Dynamic hip screw removal

primemover,

Really, the only reason to have hardware removed is if it is causing problems. There are some very specific cases, in which removal of the hardware has been planned from the beginning, but these are very unusual.

Since you are having absolutely no problems, why tempt fate? To remove the DHS, the original incision would be opened. The muscles, nerves, blood vessels, and other soft tissues have to be dissected, taken down, or moved out of the way to get to the metal. Any bone that has grown over the implant has to be taken off. Then the hardware can be attempted to be removed. It can sometimes take some concerted effort to get hardware out. The wound is then closed in layers, reattaching any muscles that have had to be taken down.

Once the screw is removed from the femoral neck, it leaves quite a large hole. This makes the neck susceptible to fracture, till it has filled in. So, in most cases, the patient is placed on a partial weight bearing status for a few weeks after the surgery.

So, there really isn't any "simple little hardware removals", as the orthopedic residents like to call these procedures. In teaching programs, hardware removals are usually given to the lower level residents, though in reality, these can sometimes be some of the most difficult cases.

The risks of the surgery is the same as those of any major orthopedic procedure. Specific risks are: not being able to remove all or part of the hardware and fracture of the bone when trying to remove the implant. If a fracture occurs, it would have to be fixed and the patient starts over from square one. Luckily this is rare, but does occur.

If you develop hip pain later on down the road, and need to have a total hip placed, the DHS can be addressed at that time. You would be considered a complicated case, but one that most total joint surgeons face all the time. Since the femoral head and neck are removed in a total hip replacement, the DHS is usually removed at the same time as the THR is put in, since the hole in the neck is a moot point. In some cases, the surgeon prefers to do a staged procedure, but that's not common.


So, since you are doing so great, why mess with things? If you were having a problem such as proud hardware that was rubbing and causing discomfort, that would be a different story. Again, why tempt fate?

Good luck.

Gaelic

As you seem to be familiar with the Dynamic Hip Screw, I wondered if you know of the PowerPlate vibration exercise machine?

I had a DHS inserted in December 2010 & am trying to find out if it's safe to use the PowerPlate with DHS metalwork in place.

Many thanks

VALMCK,

As long as your fracture is healed and your surgeon has released you to participate in activities such as recreational sports or weight lifting, there is no contraindication to the use of a Power Plate exercise system.

Good luck, hope you are doing well.

Thanks for your reply, Gaelic.

I was concerned the Power Plate may 'vibrate' the DHS metalwork & possibly weaken/crack the bones.

As a result of a bone scan, after my fracture, I have an osteoporosis diagnosis (at 44) so am considering using the Power Plate. No one at the gym is qualified to answer my specific question.

The hope is to increase bone density by drug treatment/excercise/supplements and use of the Power Plate.

VALMCK,

Again, as long as the fracture is healed, it is not a problem. Once the fracture heals, the hardware becomes unneccesary, and is sort of just there.

As to the reversal of osteoporosis, any weight bearing activity will help. The activity has to place some type of stress on the bones, so that the body will react, to increase the bone mass. This is known as Wolff's Law.

This is why swimming, while great for cardiovascular fittness, does not help with osteoporosis. Osteoporosis will occur any time there is not enough stress on the bones, such as with aging, injury, or space flight.

Wolff's Law bascially states that bone will respond to the stresses applied to it. When people lifts weights or do manual labor type of jobs, their bones will become stronger and stouter. And the opposite, if not enough stress is applied to the bones, the body will remove bone mass. It has been shown in astronauts, that they will begin to lose calcium in their urine within just a few days of space flight.

So, any activity that moves your body through space in a weight bearing manner will help. Walking, jogging, lifting weights, playing sports, whatever you want to do is fine.

The DHS is superfluous once the fracture has healed. The body just ignores the implant, and it basically becomes encorporated into the bone, as part of it, as far as the body is concerned. This is one reason that orthopedics as gone to using titanium for implants. Not because it is a magical metal (as per some patients), it is just that it has a very close bending modulus to bone. So, the metal and bone will act as one, without one being stiffer than the other.


But, have fun on the Power Plate. Hope it helps with your osteoporosis. Good luck.

Gaelic

Many thanks for your explanation. This helps a lot.

I'll continue to do what weight bearing exercise I can and keep taking the drugs & supplements.

Hopefully my next bone scan in 4 years time will show no deterioration, or maybe even an improvement.

Thanks again for taking time to reply.

respected sir,
please answer my question. i am in the need of your valuable guidance. kindly tell me 1) is removal of DHS is risky when it was implanted 9 yrs ago(patient age is 34 now).2) what happens to hole created in the hip after removal of DHS.my e-mail is

Sanjeevsahaji,

As to the second question first, the holes left from the screws (both the main one in the femoral neck and those in the femoral shaft from the side plate) will fill in with bone. It takes about 6 weeks. Some surgeons will have their patients use a cane during this time. And, patient are advised not to do any impact activities, such as running, jumping, kicking, or twisting.

As to the risk, the removal of a DHS plate is a major orthopedic surgery. After a plate has been in for 9 years, there will be some bony overgrowth around the edges of the plate. This will have to be removed so the plate can be taken off the femur. The procedure carries all of the usual risks of any orthopedic procedure, with the addition of: not being able to remove all or part of the hardware, and the possibility of breaking the femur when attempting to get the hardware out. However, though these complications do occur, they are very rare.

You should discuss the procedure with your orthopedic surgeon. He/she will be better able to advise you of the risks and benefits for your case in particular.

Good luck.

I am 47 years old and I had my DHS put in 31/2 years ago following a stress fracture of the femoral neck (undiagnosed coeliac disease and running).I am due to have it removed in a months time as it causes me pain sometimes. I had quite significant muscle wasting after the surgery last time and used a crutch to walk for 14 weeks. Am I likely to get the same amount of muscle wasting this time? What type of exercises will help a speedy recovery? I am very active and have committed myself to a group dance and rehearsals will start 6 weeks after my surgery! My surgery date was delayed by 2 months....this is the NHS!

Nukajiji,

Though you will probably be advised to use crutches or a cane when weight bearing, after removal of a DHS, you should not get the same amount of atrophy this time.

The partial weight bearing is just for protection, till the holes fill in. It usually takes about 6 weeks for the holes to fill in completely. You do not have to heal the fracture this time.

If you have access to a pool, once your wound has healed and sutures have been removed, you can start doing water exercises. There are great, as the buoyancy of the water, takes the stress off the limb. But, you can do all sorts of range of motion and strengthening exercises in the water.

Sometimes, surgeons will also allow the use of stationary bicycle after the soreness from the surgery has subsided.

Again, the use of crutches or a cane is just for protection. Some surgeons do not even require their use. But, you will have to avoid running, jumping, or twisting while the holes are filling in.

Good luck with your upcoming surgery.

Thank you Gaelic for your reply. At least now I know what to do to try and speed up my recovery and regain strength. I really was surprised by the amount of muscle wasting last time. I lost 3kg in the first 2 weeks post-op doing nothing but sitting on a sofa! But i couldn't even do a straight leg raise as one of my first physio exercises. I had been in pain and limping for about 2 weeks before I had the xray which showed the fracture. During those 2 weeks I would go for walks (since I couldn't run!), go to spinning classes and see my personal trainer for weekly sessions. So in my mind the atrophy was caused by the surgery. Why does this occur? And if the surgical procedure itself causes atrophy why is it likely to be less this time?

I have a place for a half marathon in October. I have run it the last 3 years. Do you think I might be fit enough to run it this year?

Nukajiji,

Physiologically, the atrophy is caused by non-use of the muscles. Just as the old saying go, "Use it, or lose it." Not using the muscles can be due to a lot of reasons; injury, surgery, age, illness, bedrest, space flight, etc.

Pain is a great inhibitor of patients wanting to move, to use the muscles. It even causes the muscles to lose their normal resting tone.

So, the surgery itself actually doesn't cause the atrophy, not using the muscles does. But, surgery causes pain. Also, after certain orthopedic surgeries, the patient is not allowed to use the muscles, because it would put too much stress across the healing fracture. So, all this put together, leads to significant atrophy.

Usually, in orthopedic surgery and injury, the pain is at its most intense in the first week or so, so that is the time when the patient really does not do much moving around, so development of atrophy is at its height.

Also, in some approaches used in orthopedic surgery will disrupt muscles. Usually, the surgeon tries to use approaches that move the muscle, as a whole, out of the way, rather than cutting through a muscle belly, but sometimes, muscles are disrupted. When this occurs, it takes a little longer to get the muscles going again.


So, again, anything that causes you to not use the muscles will cause atrophy. In the removal of the hardware, they have to use the same incision as when it was put in, but, usually not as much tissues has to be dissected. The fracture does not have to be reduced, not heal. So, the surgery is a much easier one. Most patients are up and moving around a lot faster. There is no fracture than has to be protected. The area has to be protected from excessive stress, but that is usually just protected weight bearing and avoiding impact activities for a few weeks.

It is a surgical procedure and you will have some pain, so you will have some atrophy, but not near as much as the first time.


Discuss the post-op protocol with your surgeon. Every surgeon has his/her own set of precautions after the procedure. But, that will give you an idea of what you are going to be allowed to do, so you can make arrangements for your post-op rehab.

Good luck.

Thank you so much Gaelic for your reply. I can't tell you how much it means to me to get some answers! I really was shocked as to the speed of the atrophy I got last time and am really keen to do as much as I can to minimise it this time...it took way too long with too much hard work for me to regain the strength I had prior to the surgery. I don't remember being in too much pain after the surgery and I chose the DHS so that I could weight bear as soon as possible as I don't tolerate being inactive! I also managed to keep myself active in the 2 weeks prior to the surgery even though I was in pain and limping. I suppose that I must have used my muscles differently to minimise the pain from the fracture. I'll just keep as active as I can now and try and get into a pool as soon as I am allowed. Thank you for your good wishes

Dear Gaelic
I am now 2 weeks post-op. The surgery was complicated by the fact that the screw in the femoral head was difficult to remove so it was left in. The plate and screws holding the plate have been removed and it was the plate that I think was causing me the pain that led me to ask for the removal. I was under anaesthesia for about 3 hours and there was a lot of digging around whilst the surgeon attempted to remove the main screw. I have been asked to partially weight bear (2 crutches) for 6 weeks as my understanding is that with all the digging the bone is weaker and I am at risk of fracture. The surgeon said to me " we don't want you to fall over in the car park and break your leg".
About 9 days post-op I noticed a dramatic improvement in my ability to walk. Whereas initially it would take me 30 miins to walk 1km, now it takes me 15mins. My gait and pace are closer to "normal". The pain under my scar area has gone. The only pain I have is a throbbing sensation in my groin which I have had since the surgery and which I attribute to the digging around. This too has improved in the last 2 weeks although is still present.
Over the last few days I have tried a variety of activities (pool based exercise, seated spinning, floor based pilates and swiss ball work) all which have caused me no pain (just some muscle ache).
So my question is does PWB mean using 2 crutches or can it be done with 1? I have another 4 weeks of this and using 2 crutches is very limiting whereas 1 crutch is annoying but tolerable. I saw a private physio earlier this week who didn't want to see me again as I am doing so well. How much weight do I have to take off my R leg in order to aid healing or for protection? Is using 1 crutch sufficient in this instance?
They wanted to keep me on 2 crutches until the post-op Xray at 6 weeks and then they would review.
I am very keen to get my life back to normal as quickly as possible as in 4 weeks time I start rehearsals for the Olympic Opening Ceremony as I was lucky to be selected as a volunteer performer!

Hi,

I got a DHS placed on September 10, 2011. Till today i.e. May 28, 2012, I am walking using a stick. without the stick there is a limp. Is the progress OK, how much time would it take more for me to be walking without the stick. I am 45 years old.

Thanks you very much.

Naresh