Hip Replacement Surgeons Toledo OH
A Breakthrough in Finding the Cause of Squeaks in Hip Replacements
Imagine trying to be quiet while entering a church or synagogue service during a silent moment only to have your new hip replacement squeak loud enough to be heard by all. Or picture yourself walking your daughter down the aisle for her wedding. With every step, that hip replacement creaks like a rusty barn door. Anyone with this odd complication can't help but ask, Doc, what is causing this new hip to squeak like that?
An investigation at the Thomas Jefferson University Hospital in Philadelphia, Pennsylvania might just have an answer to that question. They divided patients receiving a ceramic-on-ceramic implant into two groups based on implant design and then compared the results.
Group one got an implant that had a special coating on the stem made of a titanium-aluminum-vanadium alloy. The stem was shaped with a C-taper neck and had a wide, thick midsection. The stem portion of a hip replacement fits down inside the long shaft of the femur (thigh bone). Group two was given an implant with a stem made of a different combination of metals: titanium-molybdenum-zirconium-iron alloy. The design was a V-shape instead of a C-shape and the midsection wasn't as thick as in group one.
The ball-shaped head of the femur was made of ceramic. It fit inside a metal cup (socket replacement) that was lined with ceramic making the implant a ceramic-on-ceramic joint. Many patients prefer a ceramic-on-ceramic implant because the ceramic wears well and glides smoothly. And fewer patients have problems with inflammation like those who have implants that are made of plastic.
So what causes the squeak that's so loud anyone standing nearby can hear it? No one knows just yet! Sometimes metal-on-metal implants squeak or make some other obvious noise but the noise seems to disappear after awhile. Not so with the ceramic-on-ceramic implants. And squeaking isn't the only problem. Some patients end up with clicking. No one included in this study had clicking, just squeaking.
Everyone in the study was operated on by the same surgeon. The surgeon was careful to make note of the size of the ceramic head in case that was contributing to the problem. X-rays were taken after the implant was put in place to verify the position and alignment of the new joint. Patients in the two groups were matched so they were equal in age, sex, height, weight, and body mass index (BMI).
Only four of the 135 hips in group one reported squeaking (that's only about two per cent). On the other hand, 18 per cent of the patients in group two developed squeaking. There was no predicting when the squeaking might begin. Some patients developed the noise within the first month while others didn't notice it until many years later. Replacing the ceramic cup with a plastic liner eliminated the problem in all cases.
Crunching the numbers (statistical analysis) showed that patients with the thinner V-shaped neck and titanium-molybdenum-zirconium-iron stem were seven times more li...
Controlling Pain After a Total Hip Replacement
Patients are surprised after a total hip replacement by how much it can hurt those first few days. They do okay while sitting or resting, but once they get up to move: ouch! Surgeons are working hard to find ways to control that pain without using opioids (narcotics) with their many side effects.
A new approach has been started by some surgeons. That's the use of nerve blocks for the first 24 to 48 hours after surgery. In this study, three types of post-operative pain control methods were compared. The first was the standard patient-controlled analgesic (PCA) using a self-administered pain pump. With the push of a button patients can dispense an opioid-based medication. In this study, they used a morphine derivative called hydromorphone.
The second group had a femoral nerve block along with PCA. The third group had a lumbar plexus block (also with PCA). All drugs were given for 48 hours. The nerve block was set up in the operating room after the spinal anesthetic that was used during the hip replacement surgery had worn off.
The block is administered by placing a needle (catheter tip) between the psoas muscle and the quadratus lumborum muscle in the hip area. This places the catheter tip close to the nerve being blocked and is referred to as a perineural placement of the catheter.
Correct placement of the needle was verified by injecting a dye in the area and using an X-ray to confirm proper positioning. The surgeons also used a second method to check the catheter. They connected the catheter to a nerve stimulator. By stimulating the nerve, they could cause a contraction of the muscle controlled by that nerve.
In this way, they made sure the right area was blocked. After that test was completed and the nerve stimulator was removed, then a one-time large dose of drug was injected in the area. The perineural catheter was used to infuse a low dose of numbing agent (ropivacaine) for the next 48 hours.
With a successful nerve block, the patients experienced a numb sensation (to cold and to pinprick) in the skin supplied by the sensory portion of the nerve being blocked. Muscle strength for the muscles affected by blocking the motor portion of the nerve(s) was also assessed. Most often the muscles controlling the hip and knee were affected.
Everyone in all three groups also got an injection of ketorolac while still in the recovery room. This nonsteroidal antiinflammatory was delivered directly to the muscles for pain control.
The real test of these pain control measures was in physical therapy. Pain was measured before, during, and after therapy while moving the hip and walking. Amount of hydromorphone used was recorded. And any side effects such as nausea, vomiting, itching, difficulty breathing, or delirium were also noted.
The authors report the best results occurred when using the lumbar plexus block. As suspected, pain control while at rest wasn't the issue. The real problem came when patients tried to ...
The Problem With a Failed Total Hip Replacement
It doesn't take a crystal ball to see that there's trouble ahead for America's seniors. More and more older adults are in need of a total hip revision surgery. Nearly 18 per cent of all total hip replacements done in the United States have to be revised at some point. Current estimates are that in the next 20 years, the need for total hip revisions will increase dramatically.
There are other factors to consider with this problem. First, the cost. Can we really bear the financial burden of these surgeries? Second, there is already a shortage of surgeons who perform this operation. Joint replacement revision is a subspecialty all of its own.
The procedure is difficult and complex. Surgeons aren't being reimbursed adequately by Medicare. So while the number of older adults needing this operation is on the rise, the number of surgeons available to perform the procedure is on the decline. That presents an interesting dilemma for all concerned.
As with most problems, there is more beneath the surface than meets the eye. Revision of primary (first-time) hip replacements often comes with its own problems. More bone grafts are needed requiring longer hospital stays. Patients are less likely to be discharged home and more likely to be transferred to an extended care facility.
Longer operative times and longer hospital stays translate into higher total costs. And long-term studies show that these patients are more likely to be rehospitalized within the first 90-days of the revision operation. That adds to the total cost as well.
So how come there's such an increase in the number of revision operations required? And what can be done to prevent this from happening? Studies show that the relative number of revision operations hasn't really increased. It's more the fact that more adults are having their first hip replacement and more of those are being done at a younger age. If patients outlive the life of their implant, then revision surgery is needed. Or if there are complications from the first surgery, a revision replacement might be needed.
Two preoperative factors stand out as possible predictors of a poor outcome after revision surgery. One is preoperative pain. The other is medical co-morbidities. Research shows that older adults with higher levels of pain and lower levels of function because of other health problems were more likely to have a poor outcome from the revision surgery.
If revision surgery is going to be a fact in the near future, then what can be done now to head it off at the pass? Some suggest building more high-volume orthopedic specialty hospitals. Studies show that there are fewer complications when a surgeon performs the same operation on a larger number of patients.
Specialty centers of this type would draw more patients and attract more physicians with a subspecialty practice in revision hip replacements. With fewer complications, costs can be contained. Preventing infection, dislocation, or fractures...