The lower back and buttocks is frequently referred to as the “hip joint.”  In fact pain in the buttock area is most likely coming from the back rather than the hip.  Both back and hip problems are common. Both back and hip problems can cause pain and limit walking.   Determining the source or sources of pain is essential to proper treatment.

Is it a HIP problem?

When you schedule your appointment, be sure to tell the office staff if you have any of the following conditions as they may be contributing to  your hip problems:

  • Low back / buttock  pain
  • Pain running down your leg, particularly below your knee
  • Numbness in your leg or foot
  • Prior back or disc injury or surgery
  • Kidney problems
  • Prostate infections
  • Cancer

Hip bursitis:

Pain and tenderness over the outer aspect of the hip may indicate hip bursitis.  The bony prominence of the outer hip is the greater trochanter.  Some of the hip muscles attach to this prominence.  Inflammation of the tendons or the bursa of the hip may cause pain in this area.  Other symptoms of this condition may include pain with sleeping on your side and pain with climbing stairs.  This condition is usually treated without surgery. NSAID anti- inflammatory medications, cortisone injections, physical therapy and stretching are commonly used to treat this condition.  Hip injections for bursitis can be performed in the office with minimal discomfort.

Hip Arthritis:

Osteoarthritis is the most common form of more than 100 times of arthritis.  Osteoarthritis also cold degenerative joint disease or “wear and tear” arthritis, More than 20 million Americans, and is more common as we age.  Osteoarthritis results when the protective position or cartilage covering of the joints breaks down causing stiffness and pain. Osteoarthritis can affect any joint was most common in the hands spine, and weight bearing joints including the knees and hips.

Rheumatoid arthritis (RA) can also affect hips.  Rheumatoid arthritis is an autoimmune disease. In autoimmune diseases, the body defenses turn against itself.  Inflammation of the joint and joint lining is characteristic of RA. The inflammatory process releases factors that destroy cartilage and bone.

Hip arthritis typically causes pain in the groin area.  Many patients experience difficulty putting on socks and shoes or getting in and out of the car.  Standing and walking may become painful, and many patients experience pain at night.

Total Hip Replacement:

Hip replacement is a surgical procedure where worn out surfaces of hips are replaced with man-made components.  Hip replacement can reduce or eliminate pain, allow easier movement injection back to life.

Total hip replacement involves removing the diseased joint, and inserting a prosthesis to replace the diseased joint.

Hip Replacement at OCV:

At OCV, we perform hip replacements using a comprehensive program to maximize your safety, comfort, convenience and rapid return to function.   We’ve teamed up with Princeton Community Hospital to optimize every aspect of your joint replacement experience. You can be confident that your treatment is based on the latest science and technology.  You will notice attention to detail in preparation for surgery, your comfort and convenience during your hospital stay, and support during your return to activity.

Our doctors trained at top institutions including Mayo Clinic, Cleveland Clinic and Northwestern University.  We do hundreds of joint replacements each year. Our office works in lock step with Princeton Community Hospital to coordinate every aspect of your care.  Every member of the hospital staff is trained to help you achieve your goal.

Our doctors will work with your family doctor to optimize your medical condition for surgery.  You will receive a guide book with details of preparation for surgery, what to bring to the hospital and what to do when you go home.  You and your family will also attend joint class. Joint class is your chance to meet other patients as well as the staff that will work with you in the hospital. You will also have an on line coach program where you can track your progress.  Helena Griffith is the director of the Princeton Hospital Orthopedic Center. Her job is to insure every aspect of your care is as good as it can be. You will probably meet her at joint class. She is there for you to insure your procedure goes smoothly and to be sure all your questions our answered.  Our goal is for you to be informed, prepared and ready for a speedy recovery.

Do I need a Hip Replacement?

Replacement surgery may be considered for individual suffering from arthritic hip pain that severely limits activities of daily living.  Surgery is only recommended after careful examination and diagnosis of your particular joint problem, and only after other conservative care measures such as exercise, physical therapy, and medications have proven ineffective.

In some cases, xray guided hip injection may be performed.  Since the hip joint is deep under muscle, fluoroscopic guidance is required to inject steroid into the joint.  Injection may provide temporary relief. Hip injection may also be used to differentiate hip pain from back pain in cases where both conditions may be contributing to your symptoms.

Choice of Implants:

While there is a wide variety of hip implants available on the market, at OCV we currently uses mainly Stryker hip replacements.  Your OCV surgeon will discuss implant choices with you. Implant will be chosen for your surgery based on your age, activity level and other factors.

Cemented hip replacements are placed using acrylic route to fix the implants to bone.  Cemented components are frequently chosen for older patients with osteoporosis. Uncemented hip replacements are placed by a press fit between the components and the bone without the use of an acrylic cement.  Uncemented components are typically selected for younger patients with strong bone. For some uncemented components, patients may need to walk on a walker for a period of time to allow the implant to stabilize and bonded to bone.

Another choice of implant selection refers to the bearing surfaces.  Bearing surface options include ceramic on ceramic, ceramic on polyethylene, and metal on polyethylene.  The ceramic options are typically chosen for younger more active patients. Metal on polyethylene is a good choice for less active / older patients.

Surgical Approach:

Surgical approach refers to the surgical detail of how the doctor will surgically implant your hip.  The physicians at OCV and developed a modified posterior approach which minimizes surgical exposure and provides for rapid return to activity.  The modified posterior approach provides excellent surgical exposure for proper implantation, minimizes blood loss and operating time. The actual size of your incision will depend on the size of your bones as well as your body weight.  For thin patients, the procedure can be done through a 2 inch incision. 3 to 4 inches is typical, incisions may be significantly larger in heavier patients. OCV surgeons are trained in the anterior hip exposures. However the majority of our surgeries are performed using the modified posterior approach.  Your OCV surgeon will be happy to discuss the comparative risks and benefits of each approach with you.

Success of hip replacement:

Total hip replacement is recognized as one of the most successful procedures in medicine.

He states over 285,000 people have the hips replaced each year.  More than 95% of patients experience significant improvement in pain and function.  Lab testing of current implants suggest they will last forever. Survival of your implants may depend on age, gender and underlying problem with the hip prior to surgery.  For older designs, 25 year survival of components due to loosening is reported at 86%.

While it is impossible to predict how long your implant will last, current high performance biomaterials, designs and surgical techniques suggest improvement in the 10, 15 and 25 year survival rates.

How long is recovery?

While some patients may go home the same day, most patients go home 1-2 days following surgery.  Recovery can vary prom person to person. Most patients will use a walker or cane for 4 weeks or so.  Driving may be possible in 2-3 weeks. Activities such as golf and bowling can be resumed in 10-12 weeks. Keep in mind that recovery times may vary.

Risks of hip replacement:

Hip replacement is major surgery.  While the comprehensive approach to joint replacement at OCV and Princeton community hospital is designed to minimize risks, complications may occur a small percentage of cases.  Possible complications include:

  • DVT or PE: Blood clots can be serious, and a small percentage of cases can even result in death
  • Infection: Infection occurs less than 1% of the time.  It may result in further surgery and need for antibiotics.
  • Nerve or blood vessel damage: Most common nerve damage in the procedure may result in foot drop.  Foot drop may result in the need to wear a brace on your foot. Fortunately most with drops are transient or temporary.  The very small percentage of cases, the weakness in the foot may be permanent.
  • Hip dislocation: The ball and socket parts of the total hip prosthesis are not mechanically connected.  If the hip was put into an extreme position, the ball may come out of the socket resulting in dislocation
  • Fractures: Particularly with uncemented components, where a tight press-fit between the implants and bone is required, the socket for the femur may be fracture during surgery requiring more complicated surgery for fixation.
  • Change in leg length
  • Components working loose from the bone
  • Other medical problems including heart attack or stroke

OCV, we minimize the risk of complications through a comprehensive program that starts when you schedule surgery and continues until you have recovered.  Risk factors vary from individual to individual. The discussion of risk factors is an important part of your decision to proceed with surgery. Risks may increase for individuals that have a history of prior blood clots, elevated BMI (obesity), sleep apnea, diabetes, heart disease, liver disease and other medical conditions.  Your OCV physician and the orthopedic Center at Princeton hospital work in conjunction with her local physician to optimize your condition to make your surgery as safe as possible. As a patient, you can help by being certain to inform your OCV physician of all of your medical conditions.

Core Decompression / Treatment of AVN:

Avascular necrosis (AVN) of the hip is caused by loss of blood flow to the bone of the ball of the hip joint.  The loss of blood flow results in dead patches of bone in the ball. In the early stages, AVN can cause pain, and the bone retains its shape.  In later phases, the ball of the joint flattens and fragments resulting in arthritis.

Risk factors for AVN:

High dose corticosteroid treatment such as that used for asthma, COPD and autoimmune conditions is associated with a higher incidence of AVN.  Other risk factors include heavy alcohol consumption and decompression sickness. AVN may occur even if you have none of these risk factors.

Early AVN may be seen on MRI of the hip.  The study is often performed because of hip pain with normal or nearly normal Xrays.  Intermediate stages, AVN may show up on xray. In late stages, Xray may show fragmentation of the ball of the hip and collapse of the joint.

Early and intermediate stages of  AVN can be treated by core decompression.  Core decompression is an outpatient procedure where several holes are drilled into the areas of dead bone.  For some patients, the decompression can decrease pain and may slow progression of the necrosis. For some, the results may be permanent.  For others, symptoms may return. Since holes are drilled in the bone, patients need to protect the hip for 6 weeks following this procedure to decrease the risk of fracture.

Hip replacement is the treatment when AVN causes severe joint deformity and symptomatic arthritis.  Symptoms of arthritis due to AVN are the same as symptoms due to hip arthritis due to other causes.

Hip Fractures – Things families and patients should know:

Hip fractures are always unplanned, but that doesn’t mean you can’t be prepared.  When you or someone you know suffers a hip fracture, most patients are taken to an emergency room, and hope for the best.  Prepared patients know where to go and who will provide their care. Medicare rules frequently require transport to the nearest facility. You still have a choice.

Few realize how serious hip fractures can be. Hip fractures are associated with significant medical complications, death and loss of independence.  With typical care, studies report the 1-year mortality (death rate) after sustaining a hip fracture is between 14% to 58%. Women sustaining a hip fracture have a 5-fold increase and men almost an 8-fold increase in relative likelihood of death within the first 3 months following hip fracture. For many patients, hip fracture is part of a general decline in overall health. Deterioration in ability to walk and conditions involving heart, lungs or kidney is common.

A coordinated approach to managing hip fractures:

These sobering statistics are why we follow a coordinated medical and surgical approach that has been shown to improve short term outcomes. This model also demonstrates a low 1 year mortality rate, particularly in patients from nursing facilities.  We target rapid mobilization to increase the chance that you will be able to walk again.

Individual risks and expectation are related to many factors.  Limited mobility, male gender and multiple medical problems are associated with increased risk. Your individual risk and prognosis is determined by your medical problems like heart disease, diabetes, stroke, cancer and hereditary factors.   In addition to the risks due to the fracture itself, surgery may result in infection and DVT or PE blood clots. While no program can change the serious nature of this problem, our team has the experience, skills and coordinated plan to help you achieve the best possible result.

Things you can do to prevent hip fractures:

  • Avoid “nerve pills”  Nerve pills and sedatives significantly increase the risk of fall.
  • Make your home safe.  Hip fractures frequently result from trip over throw rugs, cords or other obstacles.  Remove trip hazards.
  • Mount grab bars in the bath near commode, tub or shower
  • Stable footwear.   Loose slippers and socks can cause falls.
  • Balance:  Tai Chi and other exercise to promote balance is associated with decrease risk of fall.
  • Walking aids:  if your balance is poor, use a cane or walker to prevent fall.
  • Physical therapy may  help improve balance and stability.
  • Osteoporosis:  Know your Z and T scores.  Treat osteoporosis early.
  • Lighting:  walking in the dark increases the risk of fall.  With advancing age, vision becomes a more important part of keeping balance.
  • Avoid climbing on ladders, counters or chairs.   
  • Know the side effects of your medicines.  Blood pressure, diabetes medications and others may result in dizziness when you first stand up.

Things you can do to be prepared if you fracture your hip:

When you break your hip, you may have a difficult time providing an accurate medical history.  An accurate history is a key part of making your surgery safer.

Keep a legible, updated list that includes

  • your current medications including name and dose.
  • list of your medical problems, past surgeries and allergies.
  • names of your doctors and pharmacy
  • stents, pacemaker or defibrillator
  • If fracture occurs, request immediate transport to Princeton Hospital for care.

Coordinated Hip fracture treatment – Medical optimization:

Hip fracture management starts in the emergency room.  Patients with multiple medical problems will be admitted to the medical service.  Patients with routine risk factors will be admitted to the surgical service. Screening labs, xrays and EKG are obtained. Sometimes falls occur as a result of loss of consciousness due to low blood sugar or irregular heart rhythm.  Be sure to tell the doctor about any unusual symptoms.

The prognosis is worse the longer the patient is bed.  Surgery is the only way most patients can get out of bed.  We do surgery as soon as medical conditions are improved to the extent they can be within a short period of time.  For example, surgery may be delayed for controlling diabetes, blood pressure, congestive heart failure, treat serious infections, correct anemia or reverse blood thinners.  Surgery proceeds even in the face of significant medical problems when the risk of further delay outweighs the benefit of more treatment prior to surgery. Because of the pain and misery associated with hip fractures, even patients that are unable to walk or having conditions severe enough to question survival of the procedure typically opt for surgery to improve quality of life.

Hip Fracture Types:

Hip fractures can be divided into 3 broad categories:  Fractures that can be pinned, those that require replacement of the fracture with artificial parts or prosthesis, and fractures that do not involve the weight bearing bones which can be treated without surgery.

Pinning hip fractures:

This is an intertrochanteric fracture.  The fracture lines shown in black are well below the ball of the hip.  The nail shown here is typical of the Gamma nail device we use to stabilize the fracture.   Some patients can bear full weight on the leg immediately after surgery. Patients with poor bone or severe fractures may need to limit weight bearing until early fracture healing occurs.

This type of nail provides strong fixation.   With special instrumentation, the procedure can be done using 3 small incisions.

Hip fractures requiring replacement of broken bone:

Femoral neck fractures occur closer to the ball of the joint.  Due to the blood supply of the bone, only a small percentage of these fractures can be treated with pinning.  30% or more of this type fracture treated with pin may fail to heal or develop arthritis as a result of loss of blood supply to the ball of the hip.  In young patients, or in other patients with little displacement of the fracture pinning may be considered.

Prosthetic replacement allows patients to walk immediately after surgery  Healing is predictable, and there is no risk of loss of blood supply since the broken part of the bone is removed,  The hip is replaced with a partial or total hip replacement. For most patients, we use our specialized minimally invasive approach to perform the surgery.

Non Surgical Fractures: Pelvis / Pubic Ramus and Greater trochanter:

Pubic bone fractures and greater trochanteric fractures are sometimes called hip fractures.  The majority of these fractures are treated without surgery. Xrays and sometimes CT scan is required to insuret the major weight bearing structures of the hip are intact.  Patients can bear weight and resume walking as soon as pain allows. Treatment involves pain management, prevention of blood clots and physical therapy. Initially, it may be difficult to walk.  If Medicare does not approve hospitalization, the discharge planning team may help you make arrangements for short term nursing home placement or home health services.

Common Upper Extremity Fractures – Shoulder / Proximal humerus:

Fractures of the upper end of the humerus