We are getting many emails from people who are waiting for a hip arthroscopic surgery or trying to find other solutions. They have a lot of pain, mostly a dull nuisance type pain that climbs in intensity when they try to do sports or sometimes while simply walking. Many have a hip that clicks, locks, and gets stuck in mid-step.
If the person is a master’s age athlete and the decades of active sports involvement have caused significant hip pain, then he/she may be recommended to a hip arthroscopy surgery as a means to preserve the hip from a hip replacement.
Recently, a leading surgical center, the Hospital for Special Surgery says this: “The percentage of patients with hip arthritis who had a hip replacement within two years of hip arthroscopy was unacceptably high at 68%, according to a new study of more than 2,600 patients by investigators at Hospital for Special Surgery (HSS). Prior hip arthroscopy was also associated with significantly worse outcomes after hip replacement.”
This was from a May 18, 2020 Press statement
“Arthroscopic hip surgery should not be performed in patients with a diagnosis of osteoarthritis”
This conclusion warning that people with hip osteoarthritis should not have arthroscopic surgery comes from Hospital of Special Surgery research published in the journal Hip International.(1) Here is the concluding remarks of that research:
“Analysis of a large insurance database found the conversion rate from hip arthroscopy performed in Medicare osteoarthritis patients to total hip replacement within 2 years is unacceptably high. Hip arthroscopy prior to total hip replacement also significantly increased the risk of total hip replacement revision within 2 years after index arthroscopic hip surgery . These results suggest that arthroscopic hip surgery should not be performed in patients with a diagnosis of osteoarthritis as conversion rates are high and revision rates post total hip replacement are significantly increased.”
If you have been recommend to a hip arthroscopic procedure you know why it was recommended. You had been diagnosed with femoroacetabular impingement, clean up some cartilage damage, a lot of people get the surgery to fix labrum tears, tendon problems or problems of bursitis. You were recommended to the surgery because you stiill had pain after your tried:
- Over the counter anti-inflammatories and pain relievers.
- A lot of icing.
- Balms and ointments.
- Physical therapy and stronger doses of anti-inflammatories.
- And finally an MRI may have revealed enough damage to suggest a future a labral tear and the possibility of Femoroacetabular Impingement? (Bone spur formation that is pinching at the the hip labrum).
Arthroscopic hip surgery for a labrum tear
Once the MRI has determined a labral tear and the start of the bony overgrowth (osteoarthritis) the treatment options begin to narrow to cortisone to provide temporary relief and ultimately arthroscopic surgery to shave down and trim up the labrum’s soft tissue.
For someone who is active, surgery can be a confusing option. On the one hand, surgery is seen as an attractive option because there is a promise that the patient will be able to resume normal sporting activities quicker if they do not wait. Labrum tear and impingement is something, they are told, that will not heal on its own. On the other hand, surgical recovery can take a long time. Then there is the thought that the surgery may not be that successful.
So what is this person doing in our office? Are they trying to avoid the surgery, or worse, had they already had the surgery and the surgery did not provide the results that they had hoped for?
Arthroscopic surgery for hip labrum tears has its successes and its failures.
In a recent study in the journal Sports medicine and arthroscopy review, (2) surgeons wrote of the benefits of hip labrum surgery. But watch how the study concludes, which I reproduced here, there may be a better way:
“The techniques utilized for the management of articular cartilage and labrum injuries during hip preservation surgery have changed dramatically recently . . .The overarching goal of labral treatment is to restore the native functions of the labrum to allow for more normal biomechanical function. Similarly, cartilage injuries can be managed a number of different ways, including with debridement, microfracture or drilling, cartilage transplants, and higher level restorative techniques. These cartilage restoration techniques have evolved rapidly as well, and may include the use of scaffolds, allograft cartilage cells, and other stem-cell-related procedures.)
The researchers here suggest that you can get benefit from:
- arthroscopic debridement, (the trimming down of damaged soft tissue and washing out of bone chips or fragments),
- microfracture or drilling, (hip microfracture surgery is a common arthroscopic procedure where an awl (a sharp pointed tool) is pushed into the bone where the protective hip cartilage has worn away. The small holes made by the awl are called microfractures. The goal of this surgery is to build new cartilage by bringing the blood from the bone marrow into the hip joint to form a protective scab and fill in the cartilage defects.)
- Cartilage transplants or osteochondral allografting. or OATS: In this procedure, surgeons transfer a small piece of cartilage and bone from a healthy area to the damaged area For larger damaged areas of the hip cartilage, doctors may use allografts, or donated tissue.
They also suggest that you may get benefit from “higher level restorative techniques. These cartilage restoration techniques have evolved rapidly as well, and may include the use of scaffolds, allograft cartilage cells, and other stem-cell-related procedures.”
Is stem cell therapy then an option for you? That is a question that should be decided by you and your doctor after a physical examination. But below I will provide some good research to help you with your discussion. In some cases doctors will not recommend stem cell therapy in favor of labrum reconstruction. This surgery may be considered for the patient who have a devastating and considered “unrepairable” labrum tear. A hamstring allograft or hamstring autograft may be considered to replace the labrum. It may be prudent to explore a second opinion in these types of injuries to see if stem cell therapy is a realistic alternative.
The surgical options. Why aren’t they as good as hoped for?
Doctors in Japan reported these findings in January 2017 in the Journal of orthopaedic surgery and research. (3) These finding present a more pessimistic outlook of the surgical outcome:
Active person over 50 – One in 3 will go on to hip replacement
“Many studies have examined the clinical outcomes of arthroscopic surgery for treatment of hip labral tear and/or osteoarthritis in patients over 50 years of age. Overall these studies show that clinical outcomes generally improved, however they contained cases in which conversion to total hip replacement occurred at a constant rate. In the current study, 34.8% of the patients showed a progression to osteoarthritis AFTER arthroscopic procedures.”
There are no clear cut choices in surgery – You need a surgery to see if you need surgery
In March 2017, American Hip Institute researchers presented a paper (4) that suggested:
“Currently, three commonly practiced labral treatments are available: repair (surgical), débridement, and reconstruction. Arguments for and against each treatment option exist in the literature. Reviewing the currently proposed indicators for labral tear treatments in conjunction with the treatment procedures yields a thorough decision-making guide for choosing the appropriate labral procedure.There are no clear cut choices in surgery.”
A September 2018 study in the Orthopaedic journal of sports medicine (5) suggested:
“The intraoperative appearance of the labrum is the most important factor affecting surgical decision making. However, different surgeons viewing the same tear arthroscopically may select different treatments. The indications to repair a torn acetabular labrum are highly variable among hip arthroscopic surgeons.”
The vicious cycle. The second surgery is not as good as the first. You get the second surgery because the first one failed
In January 2020, James D. Wylie, MD wrote an editorial in the medical journal Arthroscopy. (6) This is what he wrote:
“Hip arthroscopy has evolved significantly over the last 5 to 10 years. With this comes the burden of patients with continued pain after their index (first) procedure. Reasons for the need for revision surgery can be many, including incomplete resection of impingement morphology, unrecognized/unaddressed acetabular dysplasia or hip instability, failure to manage the soft tissue appropriately (i.e., labrum or capsule/ligament), or other unrecognized cause of pain, like femoral retroversion (the femoral head is not in the correct position, a tell tale sign is that the foot is pointed outward) or subspine impingement. Like many other orthopaedic procedures, revision hip arthroscopy with or without a defect in the hip capsule has significantly worse outcomes at 2 years compared with primary hip arthroscopy. This emphasizes the importance of proper diagnosis, well-done surgery, and proper rehabilitation the first time to avoid the need for revision hip surgery in the young adult altogether.
In April 2020 another editorial in the medical journal Arthroscopy (7) made these comments that pain management after the procedure is lacking.
“Pain after hip arthroscopy is a significant and challenging issue as is evidenced by the number of publications on this subject. Various analgesic strategies to circumvent this issue have been tried, with variable results. The central problem is that pain experienced by patients after hip arthroscopy is multifactorial in origin. Regarding local injection, an anatomic approach to the nerve supply to the hip with an effective pain relief strategy should take this into consideration and focus on using drugs with a low risk of complications and infiltration techniques that do not cause an unnecessary delay in rehabilitation and discharge of the patient. Furthermore, addressing traction time, surgical technique, and fluid extravasation and applying an individualized approach, keeping the patient’s personality and profile in mind, will ensure adequate analgesia after arthroscopic intervention.”
And also from April 2020, from the The American journal of sports medicine.(8)
“While the indications for primary hip arthroscopic surgery in treating femoroacetabular abnormalities continue to be defined, the indications and outcomes for revision hip arthroscopic surgery remain ambiguous. However, revision hip arthroscopic surgery is performed in 5% to 14% of patients after their index procedure. While patient-reported outcomes (PROs) generally improve after revision procedures, the extent of their improvement is not well defined. . . “
The researchers also note that after revision hip arthroscopic surgery, studies have suggested the rates of conversion to total hip replacement ranged up to 14.3%, and the rates of further arthroscopic revision ranged also ranged to 14% of patients.
Injection treatments and hip preserving surgery
The choice of treatment for a hip labrum tear is wide and varied. This is pointed out by research in the Sports medicine and arthroscopy review. (10) In this paper, hip arthroscopic surgery is seen as hip preserving and a means to help a patient avoid ultimate hip replacement.
“The techniques utilized for the management of articular cartilage and labrum injuries during hip preservation surgery have changed dramatically recently. Conservative treatment may involve image-guided injection of cortisone or viscosupplementation in conjunction with oral NSAIDs and physical therapy.
Damage to the labrum runs a broad spectrum, and the treatments are individualized, but span from debridement to repair and reconstruction. The overarching goal of labral treatment is to restore the native functions of the labrum to allow for more normal biomechanical function. Similarly, cartilage injuries can be managed a number of different ways, including with debridement, microfracture or drilling, cartilage transplants, and higher level restorative techniques. These cartilage restoration techniques have evolved rapidly as well, and may include the use of scaffolds, allograft cartilage cells, and other stem-cell-related procedures.”
I have written articles, which you can see on this website on cortisone injections and viscosupplementation / hyaluronic acid.
The non-surgical options PRP and Stem Cells
- PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected into toe joints to stimulate healing and regeneration.
- Stem cell injections involve the use of bone marrow derived stem cells. These stem cells are also injected into to the joint to stimulate healing and regeneration.
The determination of which method is used is made during the initial consultation and physical examination of the hip. Afterwards we discuss with the patient the realistic healing options that these treatment can offer them.
In May 2019, doctors at the Mayo Clinic published research on ultrasound guided platelet rich plasma injections for treatment of symptoms associated with acetabular hip labral tears. What the Mayo Clinic researchers hoped to answer was whether PRP was safe and effective. The results were published in the American journal of physical medicine & rehabilitation.(9)
- The researchers looked at 8 patients who have previously failed conservative management and received ultrasound-guided injection of PRP at the site of hip labrum tear. The patients were assessed for pain and functionality at the start of treatment, then 2, 6, and 8 weeks after injection.
- The findings: Results were good, improvements in pain and function were seen at the 2, 6 and 8 week marks post injection.
- The conclusion: “Ultrasound-guided injection of PRP holds promise as an emerging, minimally-invasive technique toward symptom relief, reducing pain, and improving function in patients with hip labral tears.”
References:
1 Malahias MA, Gu A, Richardson SS, De Martino I, Sculco PK, McLawhorn AS. Hip arthroscopy for hip osteoarthritis is associated with increased risk for revision after total hip arthroplasty. HIP International. 2020 Mar 3:1120700020911043.
2 Salata MJ, Vasileff WK. Management of Labral and Chondral Disease in Hip Preservation Surgery. Sports medicine and arthroscopy review. 2015 Dec 1;23(4):200-4.
3 Moriya M, Fukushima K, Uchiyama K, et al. Clinical results of arthroscopic surgery in patients over 50 years of age—what viability does it have as a joint preservative surgery? Journal of Orthopaedic Surgery and Research. 2017;12:2. doi:10.1186/s13018-016-0504-9.
4 Domb BG, Hartigan DE, Perets I. Decision making for labral treatment in the hip: repair versus débridement versus reconstruction. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2017 Mar 1;25(3):e53-62.
5 Herickhoff PK, Safran MR. Surgical Decision Making for Acetabular Labral Tears: An International Perspective. Orthop J Sports Med. 2018 Sep 20;6(9):2325967118797324. doi: 10.1177/2325967118797324. PubMed PMID: 30263897; PubMed Central PMCID: PMC6149026.
6 Wylie JD. Editorial Commentary: The First Hip Arthroscopy Is the Best Hip Arthroscopy, Capsular Defect or Not. Arthroscopy. 2020;36(1):137–138. doi:10.1016/j.arthro.2019.09.009
7 Sardesai AM, Garner M, Khanduja V. Editorial Commentary: Pain After Hip Arthroscopy-Are We Truly Addressing the Problem?. Arthroscopy. 2020;36(4):1045–1047. doi:10.1016/j.arthro.2020.02.013
8 O’Connor M, Steinl GK, Padaki AS, Duchman KR, Westermann RW, Lynch TS. Outcomes of Revision Hip Arthroscopic Surgery: A Systematic Review and Meta-analysis. Am J Sports Med. 2020;48(5):1254–1262. doi:10.1177/0363546519869671
9 De Luigi AJ, Blatz D, Karam C, Gustin Z, Gordon AH. Use of platelet-rich plasma for the treatment of acetabular labral tear of the hip: a pilot study. American journal of physical medicine & rehabilitation. 2019 Nov 1;98(11):1010-7.
10 Salata MJ, Vasileff WK. Management of Labral and Chondral Disease in Hip Preservation Surgery. Sports medicine and arthroscopy review. 2015 Dec 1;23(4):200-4.