February 2008
05/02
Broken trochanteric wire
I had bilateral revision hips about eight years ago. The right revision required a trocanteric osteotomy with re-wiring of the trocanter. I have had intermittent pain and difficult/inability to walk on right hip in recent times. Xray showed a broken trocanteric wire. I would be grateful if you could advise me about the problems a broken trocanteric wire can give and possible treatment options. My surgeon advises that removing the wires would necessitate an incision of approximately 4-5 inches and carries infection risk.
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Answer
Broken ”trochanteric wire” happens in patients who had a rather ”big surgery” of their total hip – usually a revision operation. To improve access to the hip, the surgeon chiseled off the attachment of the big hip muscles together with a piece of bone called trochanter and after the operation he sutured the piece of bone back to the thigh bone with a wire. This wire relatively often breaks after some time. Then the piece of bone is usually healed back and the wire is no longer necessary for fixation. In most cases the broken wire makes no trouble, but in case that it irritates the patient the wire should be removed. Usually this is very little surgery; the risk of postoperative infection is rather small, only “theoretic”. After wire removal the patients are free of their problems.
Januari 2009
20/01
Pain in the total hip hip, is it loose?
Since November 15, 2008 I cannot walk normally anymore with the hip that had the surgery and determined it was a modulus misfit...I now have lots of pain in groin, thigh and butt as I said I had after the orthotics were fitted and I began having this pain but I never wore the orthotics again but this pain has continued and I can no longer walk for more than 5 minutes without sitting....I had a bone scan and it shows as they said "no loosening of prosthesis".....this is a Zimmer Prosthesis which has been recalled for defective cups but only those from 2005 to 2008...mine was put in 2003....I feel this prosthesis is loosened or something is very wrong but after an x ray and bone scan, this is all the doctor tells me...does not show loosening. My muscles are in much pain...can this do any damage to the muscle if it is only the modulus misfit?
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Answer
I am glad to hear again from you but I am sorry that you continue to have severe pain problems with your total hip replacement. Such problems cannot be diagnosed and treated on Internet (see Disclaimer on my web site), but I can have some ideas how surgeons manage these patients with pain after total hip replacement.
First, they do blood tests that should exclude low-grade infection.
Then they do thorough clinical examination that should assess the stability of the hip joint, and assess whether any lack of stability can cause / contribute to the pain problems.
Then a thorough examination should assess whether tight, contracted muscles and soft tissues can cause the patient’s pain problems. This source of pain is often left undiscovered because many surgeons assess only x-ray pictures, not the whole patient and his/her hip.
Then assessment of all x-ray pictures should begin with the first postoperative picture. Only such consequent examination and comparison can discover whether the total hip device changed position during the postoperative period; this would be the only acceptable radiological method how to decide whether the total hip is loose. One look at only a single x-ray picture without comparison with the previous pictures is not enough.
There are a lot of other characteristics that one can see on x-ray pictures, for example position of the components, position of screws ( if any were used), length of the operated on leg. Also these characteristics should be assessed thoroughly because they can contribute to the pain symptoms.
I do not know why you had the bone scan done; usually it is used in patients with suspect infection of the replaced total hip. But then, as I wrote initially, one should first have the blood tests done. If it is negative (remember that it is not a fully reliable test method) then good, the infection is probably not causing your pain. But it does not say about all other possible sources of pain.
Probably it would be best if you wrote the important questions and then go through the list with your surgeon. If you are unsure, you may always have a second opinion.
18/01
No pain after operation of hip ossifications –it is OK?
In your experience, did you ever know of patients not having pain after your hip surgery? I ask this because I had surgery to take out heterotopic bone in my hip which came because of a revision complication. Right after surgery no pain. No drugs, it felt tight and the staples pulled but no pain. I had radiation after surgery to stop the heterotopic bone growth. I am now going through Physical Therapy, I have been through enough Physical Therapy to know always take something before you go as it can get uncomfortable. Not this time, I can move the hip, but can not lift leg yet. I don't mean to complain but this is my 7th surgery on my hip, I have never had this happen before. The hip is very swollen as it is only been 8 days. The surgeon did a lot of muscle slicing and dicing and had to dislocate the hip to take out the bone. Any ideas?
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Answer:
First of all, granulations to an (almost) pain-free postoperative course.
Perception of pain is individual. Complete insensitivity to pain is an exceedingly rare congenital deviation, I am sure you do not suffer of it; you should observe such exceptional quality already earlier. Loss of touch and pain feelings occurs also with some severe neurological diseases, but don’t think of them: doctors would discover them earlier.
If one would speculate about possible factors that diminished your pain threshold then one would think that of x-ray radiation was responsible. In old times one applied “anti-inflammatory” radiation for painful shoulders, e.g.
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12/01/2009
3 months after total knee – how much activity?
I am having a total knee replacement Oct 23 2007. My question is when would I be able to get out to go to my son varsity basketball games. Sports are a very big part of our life and I don't want to miss anything. His 1st game would be Nov 14. I know it's is a silly question but this is what's bothering me the most about the surgery. Just how soon can I start to get out and about like attending High School games.
S M
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Answer:
If you really had a total knee replacement done (as you write) on Oct 2007, then you probably have developed during the following 14 months all skills and experience necessary to live comfortably with your new knee joint (inclusive of following your son to varsity basketball games).
If the date of your knee surgery was on Oct 2008, then three months have already passed since operation.
At this period (3 months postoperatively) the total knee joint reaches (normally) almost full performance, both in muscle force and range of motion. For the patient it is important to realize that in this period he / she should begin to use the new total knee joint in regular everyday activities (in society and in sports). Prohibited are only activities producing sudden physical impact on the total knee, such as running, jumping, playing football, (and basketball) and like activities.
From this point of view couching / following your son to the varsity games is a pleasant activity that does not put any unduly stress / impact on your total knee. Please, enjoy it (the new knee joint).
10/01/2009
Metal allergy after total knee replacement
I work have worked in physical therapy for the past 12 years. I work primarily with orthopedic patients that have had total joint surgery. I currently have a patient that has perplexed me with his complaint. He had a total knee replacement approx 4 months ago. His edema, strength and range of motion improved as they usually do, but he has had the complaint of a "hot knee" from 2-3 weeks status post surgery until the present. This "hot knee" complaint is described as he feels his knee is "burning up on the inside". There is no significant temperature changes from normal to the superficial areas, and he shows no signs of infection.
My question is: Is it possible he may have an allergy to the metal components of the total knee? I do plan in investigating his skin problems at his next visit. I wonder if any of the patients that had metal allergies with a total joint had the complaint of deep heat in the joint that was described as this gentleman describes this heat.
DR
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Answer:
It is an interesting idea (or hypothesis); it is plausible that feelings of heat in the replaced total joint may be associated in some way with metal allergy. I believe that the feeling of heat in the replaced joint is a peculiar syndrome, but it exists, although infrequently. Closer examination of it is certainly warranted.
I see only two problems in the whole:
First: The reliable diagnosis of the metal allergy. There is not a generally agreed test of metal allergy, so that you should choose a specialist with experience with testing patients for metal allergy.
Second: even proven metal allergy (by for example skin test) does not prove that the symptoms of inner heat in the replaced joint are caused just by the metal allergy. From that follows that even a positive test for metal allergy would not have any therapeutic consequences just at this stage.
VS
December 2008
30/12/2009
What is PEEK material?
Excellent website. Haven’t been here for a while but will be needing revision hip surgery sometime in the next year or so…?
Have you heard anything about a new material for bearing surface called implant grade PEEK? It is a new ploy something, and can be reinforced with carbon fiber.
J
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Answer
Interesting question. PEEK materials ate not so new, first industrial applications I found are appearing about 2000. The polymer is sometimes also called PEAK (PolyArylEtherKetone), and is used reinforced with carbon fibers (CFR).
It seems that PEEK is now used in spinal surgery as replacement for titanium metal for manufacturing the “spinal cages”.
Use of PEEK materials as bearing surface in combination with ceramic materials (Biolox) in artificial joints was to my knowledge recently tested in laboratory condition (pin and disc technique), not as an complete total joint. Recent report (2007) on such laboratory test concludes that “results inspire optimism that these PEEK-based material combinations may perform well in artificial joint applications”.
Obviously, the performance of conventional bearing surfaces in artificial hip, shoulder, and knee joints is deemed as good and thus there is no hurry to go to new materials.
Especially as introduction of new materials for bearing surfaces often ended with catastrophe (carbon fiber reinforced polyethylene, Teflon, Delrin).
I think that well proven products with long follow up are still the best alternative for use in patients.
VS
29/12,2008
Pain and lameness after total hip replacement
My mother had a right total hip replacement 2 years ago at age 62. Since the surgery she has lost her gait and most ability to walk, drive, get in/out of a car, etc... I am writing this question with a great deal of emotion because since this surgery I have lost the mother I remember. She was an active woman who took four children (now grown) around the world. It is very difficult to see her as an invalid. What I can see/know is that her right leg is about a 1/4 inch longer than her left. I can also see that she has no strength in her upper right leg which has made her lean her right knee into her left to get her leg to move. Her leg seems greatly deformed with the right knee turned into her left knee and her right foot turned so far out she can not even get it straight. She depends on a walker and can only walk a short distance before the hip and knee pain is too great to deal with. She had been going to Physical Therapy, but it just doesn't seem to be helping her leg at all. She began to have leg spasms and her orthopedic surgeon sent her to a neurologist and the neurologist administered botox injections into the thigh muscle.
This really seemed to make her weaker than before. She and my father have been told by her Ortho Doc that no more surgeries are needed unless they amputate - My father is her care provider and is fed up and has basically left her to sit in the house everyday/night. She is 400 miles from me, but I want to help - if it means bringing her to live with me until she gets a gait back. When I do visit I see her doing the pages of exercises that have been assigned by the previous PT. Where do I go next? What kind of doctor/s, teams, etc... does she need to see to get a quality of life back –the one she had before this surgery? Can you offer any help? Let me know the exact questions I need to ask to help find a cure or plan of recovery for her?
RA
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Answer:
I understand the unhappy situation of your mother. From the scarce information (as is always the case with the Internet info) it seems that there were and still are serious soft tissue problems after the total hip operation of your mother.
You write that your mother had had “leg spasms” and had a neurological examination. What said the neurologist? Was there really any neurological disease causing these “spasms”? Or were these only an expression of muscle imbalance?
Was possibly the nerve disease so serious that the neurologist considered it necessary to inject the bacterial toxin botulin (commercial name) which is used to lame the muscles? That is also what happened to your mother. Someone should assess how / if this procedure (botox injection) damaged and worsened the function in the muscles around the total hip of your mother.
I think you should seriously discuss this botox injection and its consequences with the neurologists, second opinion would perhaps be necessary.
Then there should be an experienced surgeon who can assess also the soft tissue (muscles, tendons, ligaments) deficiencies (contractures) that were probably causing a greater part of your mother’s total hip problems. Now these deficiencies are multiplied by the muscle paralysis caused by botox injection. It may be difficult to differentiate between these two muscle damages caused by different mechanisms.
This surgeon should also assess all x-ray pictures to decide whether the total hip device is placed correctly and that it is not producing any further leg deformity.
If the “current” surgeon says that there is only “amputation” left, please, as him/ her to explain why: what is so serious in your mother’s condition that this “last resource” should be used.
I do not know individual surgeons in the USA at the place where you are living ( I assume that you and your mother are staying there), but I know that Anil Bhave, PT, and Doctor Michael Mont at the Rubin Institute of Advanced Orthopaedic, Sinai Hospital in Baltimore are specially studying and writing about these problems. Perhaps you may contact them and ask for more information.
E-mail of Anil Bhave : anilbhave@yahoo.com
Do not hesitate to contact me again if something is unclear.
VS
24/12/2008
Pain after arthroscopic Hip surgery
My friend had a hip labrum removal what is the prognosis for this surgery. The doctor said he is at 100% and can go back to work full time at doing
the same thing he was doing before, construction. He had his 1st surgery 10/2007 arthroscopically, the second one was arthronomy 7/2008 where
the hip labrum was totally removed. He is still having problems with decreased range of motion and pain. What are your suggestions?
KB
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Answer:
At first: the surgeons doing the arthroscopic operations on the hip joint are in accord that the results of this surgery are difficult to predict. Some patients can, thus, continue with pain and decreased range of motion in spite of surgeon’s assessment that the result is “100%”.
Second: the result of the arthroscopic hip surgery also depends on two other factors: the patient’s hip disease and the surgeon’s experience.
If the tear of the labrum of your friend was combined with greater lesion of the joint cartilage of his/her hip joint, then probably the result of arthroscopic hip surgery would be less then successful. Ask your surgeon about this possibility.
The more limited range of motion in the hip joint is usually caused by more severe lesion of the joint cartilage, but less diminished motion may also be caused by some deformity of the hip joint. This deformity could be seen on appropriate x-ray pictures of the hip joint. (The names for these x-ray projections are “cross-table”, axial, “Dunn” projections). Ask your surgeon whether these special x-ray pictures were made and what they reveal.
Ask him also whether he had seen some deformity at the open surgery.
Continuing pain in the hip after arthroscopic surgery may also be caused by nerve lesion of the nerves around the hip joint. This happens because of great traction forces used during the surgery that may produce nerve damages. This type of pain is, however, usually not lasting. Ask your surgeon whether there are sign of such nerve lesion in your friend.
Depending on what causes the continued pain and limited range of motion the surgeon should decide on further direction of treatment.
VS
23/12/ 2008
Push ups after total hip replacement
I had total hip replacement 1/7/8. My recovery has been great-Would like to resume exercise program. Is it safe to do push ups? What exercises should be avoided?
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Answer:
Congratulations to successful total hip replacement.
Push ups are not part of any rehabilitation program for patients operated on with total hips. They do not engage the muscles around the hip joint that are weak after replacement surgery. Depending on the site of the operation approach, they can be directly inappropriate in the early training period.
Ask, please, your PT who certainly has the knowledge of your surgery / which muscles were “engaged” during surgery and need special attention. Ask him/her for detailed rehabilitation program for your exercises, not only for the special muscles around the operated on hip joint but also for the whole body (training of balance etc.)
VS