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Hip Surgery: Essential Signs You Need Relief
Hip Surgery: Essential Signs You Need Relief 4

For those with severe hip arthritis, choosing hip replacement is a big decision. First, doctors try treatments like medicine and physical therapy. But if these don’t help, hip replacement surgery might be the next step.

Deciding on hip replacement depends on how bad the condition is and how it affects daily life. Doctors look at the pain, how well you can move, and your overall health.

Key Takeaways

  • Hip replacement is considered when conservative treatments fail to alleviate hip pain.
  • The decision to undergo hip replacement surgery is based on the severity of the condition.
  • Factors such as pain level, mobility, and overall health are considered.
  • Hip arthritis is a common condition that may require hip replacement.
  • The goal of hip replacement surgery is to improve quality of life.

Understanding Hip Joint Anatomy and Function

Hip Surgery: Essential Signs You Need Relief
Hip Surgery: Essential Signs You Need Relief 5

The human hip joint is a remarkable example of evolutionary engineering. It allows for a wide range of motion while supporting body weight. It is a ball-and-socket joint that connects the femur (thigh bone) to the pelvis. This enables activities such as walking, running, and climbing stairs.

The Structure of the Hip Joint

The hip joint’s structure is characterized by its ball-and-socket configuration. The femoral head (the ball) articulates with the acetabulum (the socket) of the pelvis. This allows for multi-directional movement, including flexion, extension, abduction, adduction, rotation, and circumduction.

The joint is surrounded by a capsule that is reinforced by ligaments. This provides stability and support.

Normal Hip Movement and Mechanics

Normal hip movement is facilitated by the smooth articulation between the femoral head and the acetabulum. This is lubricated by synovial fluid. The surrounding muscles, including the gluteals and hip flexors, control hip movement and maintain joint stability.

Proper hip mechanics are essential for efficient locomotion. They prevent excessive wear on the joint.

How the Hip Supports Body Weight

The hip joint bears a significant portion of the body’s weight. It distributes forces during various activities. The acetabular labrum, a cartilaginous ring surrounding the acetabulum, helps deepen the socket and enhance joint stability.

The hip’s ability to support body weight is a testament to its robust anatomy. It shows the balance of its components.

Common Causes of Hip Pain and Deterioration

Hip Surgery: Essential Signs You Need Relief
Hip Surgery: Essential Signs You Need Relief 6

Understanding the causes of hip pain is essential for improving treatment outcomes and quality of life. Hip pain comes from different conditions, each with its own signs and treatment needs.

Osteoarthritis and Its Progression

Osteoarthritis is a top cause of hip pain. It happens when the cartilage that cushions joints wears down. This makes bones rub together, causing pain, stiffness, and less mobility.

Osteoarthritis progresses slowly, allowing for early treatment. Factors like age, obesity, and past injuries increase risk. Early treatment can greatly improve outcomes.

Rheumatoid Arthritis Effects on the Hip

Rheumatoid arthritis is an autoimmune disease that can harm the hip joint. It causes inflammation, pain, and damage. Unlike osteoarthritis, it can start at any age and often comes with other symptoms.

Managing rheumatoid arthritis involves medicines to fight inflammation and slow the disease. Quick treatment is key to avoiding long-term damage.

Traumatic Injuries and Fractures

Traumatic injuries, like fractures or dislocations, cause sudden and severe hip pain. These injuries often happen from falls, accidents, or sports.

Treatment for these injuries might include surgery to fix or replace damaged bone and tissue. Rehabilitation is vital for getting strength and mobility back.

Avascular Necrosis

Avascular necrosis happens when the bone’s blood supply is cut off, leading to bone death. This causes a lot of hip pain and might need surgery.

Drinking too much alcohol, using steroids, and certain health conditions increase the risk of avascular necrosis. Finding it early is important for managing it well.

Condition

Primary Characteristics

Typical Treatment Approaches

Osteoarthritis

Cartilage wear and tear, pain, stiffness

Conservative management, lifestyle changes, surgery

Rheumatoid Arthritis

Autoimmune inflammation, joint damage

Medications to reduce inflammation, slow disease progression

Traumatic Injuries

Immediate pain, possible fractures or dislocations

Surgery, rehabilitation

Avascular Necrosis

Bone tissue death due to disrupted blood supply

Early detection, possible surgery

Hip Arthritis Symptoms: Early Warning Signs

It’s important to spot the early signs of hip arthritis. This condition harms the hip joint and can lower your quality of life if not treated early.

Pain Patterns and Locations

Pain is a key sign of hip arthritis. You might feel it in your groin, thigh, buttock, or knee. It starts as a mild ache but gets worse over time.

The pain can get better when you rest. It often gets worse with activities like walking or climbing stairs.

Stiffness and Limited Range of Motion

Stiffness in the hip is another warning sign. It’s more noticeable after resting or being inactive. This stiffness makes it hard to move your hip.

As the condition gets worse, moving your hip becomes even harder. This can affect your daily activities.

Difficulty with Daily Activities

Hip arthritis makes everyday tasks tough. Simple actions like dressing or walking can be hard because of pain and stiffness. This can make you feel less independent and lower your quality of life.

Sleep Disturbances Due to Hip Pain

People with hip arthritis often have trouble sleeping. The pain can keep you awake, making you tired and affecting your mood. Finding a comfortable sleeping position is hard, and the pain can get worse at night.

In summary, knowing the early signs of hip arthritis is key. These include pain, stiffness, trouble with daily activities, and sleep problems. If you notice these signs, see a doctor for help.

Where Is Hip Arthritis Pain Felt?

Knowing where hip arthritis pain is felt is key for the right diagnosis and treatment. Pain from hip arthritis can show up in different spots. It’s important to find out exactly where it hurts.

Groin Pain as a Primary Indicator

Groin pain is a big sign of hip arthritis. This pain can feel sharp or dull, usually in the groin. Activities like walking or climbing stairs can make it worse.

Referred Pain to Thigh and Knee

Hip arthritis can also cause pain in the thigh and knee. This happens because the nerves that serve the hip also reach these areas. So, it might seem like the pain is coming from the thigh or knee, not the hip.

Buttock and Lower Back Discomfort

People with hip arthritis might also feel pain in their buttock and lower back. This is because the hip joint affects nearby areas and how the body moves.

Distinguishing Hip Pain from Other Conditions

It’s important to tell hip arthritis pain from other similar symptoms. A detailed medical check-up, including tests, can figure out the pain’s source. This helps find the right treatment.

Signs Your Hip Is Out of Alignment

The hip joint is key for good posture and movement. When it’s not aligned right, you might notice symptoms. These can affect not just the hip but other parts of your body too.

Uneven Gait and Limping

An uneven gait or limping is a clear sign of hip misalignment. This happens when the hip joint isn’t aligned right. It can cause an abnormal way of walking due to pain or structural issues.

  • Altered biomechanics due to misalignment
  • Pain avoidance mechanisms leading to limping
  • Muscle imbalances around the hip joint

Leg Length Discrepancy

Leg length discrepancy is another sign of hip misalignment. It happens when one leg seems shorter than the other. This can cause back pain and uneven wear on joints.

Key effects of leg length discrepancy include:

  1. Postural changes to compensate for the discrepancy
  2. Increased stress on the lower back
  3. Potential for chronic pain in the hips and knees

Pelvic Tilt and Postural Changes

A misaligned hip can also cause pelvic tilt and postural changes. When the hip is out of alignment, it can affect the pelvis’s position. This can lead to an abnormal tilt and impact overall posture, causing back pain and other issues.

“The alignment of the hip joint is critical for maintaining proper pelvic alignment and overall posture.” – Orthopedic Specialist

Impact on Spine and Other Joints

Hip misalignment can affect not just the hip but also the spine and other joints. It can cause a chain reaction of issues, including back pain, knee pain, and problems with the ankles and feet.

Understanding these signs is key for early detection and treatment. By addressing hip misalignment, you can prevent further complications and improve your quality of life.

Non-Surgical Management of Hip OA

Managing hip osteoarthritis without surgery involves many treatments. These aim to lessen pain, boost function, and enhance life quality for those affected.

Physical Therapy Approaches

Physical therapy is key in handling hip OA. It boosts joint movement, strengthens muscles, and increases flexibility. A physical therapist crafts a custom workout plan. This might include:

  • Range of motion exercises to keep or enhance hip mobility
  • Strengthening exercises for the hip and nearby muscles
  • Aerobic exercises to better heart health

Physical therapy aids in pain control. It also teaches patients how to move better, reducing hip joint stress.

Medication Options for Pain Control

Several medications can manage hip OA pain. These include:

  • Oral pain relievers like acetaminophen
  • NSAIDs such as ibuprofen
  • Corticosteroid shots for quick pain relief
  • Hyaluronic acid shots to lubricate the joint

Talking to a healthcare provider about these options is vital. They can help find the best treatment plan.

Lifestyle Modifications and Weight Management

Changing your lifestyle can greatly help with hip OA. Keeping a healthy weight eases joint stress. Regular exercise also boosts health. Other changes include:

  • Eating right to stay at a healthy weight
  • Avoiding activities that worsen hip pain
  • Doing low-impact exercises like swimming or cycling

Weight management is critical. Extra weight can speed up joint wear.

Assistive Devices for Mobility

Using assistive devices can ease hip strain and enhance mobility. These might be:

  • Canes or walkers to lessen hip stress
  • Orthotics or shoe inserts to improve walking and reduce pain
  • Adaptive tools for daily tasks to lessen strain

Combining these non-surgical methods can lead to significant symptom relief and better overall health for hip OA patients.

Diagnostic Procedures for Hip Evaluation

To check hip conditions, doctors use both clinical checks and advanced tests. These steps help find the cause of hip pain and how bad it is.

Physical Examination Techniques

A detailed physical check is the first step in finding hip problems. Doctors use different methods to see how well the hip moves, its strength, and where it hurts. They might do:

  • Range of motion tests to check flexibility and movement
  • Strength tests to see how strong the muscles are
  • Palpation to find tender spots
  • Special tests like the FABER test for specific issues

Orthopedic experts say, “A careful physical check can often give big clues about hip problems.”

“The physical check is key in finding what’s wrong, helping doctors narrow down causes and decide on more tests.” – Orthopedic Expert

X-ray Findings in Hip Deterioration

X-rays are key for seeing hip damage. They show important details like:

  • Joint space narrowing, which means cartilage loss
  • Bone spurs or osteophytes, which are bony growths
  • Cysts or erosions in the bone
  • How the hip joint is aligned and if it’s deformed

X-ray Finding

Indication

Joint Space Narrowing

Cartilage loss, possible osteoarthritis

Bone Spurs

Bony growths, often linked to arthritis

Cysts or Erosions

Bone damage, possibly from inflammatory conditions

Advanced Imaging: MRI and CT Scans

For a closer look, MRI and CT scans are used. MRI is great for:

  • Checking soft tissues like tendons and ligaments
  • Looking at cartilage
  • Finding early bone marrow changes

CT scans, on the other hand, show bony details well and are good for:

  • Checking bone density
  • Finding fractures or bone breaks
  • Planning surgery

Laboratory Tests for Inflammatory Conditions

When inflammatory conditions are thought of, lab tests are key. These tests help find:

  • Markers of inflammation, like CRP and ESR
  • Autoimmune antibodies, which can point to conditions like rheumatoid arthritis

By mixing clinical findings with test results, doctors can fully understand the hip issue. This helps them make the right treatment choices.

Will an X-ray Show If I Need a Hip Replacement?

To decide if you need hip replacement surgery, doctors use X-rays. X-rays show the hip joint’s condition. They help doctors see how bad hip arthritis or other problems are.

What X-rays Can and Cannot Reveal

X-rays show the hip joint’s structure, like bone alignment and fractures. They can spot joint narrowing, bone spurs, and arthritis signs. But, they can’t see soft tissues like cartilage and tendons.

Key information that X-rays can provide includes:

  • Joint space narrowing, showing cartilage loss
  • Bone spurs or osteophytes, signs of arthritis
  • Cysts or erosions in the bone
  • Fractures or bone deformities

Grading Systems for Hip Arthritis

Doctors use grading systems to measure hip arthritis from X-rays. The Kellgren-Lawrence grade goes from 0 (no arthritis) to 4 (severe). These systems help doctors decide the best treatment.

Correlation Between Imaging and Symptoms

X-rays show the hip’s structure, but symptoms don’t always match. Some with severe X-ray signs may feel little pain. Others with less X-ray evidence may hurt more.

Factors influencing this correlation include:

  • Other health conditions
  • Overall health and activity level
  • Previous injuries or surgeries

When Additional Testing Is Necessary

If X-rays don’t clearly show what’s wrong or don’t match symptoms, more tests are needed. MRI or CT scans give detailed images of the hip and soft tissues.

Choosing hip replacement surgery needs a full evaluation. This includes clinical checks, patient history, and imaging. X-rays are important but not the only factor.

How Do You Know If You Need a Hip Replacement?

Hip replacement is considered when other treatments don’t help. It’s a big decision based on several factors.

Failure of Conservative Treatments

First, we try non-surgical ways to fix hip pain. This includes physical therapy, medicine, and changes in lifestyle. If these don’t work, surgery might be next.

Signs that these treatments aren’t working include:

  • Steady or getting worse pain
  • Little to no improvement in moving around
  • Hard time doing everyday tasks because of hip pain

Impact on Quality of Life

Hip pain’s effect on daily life is key. If it messes with sleep, daily tasks, and happiness, surgery might be considered.

Important things to think about are:

  • How much hip pain affects daily life
  • Being able to do things that matter to you
  • Its impact on both mental and physical health

Pain That Limits Daily Function

Severe and ongoing hip pain is a big sign for surgery. Even with trying other treatments, surgery might be better.

Things to keep in mind are:

  1. How bad and often the pain is
  2. How it affects moving and doing things
  3. Its overall effect on life quality

Clinical Decision-Making Process

Deciding on hip replacement surgery is a team effort. Doctors and other healthcare experts carefully look at your situation, past health, and current health.

Important parts of this process are:

  • Checking how well your hip works and how much pain you have
  • Looking at test results and images
  • Talking about the risks and benefits of surgery

Hip Surgery: Types of Replacement Procedures

Hip surgery includes many replacement techniques to improve mobility and reduce pain. The right procedure depends on the hip damage, patient’s age, and health.

Total Hip Replacement

Total hip replacement, or total hip arthroplasty, replaces both the hip socket and ball with artificial parts. It’s often used for severe hip arthritis or fractures.

Benefits: It offers significant pain relief, better mobility, and a higher quality of life.

Partial Hip Replacement

Partial hip replacement only replaces the damaged part, usually the femoral head. It’s often chosen for patients with hip fractures.

Considerations: The choice depends on how much damage the hip joint has.

Hip Resurfacing

Hip resurfacing replaces the damaged hip joint surface with a metal cap. It keeps more of the natural bone.

Advantages: It’s less invasive, might be easier for future surgeries, and saves bone.

Minimally Invasive Techniques

Minimally invasive hip replacement uses smaller cuts than traditional surgery. It aims to cause less tissue damage and speed up recovery.

Benefits: It leads to less pain after surgery, shorter hospital stays, and quicker return to activities.

Each hip replacement procedure has its own use, benefits, and downsides. Choosing the right surgery should be a joint decision with an orthopedic surgeon. It should consider the patient’s specific needs and preferences.

How Long Is Hip Replacement Operation?

The time needed for hip replacement surgery varies based on several factors. Knowing these can help patients prepare and understand what to expect during the surgery.

Typical Surgery Duration

Hip replacement surgery usually takes between 45 minutes to 2 hours. But, the time in the operating room is longer. This includes preparation and recovery from anesthesia.

Factors That Affect Surgical Time

Several things can change how long hip replacement surgery takes. These include:

  • The complexity of the case, including the extent of joint damage
  • The patient’s overall health and any comorbid conditions
  • The surgeon’s experience and technique
  • The type of hip replacement procedure being performed (e.g., total hip replacement, partial hip replacement)

Anesthesia Options

Anesthesia is key for hip replacement surgery. It keeps the patient comfortable and pain-free. The choice between general anesthesia and regional anesthesia (like spinal or epidural) affects the surgery time and recovery.

General anesthesia makes the patient unconscious. Regional anesthesia numbs the lower body, letting the patient stay awake or lightly sedated.

Same-Day vs. Inpatient Procedures

Whether surgery is done on the same day or as an inpatient depends on several factors. These include the patient’s health, the surgical method, and postoperative care. Outpatient procedures are becoming more common. Some patients go home the same day, while others need a short hospital stay for recovery.

Hip replacement surgery is a big deal that needs careful planning. Understanding what affects surgery time helps patients prepare for the experience and recovery.

Recovery Timeline After Hip Replacement

Recovering from hip replacement surgery takes time. It involves staying in the hospital, physical therapy, and long-term care. Knowing what to expect helps patients prepare.

Hospital Stay and Immediate Post-Op Period

The recovery starts right after surgery, in the hospital. This is when doctors watch for any problems and start the healing process. Most people stay in the hospital for 1 to 3 days.

Doctors help patients get up, stand, and take their first steps. They also focus on managing pain. This is done with medicine and other methods to reduce discomfort.

First Six Weeks of Recovery

The first six weeks are key for healing and setting up for a good recovery. Patients follow a physical therapy plan to build strength and move better. They do gentle exercises, walk, and slowly increase how far they can move.

It’s important to balance activity with rest during this time. Patients may need to change their daily routines. They might use walkers or canes to help move around.

Long-Term Rehabilitation Process

After the first six weeks, the rehab keeps going. It focuses on making the hip stronger and more functional. Physical therapy gets harder, aiming to get full mobility and strength back.

Staying committed to the rehab program is important. Regular check-ups with doctors help track progress and adjust the plan if needed.

Return to Normal Activities

When people can go back to normal activities varies. It depends on their health, if there were any problems, and the surgery type. Usually, most people can do daily things again in 6 to 12 weeks.

But, getting back to full strength and mobility can take months. It’s important to be patient and not rush the recovery. This helps the surgery succeed.

Reasons Not to Have Hip Replacement

There are certain situations where hip replacement is not advised. This surgery can greatly improve life for many, but it’s important to know when it’s not the right choice.

Medical Contraindications

Some medical conditions make hip replacement risky or not suitable. For example, active infections, severe heart disease, or major neurological issues can be contraindications. People with these conditions may face higher risks during or after surgery.

Age and Health Considerations

Age and health are key in deciding if hip replacement is right. Age alone doesn’t rule it out, but younger patients might need to think about future surgeries. Older patients with many health problems also face higher risks.

Alternative Treatments Worth Trying First

Exploring other treatments before hip replacement is important. Options include physical therapy, pain meds, lifestyle changes, and mobility aids. Sometimes, these can help a lot, possibly avoiding surgery.

Realistic Expectations About Outcomes

It’s vital to have realistic hopes about hip replacement surgery’s results. The surgery can lessen pain and improve function, but it won’t let you do everything you could before. Knowing what to expect helps in making a good choice.

In summary, hip replacement is not for everyone. It’s important to think about medical reasons, age, health, other treatments, and what to expect. This careful consideration helps in making a well-informed decision.

Potential Complications and Risks

It’s important to know the risks of hip replacement surgery. This surgery is usually safe and works well. But, there are risks to think about.

Infection and Blood Clots

Infection is a big risk with hip replacement surgery. Even with careful cleaning and antibiotics, infections can happen. They might need more surgery or long-term antibiotics.

Blood clots are also a risk. They can lead to serious problems like deep vein thrombosis (DVT) or pulmonary embolism.

Prevention measures include taking blood thinners, wearing compression stockings, and moving around a lot after surgery.

Dislocation and Implant Failure

Dislocation is a risk, where the hip joint parts get out of place. This is more likely right after surgery. Implant failure, where the artificial parts wear out or loosen, is another problem. It might need another surgery.

Factors influencing implant longevity include the implant type, how active you are, and following post-op instructions.

Leg Length Discrepancy

Leg length discrepancy (LLD) can happen after hip replacement. It can cause imbalance and discomfort. Getting the leg length right during surgery is key to avoid this.

Complication

Description

Prevention/ Management

Infection

Bacterial infection of the surgical site

Antibiotics, proper wound care

Dislocation

Ball and socket out of place

Avoiding certain positions, physical therapy

Leg Length Discrepancy

Difference in leg lengths post-surgery

Accurate surgical measurement, shoe lift

Causes of Buttock Pain After Hip Replacement

Buttock pain after hip replacement can come from nerve irritation, muscle strain, or pain from other areas. Knowing the cause helps in treating it right.

Diagnostic approaches include imaging studies and physical exams to find the pain’s source.

Preparing for Your Orthopedic Consultation

Knowing what to expect and how to prepare for your orthopedic consultation is key. Being ready ensures you get the most from your visit. It also helps your specialist have all the info they need for the best treatment plan.

Questions to Ask Your Surgeon

It’s important to have a list of questions for your surgeon. This helps you understand your condition and treatment options. Some key questions include:

  • What are the possible causes of my hip pain?
  • What are the recommended treatment options for my condition?
  • What are the risks and benefits associated with hip replacement surgery?
  • How will my condition affect my daily activities, and what can I do to manage it?
  • Are there any alternative treatments or therapies that I should consider?

Medical History Documentation

Having a detailed medical history is essential for your specialist. This includes your current condition, past health, and any surgeries or treatments. Make sure you have:

  1. A list of your current medications and dosages.
  2. Records of any previous surgeries, including the type and date.
  3. Any relevant medical test results, such as X-rays or MRI scans.
  4. A summary of your symptoms, including when they started and how they’ve changed.

Understanding Your Insurance Coverage

It’s important to know what your insurance covers for orthopedic consultations and treatments. This includes knowing:

  • What percentage of the consultation fees are covered?
  • Are there any specific requirements or referrals needed from your primary care physician?
  • What are the out-of-pocket expenses you might incur?

Understanding these details with your insurance provider beforehand can help avoid unexpected costs.

Second Opinion Considerations

Getting a second opinion is common, even for big procedures like hip replacement surgery. A second opinion can:

  • Confirm the initial diagnosis and treatment plan.
  • Provide additional insights or alternative treatment options.
  • Help you feel more confident in your decision-making process.

Don’t hesitate to seek a second opinion if you’re unsure about your treatment plan.

Conclusion: Making an Informed Decision About Hip Replacement

Understanding hip replacement means knowing the procedure, its risks, and benefits. We’ve looked at the hip joint’s anatomy and function. We’ve also discussed common causes of hip pain and treatment options.

Knowing when to choose hip replacement surgery is key. It’s important to consider how severe the hip damage is and how it affects your daily life. You should also think about possible complications.

Choosing hip replacement can greatly improve your health and life quality. It’s vital to talk to an orthopedic specialist. They can help you decide if surgery is right for you.

FAQ

Where is hip arthritis pain typically felt?

Hip arthritis pain often hits the groin, thigh, and buttock. It can also spread to the knee or lower back. The pain might feel like a dull ache or a sharp stab, getting worse with activities like walking or climbing stairs.

What are the common symptoms of hip arthritis?

Symptoms of hip arthritis include pain, stiffness, and trouble moving. It can make daily tasks hard, like putting on shoes or socks. It might also keep you up at night because of pain.

How do I know if I need a hip replacement?

You might need a hip replacement if other treatments don’t work. It’s when the condition really affects your daily life. Doctors look at your pain, how you move, and if you have osteoarthritis or other conditions.

Will an X-ray show if I need a hip replacement?

X-rays can show how damaged your joint is. But, deciding on hip replacement surgery involves more than just X-rays. Doctors also look at how you feel and your symptoms.

What are the signs that my hip is out of alignment?

Signs of a misaligned hip include an uneven walk, limping, and one leg being shorter than the other. These can change how you stand and affect your spine and other joints.

How long is a hip replacement operation?

Hip replacement surgery time varies. It depends on the surgery’s complexity, the surgeon’s experience, and your health. It can take anywhere from 45 minutes to several hours.

What are the reasons not to have hip replacement surgery?

Some people might not be good candidates for hip replacement surgery. This includes those with certain health issues, older adults, or those with other health problems. Doctors might suggest other treatments instead.

What are the possible complications and risks of hip replacement?

Hip replacement surgery can have risks like infection, blood clots, and implant failure. You might also experience leg length differences or buttock pain.

How can I prepare for my orthopedic consultation?

To get ready for your consultation, collect your medical history. This includes any past treatments and test results. Make a list of questions for your surgeon. Also, check your insurance and any costs you might have to pay.

What are the causes of buttock pain after hip replacement?

Buttock pain after hip replacement can come from nerve irritation, inflammation, or issues with the implant. It’s important to talk to your surgeon about any ongoing pain to find out why.

What are the different types of hip replacement procedures?

There are several hip replacement procedures. These include total hip replacement, partial hip replacement, hip resurfacing, and minimally invasive methods. The right procedure depends on your condition, age, and health.

References

National Center for Biotechnology Information. Evidence-Based Medical Insight. Retrieved from https://pubmed.ncbi.nlm.nih.gov/34496743/

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