Pelvic fractures that result from high-energy trauma are often life-threatening injuries because of the extensive bleeding. In these cases, doctors may use an external fixator to stabilize the pelvic area. This device has long screws that are inserted into the bones on each side and connected to a frame outside the body. The external fixator allows surgeons to address the internal injuries to organs, blood vessels and nerves.

What happens next depends on the type of fracture and the patient's condition. Each case must be assessed individually, particularly with unstable fractures. Some pelvic fractures may require traction; for others, the external fixator may be sufficient. Unstable fractures may require surgical insertion of plates or screws of a biocompatible metal.

Outcome

Stable pelvic fractures heal well. Pelvic fractures sustained during a traumatic incident such as an automobile accident may have significant complications, including severe bleeding and infection. However, these are due more to the associated injuries than to the fracture. If these injuries are addressed, the fracture usually heals well. Subsequent problems such as pain, impaired mobility, and sexual dysfunction are usually the result of damage to nerves and organs that is associated with the pelvic fracture.

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Hip Bursitis

Description

A "bursa" is a small jelly-like sac usually containing a small amount of fluid. Bursae are located throughout the body. The most important bursae are located around the shoulder, elbow, hip, knee and heel. A bursa functions as a cushion between bones and the overlying soft tissues. It helps reduce friction between the gliding muscles and the bone.

The point of the hip is called the greater trochanter. It functions as an attachment point for several important muscles that move the hip joint. The trochanter has a fairly large bursa overlying it. The bursa measures about 3 inches long, 2 inches wide, and 1/4 inch thick. This bursa occasionally becomes irritated or inflamed. This is a common cause of hip pain. When this occurs, the condition is called "hip bursitis" or "trochanteric bursitis." Another bursa located on the inside (groin side) of the hip is called the iliopsoas bursa. When it becomes inflamed, the condition is also sometimes referred to as hip bursitis, but the pain is located in the groin area. It is treated in a similar manner as trochanteric bursitis, but is less common.

Diagnostic tests

The primary diagnostic test is the doctor's physical examination. The doctor will look for tenderness in the area of the point of the hip. He or she may request additional tests to rule out other possible injuries or conditions that could cause similar pain. These tests can include X-rays, bone scan and MRI (magnetic resonance imaging).

Risk Factors/Prevention

Trochanteric bursitis can affect anyone at any age. It is more common in women and in middle-aged or elderly people. It is less common in younger people and in men. The following circumstances have been associated with the development of hip bursitis:

Repetitive stress (overuse) injuries: These can include running, stair climbing, bicycling or standing for long stretches of time.

Injury to the point of the hip: This can include falling onto the hip, bumping your hip on the edge of a table, lying on one side of the body for an extended period, etc.

Spine disease: This can include scoliosis, arthritis of the lumbar (lower) spine and other spine problems.

Leg-length inequalities: When one leg is shorter than the other by more than an inch or so, this affects the way you walk and can irritate the bursa.

Rheumatoid arthritis: This makes the bursae more likely to become inflamed.

Previous surgery around the hip or prosthetic implants in the hip

Hip bone spurs or calcium deposits in the tendons which attach to the trochanter

Trochanteric bursitis can happen even when you don't have any of these conditions.

Prevention is aimed at avoiding behaviors and activities that make the inflammation of the bursa worse. Some tips:

• Avoid repetitive activities that put stress on the hips.
• Lose weight if you need to.
• Get a properly fitting shoe insert for leg length differences.
• Maintain strength and flexibility of the hip muscles.

Symptoms

The main symptom is pain at the point of the hip. The pain usually extends to the outside of the thigh area and is usually described as sharp and intense in the early stages of the problem. After awhile, it may feel more "achy" and spread out. Typically, the pain is worse at night, when lying on the affected hip, and when getting up from a chair after being seated for a while. It also may get worse with prolonged walking, stair climbing or squatting.

Treatment Options

The initial treatment for hip bursitis does not involve surgery. Many cases of hip bursitis are treated effectively with simple lifestyle changes such as:

• Modifying activities (i.e., avoiding the activities that make it worse)
• Using non-steroidal anti-inflammatory medications (NSAIDs) to control inflammation and pain (i.e., ibuprofen, naproxen, piroxicam, celecoxib and others)
• Using a walking cane or crutches for a week or more when needed

There is little evidence in clinical studies to support the use of physical therapy, but frequently patients will claim that it is helpful. The doctor may ask a physical therapist to teach you how to stretch the hip muscles and use "modalities" such as ice/heat, ultrasound or other treatments.

There are clinical studies that show an injection of corticosteroids along with a local anesthetic is helpful in relieving symptoms of hip bursitis. This is a simple and effective treatment that can be done in the doctor's office. It involves a single injection into the bursa. The injection typically provides permanent relief, but on occasion the pain and inflammation may return and require another injection or two, given a few months apart. Often, the pain will be immediately relieved after the injection, and then return when the anesthetic wears off in several hours. The steroid takes a couple of days before it starts to work, so there may be a period of time where the pain seems to return and then again subside.

Use NSAIDs cautiously. Talk with your doctor about the NSAIDs you use. NSAIDs may have adverse side effects if you have certain medical conditions or take certain medications.

Treatment Options: Surgical

Surgery is very rarely needed for hip bursitis. In cases where the bursa remains inflamed and painful after non-surgical measures have been taken, and your doctor is certain that the diagnosis is correct, the bursa can be surgically removed. This involves giving you either general anesthesia (being put to sleep), or regional anesthesia (spinal anesthetic or nerve block with a sedative). A 3-inch to 4-inch incision is made over the bursa, and it is removed. Removal of the bursa does not hurt the hip and the hip can actually function normally without it.

A newer technique that is gaining popularity is removal (excision) of the bursa with arthroscopic surgery. This involves making two 1/4-inch incisions over the hip, and inserting a camera (arthroscope) in one incision, and a surgical instrument in the other to cut out the bursa. This surgery is much less invasive, and recovery is quicker and a little less painful. Both types of surgeries are done on an outpatient (day surgery) basis, so an overnight stay in the hospital is not usually necessary.

Following surgery, a short convalescence period can be expected. Most patients find that using a cane or crutches for a couple of days is helpful. It is reasonable to be up and walking around the evening after surgery. The soreness from surgery lasts for a variable amount of time, but usually resolves after a few days.

Research on the Horizon/What's New?

More research needs to be done on the effectiveness of various non-surgical treatments for hip bursitis, such as NSAIDS, steroid injections, and physical therapy. There is currently research in progress in these areas. Early studies show arthroscopic excision of the bursa to be quite effective, but this is still currently being studied.

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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.

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Hip Fracture

Hip fractures are a serious health problem common among elderly men and women who fall in their own homes. In 2003 there were about 345,000 hospitalizations for hip fractures (Source: National Center for Health Statistics; Centers for Disease Control and Prevention; 2003 National Hospital Discharge Survey.) 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.

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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.

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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.

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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.

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Minimally Invasive Hip Replacement

Description

Total hip replacement is a common procedure. It involves removing the head of the thighbone (femur). The ball-and-socket mechanism of the hip is replaced with artificial implants.

As the population ages over the next decade, this procedure is expected to become even more common. Patients who undergo hip replacement are typically 60 to 75 years old. More than 90 percent of hip replacements last for 10 years or more. Pain and mobility improve after hip replacement. This allows patients to maintain their independence and quality of life.

Newer techniques and implants have been developed. They make hip replacement a less invasive operation. It takes less time for the patient to recover from surgery. The new implants are engineered to last longer.

Diagnosis

Osteoarthritis of the hip is the most common diagnosis that leads to hip replacement. Osteoarthritis is caused by wear and tear. It affects the cartilage surfaces of the ball-and-socket joint of the hip. The cartilage wears out. Pain and stiffness result. Patients with hip arthritis have difficulty walking, climbing stairs and performing routine daily activities.

Other conditions that can cause destruction of the hip joint include:

• Loss of the blood supply to the head of the thighbone (avascular necrosis)
• Rheumatoid arthritis (an inflammatory autoimmune disease)
• Previous injury or trauma
• Infection
• Developmental abnormalities of the hip

See your doctor to diagnose hip arthritis. Many hip patients have difficulty with walking and day-to-day activities like putting on shoes and socks or climbing stairs. Tell the doctor your symptoms. He or she will perform a physical examination and order X-rays. X-rays typically show loss of the cartilage space in the hip socket. It looks like there is "bone-on-bone". Bone spurs and bone cysts are common. Sometimes, the doctor may recommend additional tests to confirm the diagnosis. These may include MRI (magnetic resonance imaging) or CT (computed tomography) scans.

Risk Factors/Prevention

Hip arthritis may happen if you have a previous injury or mechanical abnormalities related to how the hip developed. Most patients develop arthritis as a result of lifelong wear and tear. Arthritis develops slowly. It takes a period of years. Symptoms increase gradually over time.

Some bone diseases may contribute to the development of hip arthritis. Patients with arthritis may also have brittle bones (osteoporosis). But there is no direct relationship between bone density and the development of arthritis of the hip.

Symptoms

Hip arthritis typically causes pain that is dull and aching. The pain may be constant or it may come and go. You may feel pain in the groin, thigh and buttock. You may also have pain in the knee (referred pain). Walking, especially for longer distances, may cause a limp. Some patients may need a cane, crutch or walker to help them get around. Pain usually starts slowly. It gets worse with time, and higher activity levels.

Climbing stairs can be difficult. Many patients with hip arthritis have to use a stair rail or stop on each step to get up and down. Dressing, tying shoes and clipping toenails can be difficult or impossible. You may have pain when you rest. Pain may interfere with your sleep. Resting and taking anti-inflammatory or pain medication can help.

Treatment Options

The first treatment a doctor may recommend is to take prescription or over-the-counter, anti-inflammatory medications. These include ibuprofen (Motrin®or Advil®acetaminophen (Tylenol®or mild combination narcotics (Tylenol® with codeine). Some nutritional supplements may also provide some relief. These include glucosamine. Short-term physical therapy may help with strength and stiffness.

For more advanced arthritis, you may need to use a cane in the hand opposite the affected hip. This transfers weight away from the affected hip. It can improve walking ability. Using a walker may help patients who have more trouble walking. These measures usually improve pain and function. But arthritis is progressive. Even with treatment, it gets worse over time. Weight loss can help decrease stresses on all of the joints. If you are overweight, you should strongly consider losing weight.

Treatment Options: Surgical

Even when you get all of the right nonsurgical treatments, problems with pain and mobility sometimes get worse. In this case, the doctor may recommend surgery. Surgical options include:

Arthroscopy: Arthroscopy of the hip is a minimally invasive, outpatient procedure. It is relatively uncommon. The doctor may recommend it if the joint has evidence of torn cartilage or loose fragments of bone or cartilage.

Osteotomy: Candidates for osteotomy include younger patients with early arthritis, particularly those with abnormally shallow hip socket (dysplasia). The procedure involves cutting and realigning the bones of the hip socket and/or thighbone. This creates a more normal relationship between the ball and socket. It decreases pressure in the joint. In some cases, this may delay the need for replacement surgery for 10 to 20 years.

Traditional Hip Replacement: The doctor may recommend hip replacement when all of the above measures have been considered or have been tried and failed. Traditional hip replacement surgery involves making a 10-inch to 12-inch incision on the side of the hip. The muscles are split or detached from the hip. The hip is dislocated. The ball of the femur is removed. The hip socket is prepared by removing any remaining cartilage and some of the surrounding bone. The cup implant is pressed into the bone of the socket. It may be secured with screws. A bearing surface is inserted into the socket.

Next, the femur is prepared by removing some bone from the inside of the thighbone. A metal stem is placed into the thighbone to a depth of about 6 inches. The stem implant is either fixed with bone cement or is implanted without cement. Cementless implants have a rough, porous surface. It allows bone to adhere to the implant to hold it in place. A ball is then placed on the top of the stem. The ball-and-socket joint is recreated.

Minimal Incision Hip Replacement: Minimal incision hip replacement surgery lets the surgeon perform hip replacement through one or two smaller incisions. Compared with most people getting hip replacements, candidates for minimal incision procedures are typically thinner, younger, healthier and more motivated to have a quick recovery. Before you decide to have a minimally invasive hip replacement, get a thorough evaluation from the operating surgeon. Discuss with him or her about the risks and benefits. Both traditional and minimally invasive hip replacement procedures are technically demanding. They require that the surgeon and operating team have considerable experience.

The artificial implants used for the minimally invasive hip replacement procedures are the same as those used for traditional hip replacement. Specially designed instruments are needed to prepare the socket and femur and to place the implants properly. The artificial hip is implanted in the same way. But there is less soft-tissue dissection than with longer incisions.

A single minimally invasive hip incision may measure only 3-inches to 6-inches. It depends on the size of the patient and the difficulty of the procedure. The incision is usually placed over the outside of the hip. The muscles and tendons are split or detached, but to a lesser extent than in the traditional hip replacement operation. They are routinely repaired after the surgeon places the implants. This helps healing. It helps prevent dislocation of the hip.

Two-incision hip replacement involves making a 2-inch to 3-inch incision over the groin for placement of the socket and a 1-inch to 2-inch incision over the buttock for placement of the stem. To perform the two-incision procedure, the surgeon needs guidance from X-rays. It may take up to two or three times as long to perform this surgery, as it takes to perform traditional hip replacement surgery.

Reported benefits of less invasive hip replacement include:

• Less pain
• More cosmetic incisions
• Less muscle damage
• Rehabilitation is faster
• Hospital stays are shorter--For traditional hip replacement, hospital stays average four to five days. Many patients need extensive rehabilitation afterward. With less invasive procedures, the hospital stay may be as short as one or two days. Some patients can go home the day of surgery.

Early studies suggest that minimally invasive hip replacement surgery streamlines the recovery process. But the risks and long-term benefits of the less invasive techniques have not yet been documented to represent an improvement over traditional hip replacement surgery.

Research on the Horizon/What's New?

Extensive study and development are now underway to determine the long-term benefits of minimally invasive hip replacement. New technology for imaging and computer-assisted implant placement has been developed. It continues to be modified as experience with smaller incision surgery grows. This will allow more precise reconstruction of the hip with less direct visualization. In addition, new implant designs and materials are being developed to both facilitate minimally invasive surgery on the hip and to prolong the lifespan of replacements.

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Muscle Strains in the Thigh

A muscle strain, also called a pull or tear, is a common injury, particularly among people who participate in sports. The thigh has three sets of strong muscles: the hamstring muscles in the back, the quadriceps muscles in the front, and the adductor muscles on the inside. The quadriceps and hamstring muscle sets work together to straighten (extend) and bend (flex) the leg. The adductor muscles pull the legs together.

The hamstring and quadriceps muscle sets are particularly at risk for muscle strains because they cross both the hip and knee joints. They are also used for high-speed activities such as track and field events (running, hurdles, long jump), football, basketball, and soccer.

Signs and symptoms

Muscle strains usually happen when a muscle is stretched beyond its limit, tearing the muscle fibers. They frequently occur near the point where the muscle joins the tough, fibrous connective tissue of the tendon. A similar injury occurs if there is a direct blow to the muscle. Muscle strains in the thigh can be quite painful, and may involve some bruising if blood vessels are also broken. Once a muscle strain occurs, the muscle is vulnerable to reinjury, so it's important to let the muscle heal properly and to follow preventive protocols.

A person who experiences a muscle strain in the thigh will frequently describe a popping or snapping sensation as the muscle tears. Pain is sudden and may be severe. The area around the injury may be tender to the touch, with visible bruising.

Diagnosis and treatment

Your physician will ask about the injury and examine the thigh for tenderness or bruising. You may be asked to bend or straighten your knee and/or hip so the doctor can confirm the diagnosis. An X-ray may be needed if there is a possible fracture or other injury to the bone. Muscle strains are graded according to their severity. A grade 1 strain is mild and usually heals readily, while a grade 3 strain is a severe tear of the muscle that may take months to heal.

Most muscle strains can be treated with the RICE protocol. RICE stands for Rest, Ice, Compression, and Elevation.

• Rest: Take a break from the activity that caused the strain. Your physician may recommend that you use crutches to avoid putting weight on the leg.
• Ice: Do not apply ice directly to the skin, but you can use cold packs for 20 minutes at a time, several times a day.
• Compression: To prevent additional swelling and blood loss, wear an elastic compression bandage.
• Elevation: To minimize swelling, keep your leg up higher than your heart.

Your doctor may recommend aspirin, ibuprofen or another analgesic for pain relief. As the pain and swelling subside, physical therapy will help improve range of motion and strength. The muscle should be at full strength and pain-free before you return to sports. This will help prevent additional injury.

Preventing muscle strains

Several factors can predispose you to muscle strains. These include:

• Muscle tightness. Tight muscles are vulnerable to strain, so athletes should follow a year-round program of daily stretching exercises.
• Muscle imbalance. Because the quadriceps and hamstring muscles work together, if one is stronger than the other, the weaker muscle can become strained.
• Poor conditioning. If your muscles are weak, they are less able to cope with the stress of exercise and more likely to be injured.
• Muscle fatigue. Fatigue reduces the energy-absorbing capabilities of muscle, making them more susceptible to injury.
• Insufficient warm-up. A proper warm-up is protective because it increases range of motion and reduces stiffness. You can take the following precautions to help prevent muscle strain:
• Warm up before any exercise session or sports participation, including practice. This will help increase your speed and endurance.
• Stretch slowly and gradually, holding each stretch to give the muscle time to respond and lengthen. You can find examples of stretching exercises on this site or ask your physician or coach for help in developing a routine.
• Condition your muscles with a regular program of exercises. You can ask your physician about exercises programs for people of your age and activity level.
• If you are injured, take the time needed to let the muscle heal before you return to sports. Wait until your muscle strength and flexibility return to pre-injury levels, a process that can take 10 days to 3 weeks for a mild strain, and up to 6 months for a severe strain.

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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 10 million Americans reported having been diagnosed with 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.

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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).

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Pediatric Thighbone (Femur) Fracture

Description

The largest and strongest bone in the body, the thighbone (femur) can break when a child suffers a sudden forceful impact.

Call 911 or take your child to the doctor right away if you think he or she might have a broken thighbone. Explain exactly how the injury occurred. Tell the doctor if your child had any disease or other trauma before it happened. The doctor will give your child an anesthetic or pain relief medication and carefully examine the leg including the hip and knee. The pattern of the fracture may be one of several. The pieces of bone may be aligned or out of alignment (displaced), closed (skin intact) or open (piercing the skin). Your doctor will need X-rays to see the pattern of the break. Your child's healthy leg may also be X-rayed for comparison.

An orthopaedic surgeon may check for any damage to the growth area (growth plate) near the end of the femur, which enables the child's bone to grow. If needed, surgery may restore the growth plate's function and regular X-rays may be taken for many months to track the bone's growth.

Risk Factors / Prevention

Common causes of pediatric femur fractures include:

• Falling on the playground
• Taking a hit in contact sports
• Being in a car crash
• Child abuse

Symptoms

A broken thighbone is a serious injury. It might be obvious by severe pain and disability. Your child may be unable to walk or have limited range of motion, pain made worse by movement and swelling. A child with a thighbone fracture may also have other serious injuries.

Treatment Options

Reduction and immobilization. To treat a child's thighbone fracture, the pieces of bone are realigned and held in place for healing. Your doctor will choose an appropriate treatment. It depends upon factors such as your child's age/weight, the type of fracture, how the injury happened, whether the bone broke the skin, if there was also an injury to the child's head, etc.

General guidelines for reduction while under a general anesthetic:

• Your doctor may be able to manipulate certain thighbone fractures back into place from the outside (closed reduction). In some cases, it may helpful to put the child's leg in a weight and counterweight system (traction) before the bones are realigned.
• To treat more complicated injuries, the doctor may need to surgically realign the bone with or without implants.

General guidelines for immobilization:

• A young child may need a cast to treat a femur fracture. An external or internal device may be used if the break was displaced.
• Adolescents usually need external or internal devices for a femur fracture.

Traction and spica casting: Your child stays in the hospital for several weeks with his or her leg in a traction device. When the thighbone fracture begins to heal, your child gets a plaster or fiberglass hip cast (spica cast) to immobilize the leg in the correct position.

Early spica cast: In certain cases, infants and small children can be fitted with a spica cast immediately or within 24 hours of hospitalization.

External device: An external frame immobilizes your child's fracture. It is anchored by surgical pins placed above and below the fracture site. Pin care is done at home.

Internal devices: Your child's broken thighbone is immobilized internally with a rod, nailing system or plate secured directly in the bone.

When the immobilization device is removed, your child may need to do rehabilitation exercises to restore range of motion and flexibility. The doctor may want to see your child again after the thighbone fracture heals to make sure healing is satisfactory.

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Perthes Disease

Description

Perthes disease usually is seen in children 2 to12 years of age. It is five times more common in boys than girls. It was originally described nearly a century ago as a peculiar form of childhood arthritis of the hips. Although the term 'disease' is still used, it is now known that Perthes is a condition characterized by a temporary loss of blood supply to the hip; it is not a disease. When the blood supply is diverted, the bone of the femoral head (the 'ball' of the 'ball and socket' joint of the hip) dies. Intense inflammation and irritation develop.

Perthes is a complex process in children. The stages and various forms of treatment may be confusing. Treatment of Perthes may require otherwise healthy children to submit to periods of immobilization or alter their usual activities.

The long-term prognosis is good in most cases. After 18 months to two years of treatment, most children return to normal activities without major limitations.

Symptoms

X-rays taken because of limping and mild pain usually diagnose the condition. The child may have had these symptoms intermittently over a period of weeks or even months. Pain sometimes is caused by muscle spasms that result from hip irritation. The pain may be felt in other parts of the leg such as the groin, thigh or knee. When the hip is moved, the pain worsens. Rest often relieves the pain.

Treatment Options

The child with Perthes can expect to have several X-rays taken over the course of treatment, which may be two years or longer. The X-rays usually will look worse before gradual improvement is noted.

Girls tend to have more extensive involvement; therefore, they have a generally poorer prognosis than boys. Usually, treatment for very young children (those 2 to 6 years of age) with minimal X-ray changes consists of observation. For the older child, vigorous treatment is necessary to maintain the hip range of motion. There are three components of treatment:

• Reduce the swelling or inflammation in the hip joint
• Restore an improved hip range of motion
• By taking X-rays, make sure the hip stays deep within the socket during the healing process

Hip joint inflammation. Anti-inflammatory medications such as Advil or Naprosyn are used to decrease the hip joint inflammation or synovitis. These medicines are often used for months. The medications will be adjusted or discontinued depending on the healing stage.

Restore hip range of motion. It is not desirable for the child to walk on a stiff hip. This may promote contracture of muscle and possibly flattening of the femoral head. To help restore range of motion, physical therapy, ambulation with crutches, or bed rest in traction may be needed.

Your child will be shown some simple exercises to do until the final stage of healing has occurred.

• Hip abduction: The child will lie on his back, keeping knees bent and feet flat. Place your hands on the child's knees and resist as he pushes out, then resist as he squeezes knees together.
• Hip rotation: With the child on his back and legs out straight, roll the entire leg inward and outward.

Maintain hip postion in the socket. If the range of motion (ROM) cannot be maintained, or if X-rays or MRI indicate a progressive deformity is developing, a brace or cast may be used to keep the femoral head (ball) contained within the acetabulum (socket).

Petrie casts are two long leg casts with a wooden bar that hold the legs spread apart in a position similar to the letter "A." The application of the initial Petrie cast usually is performed in the operating room. During the procedure, the surgeon usually will place a small amount of dye into the hip joint (Arthrogram) to aid in evaluating the degree of "flattening" of femoral head. Occasionally, the adductor longus muscle in the groin must be lengthened through a small incision to permit rotation of the hip into a more favorable position.

Following removal of the cast (usually in 4 to 6 weeks), the patient is reassessed for the appropriateness of continuing brace treatment with the cast or a removable orthosis such as the Scottish Rite brace. This treatment may be continued until range of motion is maintained or the hip enters the final stage of the healing process.

Treatment Options: Surgical

Surgical treatment realigns the bony structures so that the head of the femur is placed deep within the acetabulum. Fixation is maintained with screws and plates that will be removed at a later date. In some cases, the socket must also be deepened because the ball actually has enlarged during the healing process and no longer fits snugly within. After either procedure, the child is often placed in a cast from the chest to the toes for 6 to 8 weeks.

After the cast is removed the child will participate in physical therapy with protected weight bearing of the affected leg until X-rays reveal the final stages of the healing are under way.

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Slipped Capital Femoral Epiphysis

Description

Slipped capital femoral epiphysis (SCFE) is an unusual disorder of the adolescent hip. It is not rare. For reasons that are not well understood, the ball at the upper end of the femur (thigh bone) slips off in a backward direction. This is due to weakness of the growth plate. Most often, it develops during periods of accelerated growth, shortly after the onset of puberty.

The condition is diagnosed based on a careful history, physical examination, observation of the gait/walking pattern and hip X-rays. The X-rays help confirm the diagnosis by demonstrating that the upper end of the thigh bone does not line up with the portion called the femoral neck.

Risk Factors / Prevention

The cause of SCFE is unknown. It occurs two to three times more often in males than females. A large number of patients are overweight for their height. In most cases, slipping of the epiphysis is a slow and gradual process. However, it may occur suddenly and be associated with a minor fall or trauma. Symptomatic SCFE, treated early and well, allows for good long-term hip function.

Symptoms

The typical patient has a history of several weeks or months of hip or knee pain and an intermittent limp. The appearance of the adolescent is characteristic. He or she walks with a limp. In certain severe cases, the adolescent will be unable to bear any weight on the affected leg. The affected leg is usually turned outward in comparison to the normal leg. The affected leg may also appear to be shorter.

The physical exam will show that the hip does not have full and normal range of motion. There is often a loss of complete hip flexion and ability to fully rotate the hip inward. Because of inflammation in the hip, there is often pain at the extremes of motion and involuntary muscle guarding and spasm.

Treatment Options

The goal of treatment is to prevent any additional slipping of the femoral head until the growth plate closes. If the head is allowed to slip further, hip motion could be limited. Premature osteoarthritis could develop. Treatment should be immediate. In most cases, treatment begins within 24-48 hours.

Early diagnosis of SCFE provides the best chance to achieve the treatment goal of stabilizing the hip.

Treatment Options: Surgical

Fixing the femoral head with pins or screws has been the treatment of choice for decades. Depending on the severity of your child's condition, the surgeon will recommend one of three surgical options:

• Placing a single screw into the thighbone and femoral epiphysis.
• Reducing the displacement and placing one or two screws into the femoral head.
• Removing the abnormal growth plate and inserting screws to aid in preventing any further displacement.

Complications. There are several potential complications associated with a slipped capital femoral epiphysis. The most common are avascular necrosis (AVN) of the femoral head and chondrolysis. AVN means that the blood supply to the femoral head has been permanently altered by the femoral head slipping. There is no way to identify children at risk for AVN or to prevent this complication. Evidence of AVN may not be seen on X-rays for as long as 6 to 24 months following surgery.

Chondrolysis or loss of articular cartilage of the hip joint is a devastating complication of SCFE. It may cause the hip to stiffen with a permanent loss of motion, flexion contracture and pain. The loss of motion may be a result of an inflammation in the hip joint. This is still not fully understood by surgeons. Aggressive physical therapy and anti-inflammatory medications may be prescribed for this rare complication. There may be some return of motion.

Post-operative care. Most likely, your child will be admitted to the hospital by a pediatric orthopaedist. Surgery is usually performed within 24 to 48 hours. After surgery, your child will be on crutches for weeks to months. A physical therapist will demonstrate how to use crutches. The doctor will give you specific instruction about your child's weight-bearing status and activity restrictions. Follow the instructions closely.

It is important that your child be followed closely for 18 to 24 months after surgery. After the immediate postoperative period, X-rays every 3 to 4 months are needed to ensure that the abnormal growth plate has fused. Your child may be restricted from certain sports and activities during this time of recuperation. This helps to minimize the chance of further complications. The fusion must be mature enough to prevent further slippage. Then vigorous physical activities can begin.

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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.

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Thighbone Fracture

The thighbone (femur) is the longest and the strongest bone in the body. To break the thighbone across its length (shaft) takes a great deal of force, as might occur in a motor vehicle accident or a fall from a high place. Because of this, a broken thighbone is often associated with potentially life-threatening injuries to other body systems. In children younger than 3 years of age, a thighbone fracture is often an indicator of abuse.

Diagnosis

A broken thighbone is usually obvious, even if the bone does not break through the skin. Severe pain, inability to move the leg, deformity and swelling are characteristic. The injured thigh may be shorter than the uninjured one because the strong thigh muscles may force the broken edges of bone out of alignment (displacement). The injury may disrupt the rich blood supply to the muscles of the thigh, resulting in extensive bruising and loss of blood.

If the fracture resulted from high-energy trauma such as a motor vehicle accident, the patient might not be conscious and may have other injuries. It is important that emergency medical personnel tend to the injury and transport the individual to a hospital.

The physician will examine the injury and evaluate the circulatory and nervous systems, as well as the fracture. Several X-rays may be required, including the leg, knee, hip and pelvis, to determine the extent of injury to the adjacent joints.

Treatment

As with all broken bones, a broken thighbone will need to be "reduced" or returned to alignment and immobilized until it heals. There are several methods that can be used, depending on the patient's degree of skeletal maturity, the amount of displacement, the type of break and the presence of associated injuries. If you are the parent of a child with a broken thighbone, ask your orthopaedic surgeon which option he or she recommends and why.

• Traction. Traction is the traditional method of treating thighbone fractures. The leg is placed in a cast and sticky tape (skin traction) or a metal pin (skeletal traction) is used to attach a series of strings that connect to weights. X-rays are used to monitor the position of the bone so that the traction can be adjusted. Although traction is effective, it requires a lengthy hospital stay. Because research has confirmed the importance of early mobility in reducing complications and promoting successful healing, other methods of fixation are now more popular than traction.
• Casting. Very young children (under 8 years of age, depending on their size and weight) with an isolated fracture to the shaft of the thighbone can be treated with casting. A spica cast, which goes up over the hips and includes the other leg, may be used. A child with a spica cast can be cared for at home.
• Plating. In some cases, the surgeon may apply a metal plate to the side of the thighbone across the break. The plate is held in place with screws. The plate helps bear weight and makes early mobilization possible. However, the plate may also shield the bone from stress, which is not necessarily a good thing. Because some stress on the bone is necessary to strengthen it as it heals, this stress-shielding may leave the bone with a residual weakness. This generally disappears as the patient resumes normal activities. However, one concern is that when the plate is removed, the still-weakened bone may break again, but this is an infrequent occurrence. Plate-and-screw fixation can be an ideal choice for a patient with open growth plates or a nerve injury.
• External fixation. Although less frequently used for thighbone fractures, external fixation is an option if there are severe soft-tissue injuries along with the fracture. A frame around the leg is attached to the bone with pins. This has the advantage of allowing early mobilization, but caring for the pin insertions is difficult and infections are common. Nevertheless, external fixation may be appropriate for children with open growth plates and for patients with contaminated wounds.
• Internal intramedullary fixation. Internal intramedullary fixation (placing a rod inside the bone) is usually recommended for people who have attained skeletal maturity. The thighbone is like a tube, with a soft center surrounded by hard (cortical) bone. During a surgical procedure, a special rod (intramedullary nail) is inserted into the thighbone. The insertion may be near the hip or just above the knee. The rod extends into the middle of the bone and across the fracture site. It is locked in place with screws that pass through the bone and across the rod. This enables early movement and good stabilization of the fracture. After the fracture heals, the nail is removed.

Complications

A broken thighbone is a serious injury that takes a long time (3 to 6 months) to heal. Any delay in diagnosis or treatment could result in problems later. A child who has a thighbone fracture should be watched carefully and any changes in condition should be brought to the physician's attention immediately. Oddly enough, because of the plentiful blood supply to the thighbone, the injured leg may grow longer than the uninjured one in some children. If, however, the bone is not properly aligned, the opposite could occur, with the injured leg being shorter.

A fracture that breaks the skin (open fracture) is susceptible to infection. In high-energy trauma cases, other injuries (including injury to the muscles and nerves around the thighbone) may make treating the fracture difficult.

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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 information 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. Your hip may be stiff and it may be hard to put on your shoes and socks. 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, increase motion, 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 the last century. Since then, improvements in joint replacement surgical techniques and technology have greatly increased the effectiveness of this surgery. Today, more than 193,000 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.

How the normal hip works

The hip is one of your body's largest weight-bearing joints. It consists of two main parts: a ball (femoral head) at the top of your thighbone (femur) that fits into a rounded socket (acetabulum) in your pelvis. Bands of tissue called ligaments (hip capsule) connect the ball to the socket and provide stability to the joint.

The bone surfaces of your ball and socket have a smooth durable cover of articular cartilage that cushions the ends of the bones and enables them to move easily.

A thin, smooth tissue called synovial membrane covers all remaining surfaces of the hip joint. In a healthy hip, this membrane makes a small amount of fluid that lubricates and almost eliminates friction in your hip joint.

Normally, all of these parts of your hip work in harmony, allowing you to move easily and without pain.

Common causes of hip pain and loss of hip mobility

The most common cause of chronic hip pain and disability is arthritis. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease.

Osteoarthritis usually occurs after age 50 and often in an individual with a family history of arthritis. It may be caused or accelerated by subtle irregularities in how the hip developed. In this form of the disease, the articular cartilage cushioning the bones of the hip wears away. The bones then rub against each other, causing hip pain and stiffness.

Rheumatoid Arthritis is an autoimmune disease in which the synovial membrane becomes inflamed, produces too much synovial fluid, and damages the articular cartilage, leading to pain and stiffness.

Traumatic Arthritis can follow a serious hip injury or fracture. A hip fracture can cause a condition known as avascular necrosis. The articular cartilage becomes damaged and, over time, causes hip pain and stiffness.

Is hip replacement surgery for you?

The decision whether to have hip replacement surgery should be a cooperative one between you, your family, your primary care doctor, and your orthopaedic surgeon. The process of making this decision typically begins with a referral by your doctor to an orthopaedic surgeon for an initial evaluation.

Although many patients who undergo hip replacement surgery are age 60 to 80, orthopaedic surgeons evaluate patients individually. Recommendations for surgery are based on the extent of your pain, disability and general health status, not solely on age.

You may benefit from hip replacement surgery if:

• Hip pain limits your everyday activities such as walking or bending.
• Hip pain continues while resting, either day or night.
• Stiffness in a hip limits your ability to move or lift your leg.
• You have little pain relief from anti-inflammatory drugs or glucosamine sulfate.
• You have harmful or unpleasant side effects from your hip medications.
• Other treatments such as physical therapy or the use of a gait aid such as a cane don't relieve hip pain.

The orthopaedic evaluation

Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether hip replacement surgery is the best method to relieve your pain and improve your mobility. Other treatment options such as medications, physical therapy or other types of surgery also may be considered.

Your orthopaedic surgeon will explain the potential risks and complications of hip replacement surgery, including those related to the surgery itself and those that can occur over time after your surgery. These risks and complications are discussed later in this booklet.

• A medical history, in which your orthopaedic surgeon gathers information about your general health and asks questions about the extent of your hip pain and how it affects your ability to perform every day activities.
• A physical examination to assess your hip's mobility, strength and alignment.
• X-rays to determine the extent of damage or deformity in your hip.
• Occasionally, blood tests or other tests such as an Magnetic Resonance Imaging (MRI) or a bone scan may be needed to determine the condition of the bone and soft tissues of your hip.

What to expect from hip replacement surgery

An important factor in deciding whether to have hip replacement surgery is understanding what the procedure can and can't do.

Most people who undergo hip replacement surgery experience a dramatic reduction of hip pain and a significant improvement in their ability to perform the common activities of daily living. However, hip replacement surgery will not enable you to do more than you could before your hip problem developed.

Following surgery, you will be advised to avoid certain activities, including jogging and high-impact sports, for the rest of your life. You may be asked to avoid specific positions of the joint that could lead to dislocation.

Even with normal use and activities, an artificial joint (prosthesis) develops some wear over time. If you participate in high-impact activities or are overweight, this wear may accelerate and cause the prosthesis to loosen and become painful.

Preparing for surgery

Medical Evaluation. If you decide to have hip replacement surgery, you may be asked to have a complete physical by your primary care doctor before your surgery. This is needed to assess your health and find conditions that could interfere with your surgery or recovery.

Tests. Several tests such as blood samples, a cardiogram, chest X-rays and urine samples may be needed to help plan your surgery.

Preparing Your Skin. Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for a program to improve your skin before your surgery.

Blood Donations. You may be advised to donate your own blood prior to surgery. It will be stored in case you need blood after surgery.

Medications. Tell your orthopaedic surgeon about the medications you are taking. Your orthopaedist or your primary care doctor will advise you which medications you should stop or can continue taking before surgery.

Weight Loss. If you are overweight, your doctor may ask you to lose some weight before surgery to minimize the stress on your new hip, and possibly decrease the risks of surgery

Dental Evaluation. Although infections after hip replacement are not common, an infection can occur if bacteria enter your bloodstream. Because bacteria can enter the bloodstream during dental procedures, you should consider getting treatment for significant dental diseases (including tooth extractions and periodontal work) before your hip replacement surgery. Routine cleaning of your teeth should be delayed for several weeks after surgery.

Urinary Evaluation. Individuals with a history of recent or frequent urinary infections and older men with prostate disease should consider a urological evaluation before surgery.

Social Planning. Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several weeks with such tasks as cooking, shopping, bathing and laundry. If you live alone, your surgeon's office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at your home. A short stay in an extended care facility during your recovery after surgery also may be arranged.

Home planning

Here are some items and home modifications that will make your return home easier during your recovery.

• Securely fastened safety bars or handrails in your shower or bath
• Secure handrails along all stairways
• A stable chair for your early recovery with a firm seat cushion that allows your knees to remain lower than your hips, a firm back and two arms
• A raised toilet seat
• A stable shower bench or chair for bathing
• A long-handled sponge and shower hose
• A dressing stick, a sock aid and a long-handled shoe horn for putting on and taking off shoes and socks without excessively bending your new hip
• A reacher that will allow you to grab objects without excessive bending of your hips
• Firm pillows to sit on that keep your knees lower than your hips for your chairs, sofas and car
• Removal of all loose carpets and electrical cords from the areas where you walk in your home

Your surgery

You will most likely be admitted to the hospital on the day of your surgery. Prior to admission, a member of the anesthesia team will evaluate you. The most common types of anesthesia for hip replacement surgery are general anesthesia (which puts you to sleep throughout the procedure and uses a machine to help you breath) or spinal anesthesia (which allows you to breath on your own but anesthetizes your body from the waist down). The anesthesia team will discuss these choices with you and help you decide which type of anesthesia is best for you.

Surgical procedure

The surgical procedure takes a few hours. Your orthopaedic surgeon will remove the damaged cartilage and bone, then position new metal, plastic or ceramic joint surfaces to restore the alignment and function of your hip.

Many different types of designs and materials are currently used in artificial hip joints. All of them consist of two basic components: the ball component (made of a highly polished strong metal or ceramic material) and the socket component (a durable cup of plastic, ceramic or metal, which may have an outer metal shell).

Special surgical cement may be used to fill the gap between the prosthesis and remaining natural bone to secure the artificial joint.

A noncemented prosthesis has also been developed which is used most often in younger, more active patients with strong bone. The prosthesis may be coated with textured metal or a special bone-like substance, which allows bone to grow into the prosthesis.

A combination of a cemented ball and a noncemented socket may be used.

Your orthopaedic surgeon will choose the type of prosthesis that best meets your needs.

After surgery, you will be moved to the recovery room where you will remain for one to two hours while your recovery from anesthesia is monitored. After you awaken fully, you will be taken to your hospital room.

A special note about minimally invasive total hip replacement

Over the past several years, orthopaedic surgeons have been developing new techniques, known as minimally invasive hip replacement surgery, for inserting total hip replacements through smaller incisions. It is hoped, but not yet proven, that this may allow for quicker, less painful recovery and more rapid return to normal activities. Minimally invasive and small incision total hip replacement surgery is a rapidly evolving area. While certain techniques have proven to be safe, others may be associated with an increased risk of complications such as nerve and artery injuries, wound healing problems, infection, fracture of the femur and malposition of the implants, which can contribute to premature wear, dislocation and loosening of your hip replacement. Patients who have marked deformity of the joint, those who are heavy or muscular, and those who have other health problems, which can contribute to wound healing problems, appear to be at higher risk of problems. Your orthopaedic surgeon can talk to you about his or her experience with minimally invasive hip replacement surgery and the possible risks and benefits of minimally invasive hip replacement surgery. The AAOS and the American Association of Hip and Knee Surgeons have developed information for patients about minimally invasive hip replacement surgery.

Your stay in the hospital

You will usually stay in the hospital for a few days. After surgery, you will feel pain in your hip. Pain medication will be given to make you as comfortable as possible.

To avoid lung congestion after surgery, you will be asked to breathe deeply and cough frequently.

To protect your hip during early recovery, a positioning splint, such as a V-shaped pillow placed between your legs, may be used.

Walking and light activity are important to your recovery and will begin the day of or the day after your surgery. Most hip replacement patients begin standing and walking with the help of a walking support and a physical therapist the day after surgery. The physical therapist will teach you specific exercises to strengthen your hip and restore movement for walking and other normal daily activities.

Possible complications after surgery

The complication rate following hip replacement surgery is low. Serious complications, such as joint infection, occur in less than 2 percent of patients. Major medical complications, such as heart attack or stroke, occur even less frequently. However, chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur they can prolong or limit your full recovery.

Blood clots in the leg veins or pelvis are the most common complication of hip replacement surgery. Your orthopaedic surgeon may prescribe one or more measures to prevent blood clots from forming in your leg veins or becoming symptomatic. These measure may include special support hose, inflatable leg coverings, ankle pump exercises and blood thinners.

Leg-length inequality may occur or may become or seem worse after hip replacement. Your orthopaedic surgeon will take this into account, in addition to other issues, including the stability and biomechanics of the hip. Some patients may feel more comfortable with a shoe lift after surgery.

Other complications such as dislocation, nerve and blood vessel injury, bleeding, fracture and stiffness can occur. In a small number of patients, some pain can continue, or new pain can occur after surgery.

Over years, the hip prosthesis may wear out or loosen. This problem will likely be less common with newer materials and techniques. When the prosthesis wears, bone loss may occur because of the small particles produced at the wearing surface. This process is called osteolysis.

Your recovery at home

The success of your surgery will depend in large measure on how well you follow your orthopaedic surgeon's instructions regarding home care during the first few weeks after surgery

Wound Care. You will have stitches or staples running along your wound or a suture beneath your skin. The stitches or staples will be removed about two weeks after surgery.

Avoid getting the wound wet until it has thoroughly sealed and dried. A bandage may be placed over the wound to prevent irritation from clothing or support stockings.

Diet. Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to promote proper tissue healing and restore muscle strength. Be sure to drink plenty of fluids.

Activity. Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal light activities of daily living within three to six weeks following surgery. Some discomfort with activity and at night is common for several weeks.

Your activity program should include:

• A graduated walking program, initially in your home and later outside
• Walking program to slowly increase your mobility and endurance
• Resuming other normal household activities
• Resuming sitting, standing, walking up and down stairs
• Specific exercises several times a day to restore movement
• Specific exercises several times a day to strength your hip joint
• May wish to have a physical therapist help you at home

Avoiding problems after surgery

Blood Clot Prevention. Follow your orthopaedic surgeon's instructions carefully to minimize the potential risk of blood clots, which can occur during the first several weeks of your recovery.

Warning signs of possible blood clots include:

• Pain in your calf and leg, unrelated to your incision
• Tenderness or redness of your calf
• Swelling of your thigh, calf, ankle or foot

Warning signs that a blood clot has traveled to your lung include:

• Shortness of breath
• Chest pain, particularly with breathing

Notify your doctor immediately if you develop any of these signs.

Preventing infection

The most common causes of infection following hip replacement surgery are from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. These bacteria can lodge around your prosthesis.

Following your surgery, you may need to take antibiotics prior to dental work, including dental cleanings, or any surgical procedure that could allow bacteria to enter your bloodstream. For many patients with a normal immune system the AAOS and ADA recommend dental prophylaxis for two years after a primary total joint surgery. A complete discussion of this topic is available on the AAOS patient education Web site, Your Orthopaedic Connection.

Warning signs of a possible hip replacement infection are:

• Persistent fever (higher than 100 degrees orally)
• Shaking chills
• Increasing redness, tenderness or swelling of the hip wound
• Drainage from the hip wound
• Increasing hip pain with both activity and rest

Notify your doctor immediately if you develop any of these signs.

Avoiding falls

A fall during the first few weeks after surgery can damage your new hip and may result in a need for more surgery. Stairs are a particular hazard until your hip is strong and mobile. You should use a cane, crutches, a walker or handrails, or have someone help you until you improve your balance, flexibility and strength.

Your surgeon and physical therapist will help you decide what assistive aides will be required following surgery, and when those aides can safely be discontinued.

Other precautions

To assure proper recovery and prevent dislocation of the prosthesis, you must take special precautions. Do not cross your legs. Do not bend your hips more than a right angle (90 degrees). Do not turn your feet excessively inward or outward. Use a pillow between your legs at night when sleeping until you are advised by your orthopaedic surgeon that you can remove it. Your surgeon and physical therapist will give you more instructions prior to your discharge from the hospital.

How your new hip is different

You may feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending. These differences often diminish with time and most patients find these are minor compared to the pain and limited function they experienced prior to surgery.

Your new hip may activate metal detectors required for security in airports and some buildings. Tell the security agent about your hip replacement if the alarm is activated. You may ask your orthopaedic surgeon for a card confirming that you have an artificial hip.

After surgery, make sure you also do the following:

• Participate in a regular light exercise program to maintain proper strength and mobility of your new hip.
• Take special precautions to avoid falls and injuries. Individuals who have undergone hip replacement surgery and suffer a fracture may require more surgery.
• Notify your dentist that you have had a hip replacement. You will need to take antibiotics before any dental procedure for a minimum of two years after your surgery and possibly longer, depending on your past health history. Guidelines for the use of antibiotics for your surgeon and dentist are available from the AAOS and the American Dental Association.
• See your orthopaedic surgeon periodically for routine follow-up examinations and X-rays, even if your hip replacement seems to be doing fine.

Your orthopaedic surgeon is a medical doctor with extensive training in the diagnosis and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles, and nerves.

This information has been prepared by the American Academy of Orthopaedic Surgeons and is intended to contain current information on the subject from recognized authorities. However, it does not represent official policy of the Academy and its text should not be construed as excluding other acceptable viewpoints. Persons with questions about a medical condition should consult a physician who is informed about the condition and the various modes of treatment available.

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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

Bed-Supported Knee Bends - Slide your heel toward your buttocks, bending your knee and keeping your heel on the bed. Do not let your knee roll inward.

Buttock Contractions - Tighten buttock muscles and hold to a count of 5.

Abduction Exercise - Slide your leg out to the side as far as you can and then back.

Quad Set - Tighten your thigh muscle. Try to straighten your knee. Hold for 5 to 10 seconds. Repeat this exercise 10 times during a 10-minute period. Continue until your thigh feels fatigued.

Straight Leg Raises - Tighten your thigh muscle with your knee fully straightened on the bed. As your thigh muscle tightens, lift your leg several inches off the bed. Hold for 5 to 10 seconds. Slowly lower. Repeat until your thigh feels fatigued.

Standing Exercises - Soon after your surgery, you will be out of bed and able to stand. You will require help since you may become dizzy the first several times you stand. As you regain your strength, you will be able to stand independently. While doing these standing exercises, make sure you are holding on to a firm surface such as a bar attached to your bed or a wall.

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

Standing Knee Raises - Lift your operated leg toward your chest. Do not lift your knee higher than your waist. Hold for 2 or 3 counts and put your leg down.

Standing Hip Abduction - Be sure your hip, knee and foot are pointing straight forward. Keep your body straight. With your knee straight, lift your leg out to the side. Slowly lower your leg so your foot is back on the floor.

Standing Hip Extensions - Lift your operated leg backward slowly. Try to keep your back straight. Hold for 2 or 3 counts. Return your foot to the floor.

Walking and Early Activity

Soon after surgery, you will begin to walk short distances in your hospital room and perform light everyday activities. This early activity helps your recovery by helping your hip muscles regain strength and movement.

Walking with Walker — Full Weight Bearing - Stand comfortably and erect with your weight evenly balanced on your walker or crutches. Move your walker or crutches forward a short distance. Then move forward, lifting your operated leg so that the heel of your foot will touch the floor first. As you move, your knee and ankle will bend and your entire foot will rest evenly on the floor. As you complete the step allow your toe to lift off the floor. Move the walker again and your knee and hip will again reach forward for your next step. Remember, touch your heel first, then flatten your foot, then lift your toes off the floor. Try to walk as smoothly as you can. Don’t hurry. As your muscle strength and endurance improve, you may spend more time walking. Gradually, you will put more and more weight on your leg.

Walking with Cane or Crutch - A walker is often used for the first several weeks to help your balance and to avoid falls. A cane or a crutch is then used for several more weeks until your full strength and balance skills have returned. Use the cane or crutch in the hand opposite the operated hip. You are ready to use a cane or single crutch when you can stand and balance without your walker, when your weight is placed fully on both feet, and when you are no longer leaning on your hands while using your walker.

Stair Climbing and Descending - The ability to go up and down stairs requires both flexibility and strength. At first, you will need a handrail for support and you will only be able to go one step at a time. Always lead up the stairs with your good leg and down the stairs with your operated leg. Remember "up with the good" and "down with the bad." You may want to have someone help you until you have regained most of your strength and mobility. Stair climbing is an excellent strengthening and endurance activity. Do not try to climb steps higher than those of the standard height of seven inches and always use the handrail for balance.

Advanced Exercises and Activities

A full recovery will take many months. The pain from your problem hip before your surgery and the pain and swelling after surgery have weakened your hip muscles. The following exercises and activities will help your hip muscles recover fully. These exercises should be done in 10 repetitions four times a day with one end of the tubing around the ankle of your operated leg and the opposite end of the tubing attached to a stationary object such as a locked door or heavy furniture. Hold on to a chair or bar for balance.

Elastic Tube Exercises

Resistive Hip Flexion - Stand with your feet slightly apart. Bring your operated leg forward keeping the knee straight. Allow your leg to return to its previous position.

Resistive Hip Abduction -Stand sideways from the door and extend your operated leg out to the side. Allow your leg to return to its previous position.

Resistive Hip Extensions - Face the door or heavy object to which the tubing is attached and pull your leg straight back. Allow your leg to return to its previous position.

Exercycling - Exercycling is an excellent activity to help you regain muscle strength and hip mobility. Adjust the seat height so that the bottom of your foot just touches the pedal with your knee almost straight. Pedal backwards at first. Pedal forward only after comfortable cycling motion is possible backwards. As you become stronger (at about 4 to 6 weeks) slowly increase the tension on the exercycle. Exercycle forward 10 to 15 minutes twice a day, gradually building up to 20 to 30 minutes 3 to 4 times a week.

Walking - Take a cane with you until you have regained your balance skills. In the beginning, walk 5 or 10 minutes 3 or 4 times a day. As your strength and endurance improves, you can walk for 20 or 30 minutes 2 or 3 times a day. Once you have fully recovered, regular walks, 20 or 30 minutes 3 or 4 times a week, will help maintain your strength.

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Transient Osteoporosis of the Hip

Osteoporosis is generally a progressive and painless condition. But one type of osteoporosis is both reversible and painful. Because it isn't permanent and is usually most obvious in the hip joint, this condition is called transient osteoporosis of the hip.

Who's at risk?

• Women in the late stages of pregnancy (after the sixth month)
• Middle-aged men (between 40 and 70 years old)

Signs and symptoms

• Sudden onset of pain, typically in the front of the thigh, the side of the hip, the buttocks or the groin.
• No previous accident or injury to the joint that would trigger pain.
• Limited motion; pain intensifies with turning movements.
• Pain intensifies with weight bearing and may lessen with rest.
• Pain gradually increases over a period of weeks or month and may be so intense that it is disabling.
• A change in gait as the patient tries to protect the joint and ease the pain.

Diagnosis

A diagnosis of transient osteoporosis of the hip is usually made by eliminating other possible causes of hip pain, such as a muscle injury or stress fracture. Your doctor will ask you whether you can remember any injury to the joint. You may also be asked to do certain range-of-motion tests to replicate the pain. Because X-rays may not show bone loss until the condition is well-advanced, your physician may request an MRI (magnetic resonance image) or bone scan to confirm the diagnosis. If you are pregnant, your physician may elect to delay any imaging studies until the last stages of your pregnancy, or even until after the delivery.

As yet, there is no clear explanation for what causes this condition. Although it is most common in the hip joint, multiple joints may be affected.

Treatment

This condition generally resolves by itself over 6 to 12 months. Treatment focuses on preventing any damage while bones are weakened by osteoporosis. If you are pregnant, this condition increases your risk of a hip fracture.

• Your physician may prescribe a mild pain reliever.
• Using crutches, a cane, or other walking aids will help relieve the stress of weight bearing on the joint.
• To help maintain strength and flexibility in the muscles, your physician may also recommend a series of flexibility and range-of-motion exercises that you can do as the pain subsides. Aquatic exercises may be helpful not only because they ease movement, but also because they relieve weight bearing.

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