Hip Preserving Surgery

Hip Preserving Surgery at The Runnymede

What is hip preserving surgery?

Most patients under the age of 60 who have hip arthritis have an underlying cause to explain why their hip has become arthritic.

The most common causes for hip arthritis are trauma, avascular necrosis, hip dysplasia (abnormally developed hip), slipped upper femoral epiphysis (growth plate injury around puberty), Perthe’s disease (avascular necrosis of the femoral head), and infection.

Hip preserving surgery is any procedure, other than joint replacement, which addresses the symptoms that the patient has as a result of an abnormal hip joint.

The most commonly hip preserving surgeries are osteotomies around the hip joint such as peri-acetabular osteotomy and or proximal femoral osteotomy (bony procedures to realign either the socket or femur bone), open hip debridement and hip arthroscopy.

What is open hip debridement?

The fairly recent development is the identification of a particular structural hip “abnormality” which predisposes a person to getting an osteo-arthritic hip at an earlier age than one would expect.

A slight abnormality in the growth plate during development of the femoral head may lead to an irregularity on the femoral-neck junction. This irregularity may result in a process known as CAM impingement.

There may also be structural abnormalities on the socket side of the hip joint and these lead to a pincer impingement. CAM impingement is much more common and often there is a combination of both types of impingement.

hip-abnormalities

As result of this process damage can occur to the acetabular labrum and the articular cartilage which may ultimately lead to an arthritic hip joint.

cam-impingment pincer-impingement
CAM impingement Pincer impingement

Techniques have been developed where the bony abnormality is removed and the labrum is re-attached and so theoretically prevents the onset of arthritis prematurely. In order to do this, traditionally, an open hip dislocation has to be carried out, however techniques are now being developed which allow some of these procedues to be done arthroscopically in the great majority of cases.

open-hip-op

Using a jig as a guide the “aspherical” portion of the femoral head and neck is removed at surgery.

Publication on open hip dislocation

Following hip preserving surgery a patient might still require a hip replacement but hopefully at a much later stage which may ultimately reduce the need for revision hip surgery.

Information on femoral-acetabular impingement

What is hip arthroscopy?

Hip arthroscopy is a procedure by which an “arthroscope” is passed into the hip joint. This scope is attached to a camera system which allows the surgeon to look into the hip joint. This allows the hip joint to be assessed and in certain cases the underlying hip problem can be addressed and treated.

The most common reasons for carrying out a hip arthroscopy are:

  • Tear of the labrum (The labrum functions as a “seal” around the hip socket)
  • Articular cartilage damage
  • Femoroacetabular problems (Cam and Pincer impingement deformities)
  • “Snapping hip” syndromes
  • Synovitis (inflammation of the hip joint)
  • Early arthritis
  • Ligamentum teres rupture (Central ligament in the hip joint)
  • Loose bodies
  • Other uncommon conditions

Arthroscopy of the hip is much more involved and technically demanding than, for example, a knee arthroscopy. The hip joint is surrounded by many more tissue structures than the knee joint. Also because the joint is much more congruent a space has to be created for the arthroscope to gain access to the joint. This is done by applying traction to the leg. This distracts the joint and creates the space needed to carry out the arthroscopy.

arthroscopy-op

The surgical procedure of hip arthroscopy.

arthroscopy-1 arthroscopy-2 arthroscopy-3
During hip arthroscopy a needle is used to place fluid into the hip joint. With traction on the patient’s leg the hip joint is opened up so that the arthroscope and other instruments can be placed in the joint. The middle image shows a drill used to place a suture anchor for a labral repair.This intra-operative view shows a tear of the anterior labrum of the hip joint.

Information on hip arthroscopy

http://www.orthoinfo.org/topic.cfm?topic=A00572

What is trochanteric bursitis?

Trochanteric bursitis is inflammation of a fluid filled sack which separates musculo-tendinous structures from the greater trochanter (hip bone) of the hip.

trochanteric-bursa

Position of trochanteric bursa.

The main symptoms are pain overlying the hip bone sometimes radiating towards the knee during activity but especially when lying on the effected side at night.

Treatment may consist of the use of anti-inflammatories, physiotherapy, an injection with steroid and local anaesthetic, and rarely, in certain resistant cases, surgery may be indicated.trochanteric-bursa-2

There are other bursa around the hip area that can also become inflamed and cause symptoms.

Often injections around the trochanter or other areas are more accurately done with ultrasound guidance.

Mr Busch has attended course to obtain expertise in this area.

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Download the Musculoskeletal Ultrasound course here

Information on trochanteric bursitis

https://en.wikipedia.org/wiki/Greater_trochanteric_pain_syndrome

What is a snapping hip?

Clicking and snapping of the hip are common symptoms. As a rule of thumb, if they are painless than usually the underlying cause in not worrisome.

The 3 most common causes for a snapping hip are:

  1. A loose body in the hip joint (Including a labral tear)
  2. Snapping of the ileo-tibial tract over the greater trochanter.
  3. Snapping of the psoas tendon over the ileo-pectineal eminence.

The majority of treatments are non-surgical and some cases may require image guided injections around the hip joint.

If conservative management fails that there are arthroscopic procedures that can bring a solution.

Snapping of the Ilio-tibial band over the greater trochanter.

Snapping of the Ilio-tibial band over the greater trochanter.

clicking-hip-2

Snapping of the psoas tendon over the ilio-pectineal eminence.

Information on clicking hip

http://orthoinfo.aaos.org/topic.cfm?topic=A00363