Hip Clinic > Hip Preservation Surgery

There are two groups of patients who may benefit from surgery to try and prevent, or delay, the onset of osteoarthritis in the hip:

Adults with pre-arthritic wear and tear in the hip joint

Mild dysplasia causing labral wear
Traumatic labral tear
Symptomatic femoro- acetabular impingement
Pre-collapse avascular necrosis
Synovial chondromatosis

Children and adolescents with deformity of the hip causing overloading of the joint surface

Developmental hip dysplasia ("congenital dislocation of the hip")
Slipped upper femoral epiphysis (growth plate injury around puberty)
Perthe’s disease (avascular necrosis of the femoral head)
Septic arthritis (damage to the femoral head after childhood infection)

These operations are usually undertaken by specialist paediatric / adolescent orthopaedic surgeons. From my experience I would recommend the teams in Bristol or Sheffield.

Almost all studies of hip preservation surgery show that adults with established osteoarthritis do not seem to gain significant benefit. Even during short term follow up of treated patients a proportion will request total hip replacement because of intrusive symptoms, 8-12% in the first 18 months after hip preserving surgery. It is therefore important to undertake a careful and strict assessment of amount of arthritis before recommending any of these treatments.

These operations have been shown to give the best results in young (<40 years) patients with minimal osteoarthritis. Using this type of surgery in older patients with significant osteoarthritis (regardless of how young you "feel") is likely to be unsuccessful.

All procedures used to treat established arthritis in the hip should be compared to primary total hip replacement where we expect 10 years of relief from symptoms in more than 90% of patients.

How should we exclude arthritis before considering hip preservation surgery?

The harder you look, the more likely it is that there will be evidence of chondral damage associated with anatomical abnormalities of the hip joint. It would seem sensible to try and identify the extent of arthritis before formulating a treatment plan. The extent of chondral damage can be assessed from standing x-rays, MRI scans and Arthrography. Low grade chondral damage (grades 0-1) is currently considered acceptable in patients considering hip preservation surgery.

Many who feel their symptoms are severe enough for hip preservation surgery, do not feel the same about a full total hip replacement. Joint replacement very early in the progression of arthritis is unlikely to be uniformly welcome.

Does early intervention prevent progression to osteoarthritis?

In children and adolescents there is good evidence that corrective surgery will delay the onset of symptomatic arthritis. Hopefully these interventions can put off joint replacement surgery in to the patient's fourth or fifth decade.

For adults the evidence suggests that treatment for pre-arthritic hips is good at relieving symptoms. Many of the anatomical abnormalities have only recently been identified and it is not clear at what rate untreated patients develop arthritis. There are insufficient controlled trials to determine if intervention delays the onset of symptomatic arthritis.

How long does a hip preservation operation in an adult provide symptomatic relief?

The relief of symptoms will depend directly upon the suitability of the surgery to deal with the underlying problem in the hip. Symptoms are often more pronounced in athletes where the full range of hip movement is in regular use. Relieving symptoms under these demanding circumstances may be difficult.

Periarticular osteotomy for hip dysplasia, before the onset of significant arthritis, usually produces a durable joint.
The repair or removal of traumatized labral tissue, in the absence of chondral damage, appears to give good long term relief of symptoms (more than 5 years) [Aetna. Clinical Policy Bulletin: Femoro-Acetabular Surgery for Hip Impingement Syndrome. A detailed literature review with a balanced analysis. http://www.aetna.com/cpb/medical/data/700_799/0736.html].
Combined labral surgery and osteoplasty for femoroacetabular impingement, before the onset of arthritis, gives durable relief of symptoms in the majority of patients.

What options, other than hip replacement, are available for early arthritis?

Biological treatments for osteoarthritis focus on redistribution of the contact forces away from the worn surface (periarticular osteotomy), and stimulation of soft tissue regrowth on the damaged surface.

Periarticular osteotomy can be considered is there is relative uncovering of the femoral head, leading to overloading of part of the joint surface. In order to rotate the acetabulum over the femoral head, the two surfaces must be close to spherical or demonstrate increased surface contact with rotation (abduction). Osteotomy may be combined with surgery for femoroacetabular impingement.

Stimulation of soft tissue regrowth on the damaged surface of the joint is unlikely to succeed if that part of the joint remains overloaded. Transfer of techniques used in other joints should be carefully evaluated in the hip before widespread use. At present these additional procedures are not of proven value in the hip.

It is important to be clear that all operations creating an artificial bearing are by definition total hip replacements. Various designs of "small" hip replacements and hip "resurfacing" implants have a role in minimising bone loss at a first hip replacement, especially where a second and third joint may be required (young patients in their fourth or fifth decade).

These new implants are only useful if they perform at least as well as a standard total hip replacement and can be shown to allow a better result from the second joint replacement.

Is the result of total hip replacement affected by previous surgery?

There is considerable evidence that previous surgery makes total hip replacement more difficult. In some cases there is residual metal work that may need to be removed, often as a separate procedure. These difficulties may mean using special implants or techniques to compensate for abnormal anatomy.

The results of these hip replacements are not as good as primary operations where there has been no previous surgery.