Case Studies: Hip & Knee Problems
There are many reasons for joint pain, and most problems involving the hip and knee have options that can help us avoid surgery. However, if it is determined that you need a surgery, it is important to know what the surgery is, and why it is being done.
Every patient is different and each situation needs to be respected by your surgeon. In addition, you should have confidence in your surgeon’s knowledge and experience. You should be comfortable asking any question addressing any concern with your surgeon without fear of judgment. Knowledge and perspective will help you be more comfortable asking questions and help in your successful outcome.
Here are a few examples of hip and knee problems which have been treated by G2 staff in the past.
Arthritis of the hip is very common. Though most common in the older population, it can occur much earlier in life. It can come on over years, or progress very quickly. In general, it is caused by damage to the cartilage within the joint itself. The normal smooth surface can become rough or develop “potholes” that cause pain when you move, walk, or run. This can come around because of some injury, but most commonly, it is just normal wear and tear over years.
Our bodies are able to function relatively pain free, but eventually you may begin to notice pain with certain activities. Typically, walking up stairs or inclines, getting in and out of the car, or simply bending to put your socks on can cause this pain.
It can also feel very different to each person. Most times it is in the front of the hip, most people say it started by feeling like a groin pull. That is not everyone, and it is up to you and your physician to identify the sources of your pain.
If we think you have arthritis of the hip, we can initiate treatment. We always start by treating arthritis in the most simple and conservative way possible. Often, this can mean over the counter pain medications, exercises, injections into the joint itself, or walking aids like canes or walkers.
If you are overweight, it is essential that you begin a program of diet and exercise to lose weight, which can help to relieve pain without any need of other treatments. It is difficult to exercise with joint pain, but there are many ways to exercise to help with weight loss. ALSO, diet is the most important factor in your weight loss, and sometimes consultation with a nutritionist or dietician is the correct first step.
Sometimes, we are not able to control your pain with these treatments. Then we may have a discussion about a possible joint replacement surgery. With hip arthritis, this means a total hip replacement. That means replacing the ball and the socket to remove the arthritis and re-create your normal hip function.
There are many different ways to do a hip replacement, and many choices for you and your surgeon to make. The first decision for you and your surgeon is the type of “approach” to use. An approach is how the surgeon gets to the hip joint itself. There are several of these, and each has good reasons for and against it. Often, a surgeon has one or two that they will choose.
Dr. Budny is fellowship trained in hip reconstruction, and has extensive experience after years in independent practice. In most patients, he will perform a Direct Anterior total hip replacement. There are some cases where he will have to adjust his plan, and is capable of performing any approach necessary; he will discuss with you his plan ahead of surgery.
Case 1: Unilateral Primary Osteoarthritis of the Hip
This is a 60 year old female who presented with the symptoms consistent with hip arthritis. As you can see, the hip to the left side of the screen (her right side) has almost completely lost the cartilage (dark space around the ball) and appears to have bone touching bone. She has also created bone spurs (otherwise known as osteophytes) around the joint. She does have a similar looking x-ray on her left side, however, she had no pain, and did not require treatment on that side. As she had exhausted all other treatments, she elected for a total hip replacement through the Direct Anterior approach.
Postoperatively, she did very well, with no pain or problems. She left the hospital the next day, requiring only ibuprofen for pain control. Within 2 weeks, she was walking normally and far better than she was before surgery. Here are her x-rays from 1 year after surgery. Everything is working well, with no complaints and no restrictions on her activities.
Case 2: Bilateral Osteoarthritis of the Hip
Sometimes, a patient will have symptoms coming from both hips, and they cannot control their pain otherwise, requiring surgery. Some patients are good candidates for having bilateral (both) hip replacements in the same setting. Through the Direct Anterior approach to the hip, Dr. Budny is able to perform both hip replacements in the same procedure on the same day. This helps to minimize your exposure to anesthesia, simplifies the recovery phase, and gets you back to life faster.
This is a 66 year old female who tried everything to control her hip pain, which was coming from her hip joints. This x-ray demonstrates bilateral hip osteoarthritis. Based on her excellent health and motivation to get back to life faster, she requested bilateral total hip replacements.
Her surgery went very well, with no issues. Her x-rays show that she has symmetrical hip replacements without complication. You will note two screws in the hip on the left, these are sometimes used in the setting of relatively softer bone. They do not affect the recovery phase, and aid in the process of integration of the hip replacement into your body.
Case 3: Post Traumatic Arthritis of the Hip
When there is trauma to a joint, sometimes the structure and function change so much that a person can develop arthritis because of that single injury. We call this Post-Traumatic Arthritis. Although we try to stop this from happening by treating the trauma (sometimes with surgery), once the process progresses to arthritis, the treatments become similar before we get to surgery. Once this fails though, an option is reconstructive surgery.
This is a 42 year old male who was in a car accident a year before these xrays, as you can see, he has had a previous surgery on the left hip and a femoral nail (rod) in the right femur. If you look closely at the left hip, you will see that his ball is not quite round; we discovered through our workup in the clinic, that he had not healed his pelvic fracture and had worn away his ball (femoral head). Even though he was so young, he needed a walker even to get around his house. After a long discussion about the risks and benefits, he and Dr. Budny elected to proceed with a total hip replacement.
This is a more technically demanding surgery, as the scar tissue and previous hardware need to be considered before and during surgery. Sometimes, the old plate and screws can get in the way of a total hip replacement. Dr. Budny was confident that he could proceed safely, having planned ahead for any difficulties.
The x-rays above are after this patient’s surgery, you can see a total hip replacement where the old, worn out ball and socket had been. Dr. Budny took out only the hardware he needed to for a safe, effective, and long lived hip replacement.
This patient went home the following day, with no issues post-operatively, and has complete pain relief without need for a walker or cane.
Case 4: Text
Failed total hip replacement with infection
One of the most difficult problems in all of surgery, and especially joint replacements, is infection. Though rare, it often requires one, two, or more, surgeries to clear the infection. In some cases, it is difficult or impossible to clear, but we do have good protocols and specialists to care for these difficult problems. Dr. Budny happily has an exceptionally low infection rate, but as a joint replacement specialist, has knowledge of the most modern techniques and treatments for prosthetic joint infections.
In this case, a 50 year old male who had previously undergone a total hip replacement by another surgeon presented with pain in his hip. A workup revealed a socket which had become loose, and a deep infection in the joint. Based on this, Dr. Budny recommended a two stage (two surgery) protocol to clear his infection. Think of the bacteria in a hip as an army, and the first surgery is meant to decrease the number of soldiers (bacteria) so that the body can effectively fight off the infection, and the second surgery is to definitively replace the joint after the infection is cleared.
In this x-ray, a previously placed total hip replacement is seen. The x-ray is concerning for loss of fixation of the socket, as well as some heterotopic (extra) bone around the hip, which is related to the previous surgery. Workup demonstrated an infection within the joint, which means two surgeries to clear it would be necessary.
This intermediate x-ray shows the first stage of clearing an infection. The first is meant to decrease the number of bacteria in the joint, so that the body’s immune system and antibiotics can do their job. You will see this doesn’t look like a normal hip replacement. It is meant to be temporary, and it is filled with antibiotics in order to clear the joint from the inside. Also, you can see three small wires and a dark line below them. This is because Dr. Budny needed to make a planned cut in the femur bone to remove the previous stem.
After the appropriate length of antibiotics and time, the patient was found to be successfully cleared of infection. Therefore, it was time to put a definitive hip replacement in place. In this setting, Dr. Budny will use “revision” components, meaning those designed to be used after a previous joint replacement had been removed.
In this final x-ray, you can see a different appearing hip replacement, one that is longer and wider than the ones in the other cases. These are the revision components. As you can see, they are in good position and have restored the patient’s leg length and hip to a normal position. Also, you will see that the previous cut in the bone is healing well, with the old wires being removed during the second surgery.
This patient went on to do very well, with no lingering infection, no pain, and full function of the hip.
Case 5: Knee Osteoarthritis
Knee arthritis is extremely common. It is more common than hip arthritis. It is a similar process of cartilage damage that causes the pain. Often, it is wear and tear that causes it. It happens more on the medial (inside) part of the knee than the lateral. Luckily, it can be treated well without surgery through the use of different forms of oral medications, injections, bracing, physical therapy, weight loss, and other types of treatment. If these fail, and the patient is willing and safe to have surgery, we discuss some form of knee replacement surgery.
There are many forms of total knee replacement, partial knee replacement (replacing only a part of the knee) is common, and can be successful. Total knee replacement is replacement of the entire knee surface itself, and is successful as well. The decision for one or the other is an important discussion for you and your surgeon to have.
Case 6: Partial Knee Replacement
The knee can be broken down into different parts, otherwise known as compartments, and each of these can individually become arthritic. If it does, and the other portions of the knee are normal, there is a chance that a patient can undergo a partial (one compartment) knee replacement. There are many factors that go into this decision, and it is a discussion to be had with your treating surgeon.
This case is a 44 year old male who works a very physical job. He has had pain specifically on the medial (inside) part of his knee with activities at work and home. He has tried bracing and injections, as well as other treatments. He does not have arthritis symptoms in any other part of his knee.
These are his x-rays, as you can see, he has a bone on bone appearance in both knees, but only medially. The other parts of his knee are acceptable and pain free. He elects for a partial knee replacement on the left side.
The above two images are of him after his partial knee replacement. You can see that the other portions of his knee are intact and unchanged, and only part of the knee is replaced. His recovery was much faster than if he had undergone a total knee replacement. He had the other side done a month later, and returned to his labor intensive work two months after his first surgery.
Case 7: Primary Knee Replacement for Osteoarthritis
This is a 59 year old male who had been trying to treat his knee pain in the normal way. As the years went by, it was harder and harder for him to control his pain, and he requested a total knee replacement. As you can see, his knees bow out (called varus knees), and the joint surfaces on the medial (inside) part of the knee are closer together than the outside (lateral). After an appropriate workup, and thorough discussion, Dr. Budny and the patient decided to proceed with a total knee replacement.
He went on to have his surgery, doing well. He participated in his normal rehab, which normally is 6 weeks of outpatient physical therapy. Therapy is a very important part of recovery for a knee replacement, and is where a patient can influence their own outcome. It is VERY important to continue with physical therapy until told to discontinue by your treating surgeon.
Case 8: Valgus (Knock-Knee) Osteoarthritis of the Knee
Although relatively less common than the bow-legged (varus) knee, the knock-knee (valgus) form of knee arthritis is another form of arthritis which can be treated with surgery. This can be a more extensive surgery, requiring more time and therapy postoperatively, though outcomes are just as good.
This is a 68 year old female who had years of pain in her knee, with a feeling of instability and progressive knock-knee. After thorough evaluation and treatment, Dr. Budny offered her a total knee replacement.
In the x-rays above, you can see that her right knee, (to the left on the screen) shows the knee bowing in, with bone spurs and bone-on-bone appearance of the lateral (outside) part of the knee. The bone spurs can be seen on the image below, they are above the patella and behind the knee itself; these can block motion and cause changes in the angle of the knee.
She underwent surgery, where Dr. Budny removed the damaged cartilage surfaces, removed the bone spurs, and re-aligned the knee joint using different techniques. Her postoperative x-rays are seen below. You will note that Dr. Budny used a stem in the tibia (shin bone) part of the knee replacement. Just like the screws which are sometimes used in hip replacement, these do not change the function of the knee, but do add stability of your new knee with the bone.
She has done very well, and enjoys the stability and straightened leg compared to before surgery.
Case 9: Failed Total Knee Replacement
Often, people will ask, “How long will a joint replacement last.” This is a very complex question, and it is difficult to predict. With good technique and proper rehabilitation, it is reasonable to expect your joint to last well into it’s second decade.
Occasionally, however, these knee replacements can fail, either by one of the parts failing, infection, the bone around it breaking, or one of many other specific reasons. If the knee requires a revision (redo) surgery, a thorough medical workup is required, and it is very important to find the exact reason for failure. Once this is identified, we can proceed with good expectation of a positive outcome.
In this case, a 69 year old male had a previously well-functioning knee replacement and developed the feelings of instability, and difficulty moving his knee. After the normal workup, it was determined that he had lost some of the integrity of his ligaments (which hold bone to bone across a joint), and required a revision surgery. At first look, these x-rays appear fairly normal, however, careful inspection and workup determine that the implant is rotated on the bone, and requires revision.
He underwent a revision total knee replacement with Dr. Budny to stabilize the joint and correct the rotational problem of the components. The patient had a wonderful clinical outcome, and is back to all activities without restriction.
Case 10: Failed Total Knee Replacement by Loosening
Sometimes, failure of the components happens when the bone glue (cement) or other fixation fails, and the component moves against the bone. This causes pain and feelings of instability in the knee. When this happens, people often have specific symptoms, and may require surgery.
In this next care, this is a 70 year old male who previously had a knee replacement which became progressively painful over time. He also started to notice his knee bowing out (varus). He was seen and evaluated, his x-rays are below.
As you can see in the x-ray above, the knee replacement appears abnormal. The components look poorly positioned and angled differently than expected. Based on this, Dr. Budny determined that this patient required a revision total knee replacement to stabilize the components and give him better function.
Below, you can see the revision knee replacement in place, with long stems that go into the shafts of the femur (thighbone) and tibia (shinbone). These help to stabilize this component, which has been cemented into the bone with standard bone-glue (poly-methyl-methacrylate).
This patient had immediate pain relief, and after a short rehabilitation, had no pain and was able to return to his work without any restriction.