Does hip preserving arthroscopic surgery lead to hip replacement anyway? The evidence.
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. Over time he/she 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.
The problems where arthroscopic hip surgery may be suggested
- Hip impingement or Femoroacetabular Impingement (FAI) is 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 I would like to invite you to read more about this surgery at my 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 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
Many patients ask us if a congenital (genetic) hip problem requires surgical correction. The answer is – sometimes. Sometimes pelvic osteotomy or femoral osteotomy (the reshaping of the hip socket or ball, or joint replacement surgeries are needed. If someone has avascular necrosis of the hip, sometimes surgery is needed.
People think it is time for surgery when his/her leg is giving out.
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. 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 degenerative hip disease. The steady wear and tear erosion of your hip that will eventually lead to hip replacement. Because hip replacement is a big surgery, with long recoveries, and significant complication, medicine is offering a lesser surgery that it is hoped will prevent the need for the larger surgery.
“Iatrogenic (surgery causing) gross hip instability following hip arthroscopy is a concerning complication described in recent orthopedic literature.”
The title of this article is Does hip preserving arthroscopic surgery lead to hip replacement anyway? The evidence. Now it is time to present the evidence.
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 is that it will fix the things such as the labrum tears and the loss of cartilage through microfracture, that will stop the progression of osteoarthritis and help you avoid the hip replacement.
Here is an example of the type of research that discusses hip instability, it is a recent study from the journal Knee Surgery, Sports Traumatology, Arthroscopy.
“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 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.”(1)
Did you get all that? Follow the path:
- Patient has hip pain and instability
- 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 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. 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.(2) 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 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 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 an 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 (3) 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 peri-acetabular osteotomies 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 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.”(4)
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.”(5)
- 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 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.
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 led 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 recognized earlier in the disease process, these arthroscopic techniques may be used to decelerate or even prevent progression to osteoarthritis.(6)
When you should consider surgery and when it is realistic to expect surgery can be avoided
Is Prolotherapy the right treatment for you hip pain and instability?
Prolotherapy is a simple injection technique, as you can see in the video, that uses regenerative injection therapy to rebuild and strengthen the same structures surgery tries to address.
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. Best assessment would be a physical examination in office.
- 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.
- Prolotherapy prognosis for hip patients: The prognosis ranking is lowered from very good to good, to questionable to guarded to poor, based on the following criterion:
- Amount of joint space or cartilage that remains.
- The presence or absence of bone spurs (osteophytes), and their locations
- The shape of the femoral head itself. In very poor candidates, the hip does not even look like a hip anymore; the ball is flattened or egg-shaped and does not fit into the socket as well. Once the damage is this extensive, the patient will likely need a recommendation for total hip replacement.
This is best explained with a visual presentation. In the video below you will see a patient that was recommended to hip replacement but was actually a better candidate for Prolotherapy.
Please see this article: The evidence for Prolotherapy in the non-surgical treatment of hip pain and hip instability for the research.
1 Yeung M, Khan M, Williams D, Ayeni OR. Anterior hip capsuloligamentous reconstruction with Achilles allograft following gross hip instability post-arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy. 2017 Jan 1;25(1):3-8. [Google Scholar]
2 Kemp JL, Makdissi M, Schache AG, Finch CF, Pritchard MG, Crossley KM. Is quality of life following hip arthroscopy in patients with chondrolabral pathology associated with impairments in hip strength or range of motion?. Knee Surgery, Sports Traumatology, Arthroscopy. 2016 Dec 1;24(12):3955-61. [Google Scholar]
3 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. [Google Scholar]
4 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. [Google Scholar]
5 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. [Google Scholar]
6 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. [Google Scholar]