Doctor Q & A

Question: I am having my left hip replaced, and i have already had my right replaced 2.5 yrs. ago..I was wondering if they way I walk is the source of my hip replacements? as i am pigeon toed, I am 36 years old….

Answer:  Thank you for submitting your question regarding hip arthritis.  The cause of hip arthritis has been a constant source of research dating back to the 1950s and 1960s.  Since that time there have been many studies which have examined the anatomic shape of the hip joint, gender, ethnicity and other factors such as activity or body weight.  Unfortunately, there is still no clear answer as to the exact cause of hip arthritis.

Overall, the current thought is that most hip arthritis is secondary to dysplasia.  Hip dysplasia is a condition which the hip socket or hip ball is not completely formed correctly.  This results in stresses across the hip joint which are not evenly distributed across the ball-and-socket.  This then causes early wear of the cartilage, inflammation of the hip joint and formation of loose bodies, all of which lead to arthritis throughout the entire joint.  People with severe hip dysplasia may need hip replacements at a very young age.  However, studies have shown that people with subtle hip dysplasia did not necessarily have an increased risk of needing hip replacement surgery.  This appears to be related more to genetic and/or ethnic factors as Caucasian persons with subtle hip dysplasia seem to have a higher risk of needing hip replacement surgery than do African American or Asian people.

There are also several other causes of severe hip arthritis which may require hip replacement surgery.  One of the most common may be osteonecrosis of the hip.  This is a condition in which the bone of the hip ball temporarily loses its blood supply and becomes necrotic (dead).  Then the process by which this dead bone is replaced by live bone results in a weakened hip ball which then collapses.  The ball, which then is no longer round leads to early wear of the hip cartilage.  Risk factors for osteonecrosis include the use of corticosteroids which are often use to treat conditions such as asthma, heavy alcohol use, bleeding disorders and Caisson’s disease which is related to scuba divers.  Other causes of hip arthritis include rheumatoid arthritis, Paget’s disease or history of severe trauma/dislocation.  All of these conditions result in wearing out of the cartilage and severe arthritis.

The fact that you are “pigeon toed “may actually be related to your need for hip replacement surgery at 36 years of age.  The actual etiology of being “pigeon toed “or intoeing is sometimes related to excessive forward angulation of the hip joint/femur.  We refer to this as anteversion.  There have been studies which suggests that excessive anteversion may lead to early degenerative changes of the hip.  However, other studies have not confirmed that finding.  Without seeing your x-rays, it would be impossible to make a firm conclusion but I would suspect that you may have some subtle underlying dysplasia along with your femoral anteversion which is lead to early wear of your hip socket.

Hip replacement surgery in a young person such as yourself can be challenging.  One of the main challenges is that many patients with dysplasia of the hip socket have altered anatomy of the bone which may make it difficult to appropriately place the hip replacement components.  If the components are not placed in the proper position, the hip can dislocate and the components may wear out prematurely.  In addition, traditional hip replacement surgery done through the posterior approach cuts several muscles and may not result in a functional outcome commensurate with a person in her 30s or 40s.  Alternatively, anterior hip replacement surgery is done between muscles and is thought to result in better function and quicker recovery.

At Specialty Orthopedic Surgery we have experts in hip and knee replacement surgery. Our physicians routinely take on extremely difficult cases with successful outcomes.  We would be happy to see you for a second opinion regarding hip replacement surgery.  In addition, our physicians are also experienced and trained in the anterior hip replacement which may be a good choice for a young person having hip replacement surgery.

Dr. Mattew Seidel, MD

 

Question: My wife has been suffering from Morton’s neuroma. Is there a permanent solution or treatment that would provide long term relief?

Answer: Thank you for your question.  Morton’s neuroma can be a very painful and frustrating problem for patients.

Morton’s neuroma is thought to be caused from irritation to the nerve travelling between the metatarsals of the feet, near the toes.  This irritation can result in the nerve forming a painful nodule called a neuroma.  Patients with this problem have a constellation of symptoms which can range from the sensation of walking on a rock or marble to painful shooting pains in the toes or other symptoms of nerve irritation, such as electrical type pain or burning pain.

The actual cause of Morton’s neuroma is not exactly known.  We do know it is most common between the third and fourth metatarsals and tends to be relieved with flat, wide shoe wear.  Often patients prefer to go shoeless as this allows the metatarsals to spread out as much as possible and relieve pressure on the irritated nerve.  Since many patients with this problem present after years of wearing high-heeled shoes or pointed/tight toe box shoes, one of the prevailing thoughts is that Morton’s neuroma results from chronic compressive trauma to the nerve.

Diagnosis of Morton’s neuroma can often be made clinically based on the patient’s symptoms (described above) and the physical exam findings.  Findings consistent with a Morton’s neuroma often include decreased or altered sensation in the area supplied by the nerve, usually the opposing sides of the third and fourth toes or the sole of the foot directly under the painful area.  The doctor will also test for a Mulder’s Click, where the foot is compressed from side to side and then the metatarsals are moved up and down.  This test is positive if the physician feels a ‘click’ and/or the patient has a painful clicking.  Another diagnostic test often used is a lidocaine injection (‘numbing medicine) into the area.  If this relieves the pain then it is considered a positive test and suggests the pain is truly coming from the nerve.  Finally, ultrasound or MRI can be useful in identifying the nodule or swelling of the nerve.  Other tests such as xrays may be necessary to rule out other diagnoses, such as a stress fracture or arthritis, as part of your evaluation.

Treatment of Morton’s neuroma usually proceeds in two stages.  The first is non-operative treatment and has several facets.  The first (and possibly most helpful) is to change shoe wear to avoid high heels and change to shoes with a wide toe box.  Additionally, orthotics or shoe inserts can be fabricated to help spread the metatarsals out in the painful area in an attempt to relieve pressure on the nerve.  Some studies have also shown that a single or series of cortisone injections into the area can provide lasting relief, especially when shoe modification is also done.  Physical therapists can also play a helpful role as they can provide manual therapy, heat/ice therapy and other exercises to make sure the heel cord (Achilles tendon) is appropriately stretched out.  A tight heel cord can cause the patient to walk more on the ball of the foot and therefore put more pressure on the affected area.  Finally, there have been some recent reports suggesting that Shock Wave Therapy may help with Morton’s neuroma.   There is no consensus as to whether Shock Wave may help but it is a non-invasive procedure with very low theoretical side effects.  There have been several studies showing that non-operative treatment for Morton’s neuroma is successful in 80% of cases.

For those patients who do not have relief from the non-operative measures listed above, surgery is an option.  The surgery generally involves releasing a ligament between the metatarsals, which may be causing some or all of the pressure on the nerve and removing the neuroma itself.  There have been several different surgical approaches described in the medical literature and vary from an incision on the top of the foot to an incision on the sole of the foot to an incision between the toes.  Generally, surgical treatment of Morton’s neuroma results in a 90% satisfaction rate.  The most important thing to know about the surgery is that when the nerve is removed, the patient will have permanent numbness on the side of the toes supplied by the nerve and possibly on a small area of the ball of the foot.  However, many patients would rather trade some numbness of a part of the toe for pain relief.

So, to answer your question – Is there a permanent solution for Morton’s neuroma?  The answer is probably (90%) when the solution is surgery.  However, at Specialty Orthopedic Surgery we always advocate trying non-operative treatment when there is a reasonable chance that will cure the problem.  I would recommend your wife make an appointment to see our Foot and Ankle Specialist, Dr. Brimacombe for a complete evaluation.  Appointments can be made online or by calling 602-258-8500.

We hope this information was helpful and we hope your wife feels better soon.