Hip arthroscopy success and failure rates and non-surgical options
Ross A. Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C
Hip arthroscopy success and failure rates and non-surgical options
If you are reading this article you likely have a somewhat lengthy medical history of hip problems and you have graduated to the point where the various surgical options are now being discussed with you. You may have just returned from a follow-up visit to your orthopedic surgeon. You may have gotten a prescription for stronger pain medications, cortisone, or hyaluronic acid injections to help hold you over until surgery can be performed.
Over time your orthopedic surgeon may have been exploring conservative care options for you but now you have more pain and more hip instability following these treatments. Your hip may be making a lot of noise such as grinding, clicking, and popping as a signal to you that something is not right.
So now you are in a situation where a hip preserving (not a replacement) arthroscopic surgery may be recommended. Your situation may be a little more concerning in that your surgeon is telling you there is a very good chance the surgery will not work that well and that you may need to be managed along until such time that you can get a hip replacement. But why wouldn’t arthroscopic surgery work for you? Maybe the surgery is not addressing the cause or the pain.
The challenges of isolating where the pain is coming from in the hip
A problem in the hip may commonly manifest itself as groin or inguinal pain. Someone suffering from groin pain should be examined at the pubic symphysis, sacroiliac joint, iliolumbar ligaments, and hip joint. Pain from the hip joint may also be felt locally, directly above the hip joint in the back. When the hip joint becomes loose and unstable, the muscles over the joint compensate for the looseness by tensing or spasming. As is the case with any joint of the body, loose ligaments or ligament laxity initiate muscle tension in an attempt to stabilize the joint. This compensatory mechanism to stabilize the hip joint eventually causes the gluteus medius, piriformis muscle, and iliotibial band/ tensor fascia lata muscles to tighten because of chronic contraction in an attempt to compensate for a loose hip joint. The contracted gluteus medius can eventually irritate the trochanteric bursa, causing a trochanteric bursitis. A bursa is a fluid-filled sac which helps muscles glide over bony prominences. Patients with chronic hip problems often have had cortisone injected into this bursa, which generally brings temporary relief. But this treatment does not provide permanent relief because the underlying ligament laxity is not being corrected. Prolotherapy injections (a non-surgical option discussed below) to strengthen the hip joint and iliocapsular ligaments can provide definitive relief in such a case.
Why was arthroscopic hip surgery recommend to you?
Diagnosis: Avascular necrosis of the femoral (AVN) head
Many people suffering from bone death (avascular necrosis) may be recommended to arthroscopic surgery as opposed to total hip replacement. This recommendation is based on the good news that the femoral head (the ball of the ball and socket). Please refer to our article Treating avascular necrosis of the femoral head without hip replacement, for a very detailed discussion.
Acetabular or Hip Labral Tears
If you have been experiencing symptoms of catching/locking, popping/clicking noises in your hip it is likely that you have been told that you have a hip labrum tear. The labrum is the soft tissue/ cartilage that holds the ball of the hip in the socket of the hip. Arthroscopic surgery will remove tissue that is damaged /torn or try to sew up the tear. In our article Non-surgical Treatment of Acetabular or Hip Labral Tears, we discuss conservative care treatments, regenerative medicine injections, and surgical outcome studies.
In Femoroacetabular Impingement, tissue is impinged. How did the tissue get caught between boney structures which is the impingement? If the cause is some tremendous structural problem with the hip such as a dysmorphic (an anatomic deformity) problem or orientation problem of the femur, then surgical correction may be needed. There are two types of femoroacetabular impingement.
In pincher femoroacetabular impingement when the hip is in full flexion, the femoral head-neck junction hits or abuts the anterosuperior aspect of the acetabulum. It is commonly caused by too deep of an acetabular socket as in coxa profunda or protrusion acetabuli. One can easily imagine that if the socket portion of the hip is too deep that when the patient flexes the femur bone (thigh), it will pinch structures like the labrum between the acetabulum and the femur neck, so it pinches the labrum. In cam femoroacetabular impingement, abnormal contact between the head and socket of the hip occurs because of a loss of roundness of the femoral head. Cam comes from the Dutch word meaning “cog” because the femoral head is not round. This loss of roundness causes an abnormal contact between the head and the socket of the hip. In cam FAI, the impingement typically occurs when the hip is flexed, but also internally rotated. As already mentioned, patients often have “mixed” FAI, meaning they have a combination of both.
Both types of FAI can cause premature osteoarthritis of the hip because both types progress to hip labral and cartilage damage. For the person who desires a more conservative approach, we recommend Prolotherapy inside the joint, as well as around the structures of the joint causing some or all of the pain. What most patients may not realize is the cartilage has no nerve endings, so pain in a joint originates from some other structure(s) than cartilage. This is another reason that just getting injections inside the joint does not make much sense. HackettHemwall dextrose Prolotherapy, along with other proliferants, addresses all the pain-producing structures. It typically works well with FAI, along with the other conditions causing premature hip osteoarthritis. Again, this is used along with an exercise program geared at stimulating joint health. Like other causes of premature hip osteoarthritis, sometimes surgical procedures are needed. The operative procedures are designed to address the adverse mechanical effects of impingement and hopefully address the reasons for it. Sometimes a combination of Prolotherapy and surgery is required.
This occurs when the femoral head rubs against the acetabulum – part of your hip socket. It is a condition often seen in active patients who experience movement-related groin pain. Patients may also notice a limited range of motion or a clicking or popping sensation when they move.
Bursitis occurs when there is inflammation and swelling of the bursae, or the fluid-filled sacs that lubricate the joints. Patients who experience hip bursitis may notice pain in the hip and outside thigh, which can be aggravated by simple movements like walking or moving around.
Snapping Hip Syndrome
Snapping hip syndrome is also known as iliopsoas tendinitis or “dancer’s hip. Patients often complain of a snapping or popping sensation when the hip is flexed. It is caused by repetitive, physically demanding movement such as dance, strength-training, tennis, and other sports.
Dysplasia occurs when the hip joint is abnormally shallow, meaning it has a harder time holding the femoral head in place. Hip dysplasia may cause more labral tears because it puts increased stress on the tissue.
Synovitis refers to inflammation in the joint lining, or the synovial membrane. The hip may become swollen and sensitive to the touch, limiting a patient’s ability to move around comfortably.
Additionally, hip arthroscopy can be used to remove any loose bodies around the hip joint. These can include bits of cartilage and bone that become loose and move around the joint, causing pain, inflammation, and damage. This procedure can also be used to stop a hip infection from worsening and possibly causing permanent damage.
“Understanding risk factors for conversion to total hip replacement or revision is paramount during discussions with patients.”
For some people hip arthroscopic surgery can be very beneficial. These are typically not the people we see in our offices. We see the people for whom the surgery did not help as much as had been hoped for and now the patients are trying to figure out their next move. Hip replacement, maybe more arthroscopic surgery, other options.
In the surgical journal Orthopedics (1), researchers wrote in May 2020:
“Hip arthroscopy for femoral and acetabular pathologies has increased dramatically. However, there is little literature analyzing procedures as predictors of revision arthroscopy or arthroplasty.” (In other words, there are a lot of surgeries and there is really no studies that suggest how many of these hip arthroscopes needed to be redone in a “revision surgery,” or how many of these surgeries did not work out and wound up turning into eventual hip replacement surgeries.)
What the researchers in this study did was to go back and look at patients undergoing first-time hip arthroscopy for a labral tear with a minimum 2-year follow-up and between 18 and 60 years old.
- Follow-up was obtained for 1118 patients (1249 hips) with an average age of 38.7 years (range, youngest patient in the study was 18, the oldest was 60.)
- Many patients in the study were considered overweight – average body mass index of 26.4
- The average follow up was about 50 months
- It took about three years for those patients who had hip arthroscopy that failed, to be sent to total hip replacement
- It took about 21 months for those patients who had first-time hip arthroscopy that failed to be sent to second-time or revision hip arthroscopy.
Conclusion: “Understanding risk factors for conversion to total hip replacement or revision is paramount during discussions with patients.”
Who are the high-risk groups for failed hip arthroscopic surgery? People who already had failed hip arthroscopic surgery
Many patients we see come in after undergoing an arthroscopic hip surgery that did offer the hope or promise of pain relief that the patient thought would be the outcome of their procedure.
A July 2020 study published in The Bone & Joint Journal (2) and lead by Cambridge University Hospitals in the United Kingdom found that “the most frequently reported risk factor related to a less favorable outcome after hip arthroscopy was older age and preoperative osteoarthritis of the hip. (The more surgeries the higher the risk for failure). . . . Athletes (except for ice hockey players) enjoy a more rapid recovery after hip arthroscopy than non-athletes.
Who are the high-risk groups for failed hip arthroscopic surgery? People with bone spurs, hip impingement, and hip instability
A July 2020 paper in The Journal of the American Academy of Orthopaedic Surgeons (3) stated:
“There has been an exponential increase in the diagnosis and treatment of patients with femoroacetabular impingement, leading to a rise in the number of hip arthroscopies done annually. Despite reliable pain relief and functional improvements after hip arthroscopy in properly indicated patients, and due to these increased numbers, there is a growing number of patients who have persistent pain after surgery.
The etiology of these continued symptoms is multifactorial, and clinicians must have a fundamental understanding of these causes to properly diagnose and manage these patients. Factors contributing to failure after surgery include those related to the patient, the surgeon and the postoperative physical therapy.”
The common causes of failure, residual bony deformity (what’s left of incomplete bone spur removal causing still causing hip impingement) as well as a capsular deficiency (degenerative hip instability).
Who are the high-risk groups for failed hip arthroscopic surgery? People who had an incomplete surgery
In the above study, residual bony deformity is cited as the main problem in failed hip arthroscopic surgery. Five years earlier in 2015, doctors writing in the Clinical Orthopaedics and Related Research (4) suggested that in reviewing patients who had failed hip arthroscopic surgery, they found “marked radiographic evidence of incomplete correction of deformity in patients.”
So why are you being recommended to hip arthroscopic surgery?
People think it is time for surgery when his/her leg is giving out or gets stuck
If you went to your surgeon, he/she may explain to you that you are being recommended to hip arthroscopic surgery in an effort to save or preserve your hip. One of the great benefits of this surgery, you are told, is that it will fix the things such as labrum tears and the loss of cartilage through microfracture, which will stop the progression of osteoarthritis and help you avoid hip replacement.
Most people who come to see us for non-surgical hip pain options are recommended to surgery and in some cases get the surgery because their hip gets stuck, and the frequency of their hip freezing up or being stuck increased and so did the pain when it happened. When it does happen, many of these patients, and probably you also, have specific tricks for wiggling or shaking your leg that will free the hip up. At this point the patient, and you, have decided something more needs to be done. Your doctor appointments have now left you with a typical diagnosis of:
- Hip impingement or Femoroacetabular Impingement (FAI) was explained to you as a condition where abnormal contact and rubbing of the ball and socket portion of the hip bones creates joint damaging friction. This “bone-on-bone” situation subsequently develops into degenerative osteoarthritis in addition to causing injuries to the labral area. If you are being recommended to arthroscopic surgery for Femoroacetabular Impingement we would like to invite you to read more about this surgery in our article on surgical and non-surgical options for Femoroacetabular Impingement.
- You have a hip labrum tear. The hip labrum is an important ring of cartilage that holds the femoral head, or top of the thigh bone, securely within the hip anatomy. It also serves as a cushion and shock absorber to protect the hip and thigh bones. Damage or degeneration to the labrum causes pain, hip instability, and bone overgrowth in an attempt to stabilize the area. If you have been recommended to this surgery please see our article Comparing Hip Labrum Surgery and Non-Surgical Prolotherapy | The evidence
“Iatrogenic (surgery causing) gross hip instability following hip arthroscopy is a concerning complication described in the recent orthopedic literature.”
Many people do have great success with hip surgery. These are the people we do not see. What we see are the patients trying to avoid the first surgery, we also see the patients trying to figure out what to do to avoid a second or revision surgery. For some of you reading this article, perhaps nothing is as disappointing s a surgery that has failed and that is why you are here.
What is hip instability? Hip instability to you means grabbing for a chair, railing, or anything you can hold onto because your leg just gave way. It can also mean looking at a staircase as if it were a mountain or preparing yourself for the pain by holding onto the car door as you prepare to get in or out of your vehicle. You may be sleeping with a pillow between your legs because sleeping on your hip is painful too.
To the medical community, hip instability is a degenerative hip disease. The steady wear and tear erosion of your hip will eventually lead to hip replacement. Because hip replacement is a big surgery, with long recoveries, and significant complications, medicine is offering a lesser surgery that it is hoped will prevent the need for the larger surgery.
Here is an example of the type of research that discusses hip instability, is a recent study from the journal Knee Surgery, Sports Traumatology, Arthroscopy. (5)
“The increasing use of hip arthroscopy has led to further development in our understanding of hip anatomy and potential post-operative complications. Iatrogenic (surgery causing) gross hip instability following hip arthroscopy is a concerning complication described in the recent orthopaedic literature. Post-arthroscopy hip instability is thought to be multifactorial, related to a variety of patient, surgical and post-operative factors. . . This study reports a case of gross hip instability following hip arthroscopy, describing a (new surgical) technique of management through anterior hip capsuloligamentous reconstruction with Achilles tendon allograft.”
Did you get all that? Follow the path:
- The patient has hip pain and instability
- The patient is recommended to arthroscopic labral or other clean up and repair surgeries
- The surgery that promised repair, stability, and relief of pain, itself caused instability and more pain. (Mostly from dislocation and chronic subluxation (the hip keeps popping out of place)).
- One solution was to come up with a surgery to fix the surgery.
These surgeries were designed to save the hip from a hip replacement, but, to do so, the surgeries needed to halt or significantly slow the progression of osteoarthritis. As research points out, surgery many times will not achieve this goal.
Hip preserving arthroscopic surgery complications and concerns
- Labral Debridement and Repair: Debridement refers to the removal of tissue via an arthroscopic blade, shaver, or ablator. The goal of debridement is to relieve pain by removing any torn or frayed labral tissue from the labrum.
In a recent study published in the journal Knee Surgery, Sports Traumatology, Arthroscopy (6) hip range of motion and adduction strength (the lateral movement of the hip joint) were associated with weakened and damaged hip labral tears and considered to be important quality-of-life in patients with labral problems. This clearly indicates that patients want a repair, not tissue removal.
- Chondroplasty: The removal of damaged cartilage during surgery via shaving, cutting, scraping, laser, or burring away. The idea is that after the damaged cartilage is removed via chondroplasty, the body may recover the area with new cartilage.
- Microfracture: A surgical procedure whereby a “pick” is used to spike holes in damaged cartilage to promote bleeding and the migration of bone marrow cells to the joint surface. The idea is that the blood cells/bone marrow will heal the damaged cartilage. As aforementioned, microfracture is the only technique performed during this patient’s surgery that may be considered regenerative, in that the technique is applied in an attempt to grow new tissue. However, a much simpler, less risky, and more cost-effective treatment would be PRP and stem cells to stimulate the growth of new cartilage. A similar technique is Core Decompression
- Core decompression is considering a “joint sparing” surgery. If it works, there can be avoidance or delay of hip replacement. The core decompression surgical procedure involves drilling a hole(s) into the femoral head of the hip to relieve pressure in the bone and hopefully create new blood vessels to nourish the affected areas of the hip. The overall success of this treatment is unclear. Please see my article Treating hip pain and necrosis without core decompression for more on this subject.
- Osteoplasty: The surgical alteration of bone.
- Synovectomy: The surgical removal of the entire or partial synovial membrane of a joint.
Does hip preserving arthroscopic surgery lead to hip replacement anyway? The evidence.
A study of 1013 patients who had undergone Joint-preserving surgery of the hip
A 2017 study from surgeons at The Ottawa Hospital published in the Bone and Joint Journal (7) made these observations concerning surgical complications.
The doctors reviewed 1013 patients who had undergone Joint-preserving surgery of the hip by a single surgeon between 2005 and 2015. There were 509 men and 504 women with a mean age of 39 years (16 to 78).
Of the 1013 operations:
- 783 were arthroscopies,
- 122 surgical dislocations,
- and 108 peri-acetabular osteotomies. A periacetabular osteotomy seeks to correct hip dysplasia, a condition where the hip socket is not deep enough or anatomically deficient to hold the ball portion of the joint/
The doctors analyzed the overall failure rates and modes of failure. Re-operations were categorized into four groups:
- Mode 1 was arthritis progression or hip organ failure leading to total hip replacement
- Mode 2 was an Incorrect diagnosis/procedure
- Mode 3 resulted from malcorrection (the surgery did not correct the problem) of femur (type A), acetabulum (type B), or labrum (type C) and
- Mode 4 resulted from an unintended consequence of the initial surgical intervention. (Other complications)
At an average follow-up of 2.5 years, there had been:
- 104 re-operations (10.2%)
- There were 64 Mode 1 failures (6.3%) arthritis progression or hip organ failure leading to total hip replacement
- There were 17 Mode 2 failures (1.7%) Incorrect diagnosis/procedure
- There were 19 Mode 3 failures (1.9%) malcorrection (the surgery did not correct the problem)
- There were 4 Mode 4 failures (0.4%). (Other complications).
Opioid-related complications in hip arthroscopy
An October 2017 study published in the American Journal of Sports Medicine (8) comes doctors at the University of Pittsburgh Medical Center and University of Texas Southwestern. In it, the doctors discuss opioid-related complications in hip arthroscopy.
- Hip arthroscopy is often associated with significant postoperative pain and opioid-associated side effects. Effective pain management after hip arthroscopy improves patient recovery and satisfaction and decreases opioid-related complications.
- Several methods of pain management have been described for hip arthroscopy.
- Single-injection femoral nerve blocks and lumbar plexus blocks provided improved analgesia, but increased fall rates were observed.
- Fascia iliaca blocks do not provide adequate pain relief when compared with surgical site infiltration with local anesthetic and are associated with an increased risk of cutaneous nerve deficits.
The concern is: “There is a lack of high-quality evidence on this topic, and further research is needed to determine the best approach to manage postoperative pain and optimize patient satisfaction.”
Doctors warn patients that joint-sparing surgery may complicate the eventual hip replacement in patients over 50.
A study from the Steadman Philippon Research Institute appearing in the Clinical Orthopaedics and Related Research looked at 96 patients over the age of 50 who had “joint-preserving hip arthroscopy.”(9)
- Of the 96 patients, 31 went on to have a total hip replacement. That’s approximately one in three patients who had “joint-preserving” surgery that led to replacing the joint.
But the numbers are not what this research was all about. The research sought to predict who would need the hip replacement after the arthroscopy – and the best predictions came after radiographic evidence. If there was a joint space of 2 mm or less (meaning the cartilage had worn down) 80% of those patients would need a total hip replacement. It is all about the joint space.
Hip preserving arthroscopic surgery or Hip Replacement?
As mentioned above, medicine’s way is to seek and find new procedures. As I mentioned above if femoroacetabular impingement and labrum tears are risk factors for later development of hip osteoarthritis and current operations are not halting the development of hip osteoarthritis, then what is needed are newer operations.
The problems of hip arthroscopy have led many to abandon the procedure in favor of total hip replacement. In recent years, however, hip arthroscopy has evolved and returned to prominence. A 2014 study in the Bone and Joint Journal says:
- The use of joint-preserving surgery of the hip has been largely abandoned since the introduction of total hip replacement.
- However, with the modification of such techniques as pelvic osteotomy, and the introduction of intracapsular procedures such as surgical hip dislocation and arthroscopy, previously unexpected options for surgical treatment have arisen.
- Femoroacetabular impingement has been identified as a significant factor in the development of osteoarthritis in many hips previously considered to suffer from primary osteoarthritis. As mechanical causes of degenerative joint disease are now recognized earlier in the disease process, these arthroscopic techniques may be used to decelerate or even prevent progression to osteoarthritis. (10)
When you should consider surgery and when it is realistic to expect surgery can be avoided
Prolotherapy injections. Can they help you?
Prolotherapy is an injection of simple sugar, dextrose. Dozens of research studies have documented Prolotherapy’s effectiveness in treating chronic joint pain.
In this video, Ross Hauser, MD demonstrates and describes the Prolotherapy treatment. A summary transcription is below the video.
- This is a hip procedure on a runner who has hip instability and a lot of clicking and popping in the front of the hip.
- This patient has been diagnosed with a suspect labral tear and hip ligament injury.
- The injections are treating the anterior or front part of the hip which includes the hip labrum and the Greater Trochanter area, the interior portion, the gluteus minimus is treated.
- The Greater Trochanter area is where various attachments of the ligaments and muscle tendons converge, including the gluteus medius.
- From the front of the hip (1:05), we can treat the pubofemoral ligament and the iliofemoral ligaments.
- From the here posterior approach I’m going to inject some proliferant within the hip joint itself and then, of course, we’re going to do all the attachments in the posterior part of the hip and that will include the ischiofemoral ligament, the iliofemoral ligaments. We can also target the attachments of the smaller muscles too including the Obturator, the Piriformis attachments onto the Greater Trochanter.
- Hip problems are ubiquitous, the hip ligament injury or hip instability is a cause of degenerative hip disease and it’s the reason why people have to get to get hip replacements.
- This athlete is training for a half marathon and did not want to have their training regiment stopped because of this injury and believe it or not within 10 days of this treatment the athlete was back to running. At the time of this video, they were scheduled to have another treatment. One treatment may not resolve a runner’s injury. Depending on the injury we get people sometimes back to their sport really quickly sometimes it takes a few treatments before they’re back to their exercise
Is Prolotherapy an appropriate treatment for you?
When we receive hip x-rays from prospective patients via email, they provide a good assessment of how many Prolotherapy treatments might be needed to achieve the patient’s goals. The best assessment would be an in-office physical examination.
- Rating a hip Prolotherapy Candidate: We will rate the potential hip pain patient on a sliding scale of being a very good Prolotherapy candidate to a very poor one. In a very good candidate’s x-ray, the ball of the femur will be round, fitting nicely into the socket in the pelvis, with good spacing between these two bones. This space is the cartilage that cushions and allows the femur to rotate freely within the socket.
Published research papers from our doctors at Caring Medical on Hip Disorders
- Regenerative Injection Therapy (Prolotherapy) for Hip Labrum Lesions: Rationale and Retrospective Study
- This paper was published in The Open Rehabilitation Journal.
- Hauser R, Orlofsky A. Regenerative injection therapy (prolotherapy) for hip labrum lesions: rationale and retrospective study. The Open Rehabilitation Journal. 2013 Oct 18;6(1). [Google Scholar]
In the Journal of Prolotherapy, we sought to show how Prolotherapy could provide high levels of patient outcome satisfaction while avoiding hip surgery. Here is what we reported:
- We examined Sixty-one patients, representing 94 hips, who had been in pain an average of 63 months We treated these patients quarterly with Hackett-Hemwall dextrose Prolotherapy.
- This included a subset of 20 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of eight patients who were told by their doctor(s) that surgery was their only option.
Patients in the study have contacted an average of 19 months following their last Prolotherapy session and asked questions regarding their levels of pain, physical and psychological symptoms, and activities of daily living, before and after their last Prolotherapy treatment.
Results: In these 94 hips,
- pain levels decreased from 7.0 to 2.4 after Prolotherapy;
- 89% experienced more than 50% of pain relief with Prolotherapy;
- more than 84% showed improvements in walking and exercise ability, anxiety, depression, and overall disability;
- 54% were able to completely stop taking pain medications.
The results confirm that Prolotherapy is a treatment that should be highly considered for people suffering from chronic hip pain.
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