Prolotherapy or hip preserving arthroscopic surgery | Can you avoid hip replacement
Numerous structural risk factors for the development of hip arthritis exist including labrum tear, labrum degeneration, femoroacetabular impingement, hip dysplasia, slipped capital femoral epiphysis, degenerative arthritis on the opposite hip, as well as joint instability.From an orthopedic surgeon’s point of view, if for instance femoroacetabular impingement and hip labrum tears are risk factors for later development of hip osteoarthritis and current operations are not halting the development of the hip osteoarthritis, then what is needed are newer operations. As we will discuss below.
Hip joint-preserving surgery includes a number of procedures including arthroscopy to avoid hip replacement and those procedures where an anatomical defect is being addressed so as in surgical dislocation and redirectional osteotomies or a reshaping of the bone – femur and socket – acetabulum.
When you should consider surgery and when it is realistic to expect surgery can be avoided
Many patients ask us if a congenital (genetic) hip problem requires surgical correction. The answer is – sometimes. Sometimes pelvic osteotomy, femoral osteotomy, or joint replacement surgeries are needed. If someone has avascular necrosis of the hip, sometimes surgery is needed.
If the patient has some reasonable range of motion remaining, for instance 50% or greater normal range of motion, then Prolotherapy injections into the hip will work well in many instances as a surgical alternative in helping with the pain and exercises like cycling and swimming will slowly allow the patient to regain some of the lost range of motion.
Sometimes the patient will only achieve pain relief, which, of course, the patient is excited about. However, some sports like martial arts require not only improved pain levels, but also improved range of motion. So sometimes, even though the patient is a good Prolotherapy candidate for decreasing pain levels, the patient may still need arthroscopy or some other surgical procedure to help with range of motion.
It is surprising, however, the high number of patients we have seen over the years who do not really get much improved range of motion with surgical procedures.
For those who are inquiring about a surgical procedure for premature osteoarthritis of the hip, have a discussion not just with your Prolotherapy doctor, but also with your orthopedic surgeon. If you end up choosing surgery, you can always get Prolotherapy after the surgical procedure. Better yet, if Prolotherapy does not fully meet your expectations, you can always then choose surgery. Our philosophy is always to go the least invasive, most potentially successful route first.
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 the hip osteoarthritis, then what is needed are newer operations.
The problems of hip arthroscopy have lead many to abandon the procedure is 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 the surgical treatment has 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 recognised earlier in the disease process, these arthroscopic techniques may be used to decelerate or even prevent progression to osteoarthritis.(1)
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. 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.(3) This clearly indicates that patients want 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 chondroplasy, 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 attempt 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.
- Osteoplasty: The surgical alteration of bone.
- Synovectomy: The surgical removal of the entire or partial synovial membrane of a joint.
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.
The doctors analyzed the overall failure rates and modes of failure. Re-operations were categorised 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).(2)
An October 2017 study published in the American Journal of Sports Medicine 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 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.”(3)
Doctors warn patients that the 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.”(4)
- Of the 96 patients, 31 went on to have 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 joint space of 2 mm or less (meaning the cartilage had worn down) 80% of those patients would need total hip replacement. It is all about the joint space.
For your specific condition you can visit these pages on our site
- Hyaluronic acid vs platelet-rich plasma in the treatment of hip osteoarthritis
- Exercise and physical therapy fail to restore muscle strength in hip osteoarthritis patients
- Understanding hip replacement complications before the surgery
- Greater trochanteric pain syndrome
- Core decompression | osteonecrosis | avascular necrosis
- Hip impingement syndromes
1 Leunig M, Ganz R. The evolution and concepts of joint-preserving surgery of the hip.Bone Joint J. 2014 Jan;96-B(1):5-18. doi: 10.1302/0301-620X.96B1.32823.
2 Beaulé PE, Bleeker H, Singh A, Dobransky J. Defining modes of failure after joint-preserving surgery of the hip. Bone Joint J. 2017 Mar;99-B(3):303-309. doi: 10.1302/0301-620X.99B3.BJJ-2016-0268.R1.
3 Shin JJ, McCrum CL, Mauro CS, Vyas D. Pain Management After Hip Arthroscopy: Systematic Review of Randomized Controlled Trials and Cohort Studies. The American Journal of Sports Medicine. 2017 Oct 1:0363546517734518.
4 Philippon MJ, Briggs KK, Carlisle JC, Patterson DC. Joint Space Predicts THA After Hip Arthroscopy in Patients 50 Years and Older. Clinical Orthopaedics and Related Research. 2013;471(8):2492-2496. doi:10.1007/s11999-012-2779-4. [Pubmed]