By Liang Zhou, MD, orthopedic surgeon
For people living active lifestyles, particularly those less than 50 years of age, the pain and functional limitations of a hip condition can be devastating. Patients feel stuck between getting a new hip or living with the pain. In either case, they are understandably worried about their ability to return to full form again. And since hip replacements have a limited lifespan, getting one at age 40 could mean needing another one at an older age, when risks of surgery are significantly higher.
Liang Zhou, MD
But with the expansion of hip-preservation surgery, these patients may now be able to get years of full use out of their natural hip and possibly avoid future replacement. In fact, arthroscopic treatment options for many conditions allow people to return to their favorite activities within months after surgery.
Hip arthroscopy is relatively new compared to arthroscopy of other joints, so many patients may be unaware of this treatment option. Below, I walk through two common conditions with arthroscopic options and what PCPs need to know in order to provide the best guidance.
Hip impingement: Common and curable
Femoroacetabular impingement (FAI) is the most common condition I see and is a known precursor of arthritis and subsequent total hip replacement.
What it is: The ball (femoral head/neck junction) and socket (acetabulum) of the hip joint are not perfectly shaped, causing a pinching/shearing phenomenon that tears and abrades the hip cartilage.
Treatment and results: By utilizing only a few portals, I can arthroscopically repair the torn cartilage (labrum) and reshape the femur and acetabulum so the impingement no longer occurs. Patients usually transition off crutches about two weeks after surgery, and research shows nearly 9 in 10 patients return to sports and fitness activities within six months. In the long term, they have also reduced their chances of developing arthritis and the need for a new hip.
What to look for: Patients with FAI tend to present with pain in the front of the hip (groin region), especially during deep flexion activities such as squatting, ascending stairs, and getting in and out of a car. Patients may also complain of mechanical symptoms, such as catching, locking or popping of the hip.
Avascular necrosis: Know the risk factors
Avascular necrosis (AVN) affects up to 20,000 new people in the U.S. each year, most of whom fall between the ages of 20 and 60. Common causes include traumatic injury and prolonged corticosteroid use.
What it is: Blood vessels feeding the femoral head are damaged, so it loses blood supply and gradually decays/collapses.
Treatment and results: Arthroscopic core decompression involves drilling holes in the femoral head to relieve pressure, remove necrotic bone, and stimulate the growth of vascular channels to promote bone growth and preserve the hip. It can be highly effective in early stages of necrosis, but it becomes less effective in later stages of disease progression. So it’s important to refer patients as soon as symptoms arise and imaging findings are noted.
What to look for: Pain may be non-specific with gradual onset, but it predominantly localizes deep in the groin. Pain increases with weight-bearing activity and getting up from a seated position. Also look for additional known risk factors like tobacco use, hematologic disorders and alcoholism.
Whatever the condition, the first step is listening to the patient
As you can see above, different types of hip pain point to different conditions and treatment algorithms. Our ability to recommend the right treatment relies heavily on our understanding of the patient’s symptoms and pathology.
For example, imaging may show features of FAI, but the patient complains of pain mostly in the posterior hip and lower back. This presentation sounds like sciatica. So maybe the femoral head is misshapen, but it isn’t actually contributing to the pain. In that case, I might opt for a diagnostic injection, if further clarification is needed. Or I might refer to a colleague in our excellent Spine Program, who might offer a more targeted approach to the lower back with a more effective outcome for that patient.
It’s also important to get to know the patient as a whole, not just their hip condition. Arthroscopy may not be recommended for some patients whose circumstances may not allow them to achieve an excellent outcome following surgery, particularly when surgical risks outweigh the expected benefits. Similarly, a hip replacement may be the right option for a patient with more advanced arthritis who wants to minimize the total number of surgeries they undergo. This is why it is so important to discuss the treatment plan with patients on an individual basis.
But for someone who thrives on playing sports every weekend, and who has the support and determination necessary for a successful march through physical therapy and rehab, I am thrilled to say, “You can have a minimally invasive surgery today that lets you live with that same hip for years to come.”