Diagnosis & Treatment
Biological or joint preserving solutions are those that preserve your own living tissues. Unlike prosthetic implants these alternatives can adapt more effectively to the strains of everyday life and, accordingly, they can be advantageous to the younger, more active individual. Although traditional, stem-type total hip replacement (THR) is one of the most successful surgical procedures introduced, survivorship of cemented and cementless stem-type THR at 15-20 years in patients less than 50 years of age at time of surgery has been disappointing with failure rates ranging from 10% to 33% as reported in various studies. It is also important to differentiate a less than optimal outcome following THR versus that of a joint preserving procedure. For instance, a poor outcome following THR could include either dislocation or loosening of the prosthesis with loss of bone.
On the other hand, a poor outcome following joint preserving
surgery could include continued pain or the eventual onset of osteoarthritis
of the hip. If either of these scenarios were to occur following joint
preserving surgery, then you may need to take anti-inflammatory medication
and/or eventually consider hip replacement surgery. However, the critical
point is that you have preserved and maintained your entire hip joint
thereby preserving more options for the future.
Below is a discussion of joint preserving procedures performed by Dr. Beaulé including indications for their use.
Indications for treatment: Hip pain resulting from tears of the acetabular labrum and use of a diagnostic tool and removal of loose body.
Discussion: The acetabular labrum is a horseshoe-shaped fibrocartilaginous structure attached to the periphery of the acetabulum that adds depth to the hip joint. It is a different type of cartilage than that which cushions the hip joint. Its function is to provide additional stability to the hip when moving the hip to its upper limit of motion.
The labrum can tear suddenly as a result of a fall or by moving the hip to its upper limits of motion or it can tear gradually from repetitive stresses. The patient may experience catching or clicking associated with discomfort on the front of the hip. Pain may worsen with long periods of sitting. Only 1/3 of patients recall trauma to the hip joint.
A labral tear can also occur if the hip socket is shallow or as a result of impingement. In this condition, the labrum is trying to compensate for insufficient bone covering the femoral head and it is bearing the majority of the load. In this type of hip dysplasia, repairing the labral tear is not indicated as it will not solve the underlying cause (i.e., shallow socket) and an osteotomy needs to be considered. It should be noted that pure labral tears with no underlying hip malformation are rare in comparison to other conditions that necessitate hip repair, reconstruction or replacement.
Diagnosis: On physical exam, a labral tear manifests itself when the range of motion is more than normal and there is pain either with hip flexion, internal rotation and adduction or extension in external rotation. General radiographs are initially reviewed to rule out hip dysplasia followed by an MRI with contrast injection (gadolinium enhancement). The MRI cannot detect all labral tears and, in fact, a false-negative result occurs in about 10% of cases.
Most of the focus on hip malformations has been on the socket although it has long been recognized that abnormalities of the femoral head and neck or ball of the hip joint can lead to early osteoarthritis. Indications for use: Femoro-Acetabular Impingement /late sequalae of childhood hip problems including Legg-Calvé-Perthes and slipped capital femoral epiphysis.
If the MRI is positive and the hip joint is properly formed then a hip arthroscopy is the procedure of choice. It will permit repair of the tear resulting in pain relief and a return to near normal function. Some patients (5%) do not experience full pain relief because of damage to the cartilage lining. The procedure is performed on an outpatient basis. The recovery is relatively simple in that the patient is on crutches for one to two weeks and they are able to bear full weight on the operated leg. 70-90% of patients with labral tears who undergo hip arthroscopy report good to excellent results at three years.
The head and neck relationship is critical in avoiding an impingement at the rim of the socket. If that relationship has been disrupted (i.e., a wide neck or lack of offset between the two), then this will create a cam effect and initially damage the labrum anteriorly (See Figure 9). It can also create a shear force on the cartilage lining leading to its degeneration, in other words, hip arthritis. The onset of symptoms and the clinical presentations will be very similar to those for acetabular or socket dysplasia. Patients will have difficulty in maintaining a high activity level initially and over time the pain will evolve to a constant, dull ache in the hip region worsening after long periods of sitting.
Until recently, there was no safe way to gain access to the femoral head and neck without interrupting its blood supply resulting in avascular necrosis (i.e. death of part of the femoral head). The surgical approach known as surgical dislocation was introduced to permit easy access to the hip joint without disrupting the blood supply to the femoral head and neck.
Treatment and Post-Operative Recovery: In some cases, it is not necessary to perform a surgical dislocation because the pathology is limited to the anterior aspect of the hip joint. In these cases, a combination of hip arthroscopy and a mini anterior approach may be sufficient and would result in a quicker recovery (e.g., two weeks).
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Chondro-Osteoplasty with a surgical dislocation approach involves releasing a medallion of bone from the greater trochanter permitting access to the head and neck by dislodging the hip from the socket. Once the desired correction of the deformity is completed, the medallion of bone is reattached with two screws. At six weeks post-op, the patient can bear full weight and physical therapy is then prescribed for four to six weeks. Patients typically experience immediate pain relief and they can gradually resume normal activities at eight to twelve weeks following surgery.
Periacetabular Osteotomy (or Bernese)
Indications for treatment: Hip Dysplasia/Retroverted Acetabulum. Note: In some cases, the deformity is present on both the socket and head/neck areas requiring that both a PAO and Chondro-Osteoplasty be performed either simultaneously or staged.
Discussion: The word dysplasia refers to malformation or lack of full development. Some patients develop this condition from birth or in early childhood and surgery is performed at that time. In others, the hip becomes painful in early adulthood or they have been treating the painful hip as a groin injury for several years with either physical therapy or anti-inflammatory medication. Symptoms are often unrecognized as hip dysplasia as patients will complain of buttock pain or pain over the lateral aspect of their hip going down the side of the thigh. Some patients are given injections in their greater trochanter or buttock area to relieve the pain.
Diagnosis: Physical findings are similar to labral tears. Xrays will typically reveal the obvious malformation (See Figure 16) and sometimes a small bone rim of the socket will have dislodged. After a careful radiographic review, the location and severity of the dysplasia is established and this will dictate the most appropriate joint preserving procedure.
Treatment and Post-Operative Recovery: The role of pelvic osteotomies for the treatment of hip dysplasia has a long history in orthopedics. Until the advent of the PAO in the mid-1980s, most pelvic osteotomies did not result in reproducible or sufficient corrections. Further, they modified the normal anatomy of the pelvis and often required casting. Trained surgeons are now able to routinely perform the PAO with excellent results and a relatively quick recovery.
A periacetabular osteotomy involves dislodging the hip socket from its bony bed in the pelvis without distorting the normal pelvic anatomy. The socket is then reoriented in the proper position to relieve hip pain and prevent osteoarthritis. This is verified by taking an x-ray during the surgery. When the socket has the correct orientation it is fixed with three screws. Two of the screws can be removed at a later date if they irritate the skin.
The patient ambulates the day following surgery using crutches and under the supervision of a physical therapist. Most patients are discharged four days after the surgery. The internist to whom you are assigned for medical management during your hospital stay will order any necessary medications at the time of discharge.
You will use crutches for eight weeks (i.e., restricted weight bearing) at which time an x-ray will be taken. If you live out of state, then you may be seen by a local surgeon and have the x-rays forwarded to our office. Physical therapy will be prescribed at that time and you can apply full weight on the operated leg. After 4 to 6 weeks of physical therapy, most patients return to regular activities including sports.
Clinical Results: At five to ten years following PAO, 80% of patients have good to excellent results with either no pain or minimal pain and a return to normal function. Patients who did experience better results either had early signs of arthritis prior to the osteotomy or the arthritis had progressed despite the osteotomy.
A 44 year-old female presented with a 5-year history of bilateral hip pain (right greater than left). The pain had been constant in nature over the last several months with increased severity associated with high activity levels and periods of long sitting. The pain was always referred to the groin area and the patient had negative impingement test on physical exam.
On the AP view (Figure 17a), both hips were dysplastic. The right hip had significant arthritis although the left did not have signs of arthritis. The dysplasia is recognized by the lack of coverage of the femoral head and the acetabular roof being too vertical. The patient underwent a periacetabular osteotomy of her left hip (Figure 17b). The patient is now ten months post surgery with significant pain relief and return to normal activities.
Core Decompression and Grafting
Indications for use: Osteonecrosis (or avascular necrosis AVN)
Discussion: Osteonecrosis (ON) also referred to as avascular necrosis involves a disruption of the blood supply to the femoral head and subsequent death of bone cells to varying degrees. The diagnosis is usually made by MRI or general x-rays. The disease is bilateral in nearly 50% of cases. Once the reparative process is initiated the old bone is replaced by new bone which for a period of time is weaker. It is during this reparative process that the femoral head can collapse which then necessitates prosthetic intervention. Therefore, we can separate the treatment of ON of the head into two stages: pre-collapse and post- collapse. In the pre-collapse stage, the goal is to facilitate the reparative process and minimize the possibility of collapse. (Post-collapse options are discussed under the section entitled Prosthetic Solutions)
Treatment and Post-Operative Recovery: Two treatments are available in
Core decompression involves drilling a 3-4mm core into the dead part of the femoral head to relieve pain. The area that has been drilled out is then grafted using bony substitutes to promote vascularization and healing and to avoid collapse. These bony substitutes are numerous with different properties. The advisability of this technique is determined by the size of the lesion. Generally, the smaller the lesion, the more effective the treatment can be. Typically, patients can expect complete pain relief and a halt in the progression of the disease process in over 80% of cases.
The core decompression procedure lasts only 45-60 minutes and most patients can go home within 1-2 days. Youll need crutches for 6 weeks until the bone heals. It is not uncommon that core decompression is performed on both hips since AVN affects both hips in over 50% of the cases.
Indications for use: Osteonecrosis - Post-collapse stage
Discussion: In the post-collapse stage of osteonecosis, the femoral head has lost its contour and this will eventually lead to srthritis because of the persistent damage to the articula cartilage of the socket.As a result, we recommend surgery sooner rather than later in order to preserve healthy acetabular cartilage. The prefered option to best accomplish this is hemiresurfacing arthroplasty.
Treatment ans Post-Operative Recovery: Hemiresurfacing is similar to a dental crown in that the diseased femoral head is reshaped and capped with a metal "shell" component. This re-establishes a smooth surface articulating against the acetabular cartilage while relieving hip pain and halting the damage to the remaining cartilage. The patient is able to return to normal activities with minimal discomfort. Pain relief is sometimes not as predictable because of the pre-existing damage to the acetabular cartilage.
The main advantage of this technique is that the femoral canal is not violated. Although proximal femoral osteotomies and free-vascularized fibular grafts are non-prosthetic options depending upon the size of the lesion, hemiresurfacing offers faster healing and recovery with minimal restriction on weight bearing. Further, conversion to a THR following a hemiresurfacing is simpler with much less morbidity than a revision of a traditional THR. Typical post-operative dislocation precautions that are normally required following THR are not applicable with hemiresurfacing and patients may bear weight as tolerated. At six weeks following surgery, physical therapy is prescribed for four to six weeks. The patient may resume normal activities at two to three months. Most patients are discharged four days after the surgery.
Indications for use: Osteoarthritis
Discussion: In surface arthroplasty, the femoral neck is preserved rather than removed as is done in conventional stem-type total hip replacement. The femoral head is reshaped and resurfaced with a prosthetic shell. As a result, the femoral bone is loaded more like a normal hip and the bone is preserved. Since the resurfaced head is very similar in size to the normal hip (about 40-50 mm), it is more stable and dislocation risk is minimal. Revision of a surface arthroplasty is comparable to primary replacement since the bone is intact. The conservative and more physiologically compatible nature of the surface arthroplasty has always been appealing to both surgeons and patients. Renewed interest in this procedure has been fostered by the reintroduction of all-metal bearings that could dramatically increase durability. Surface arthroplasty may also permit higher levels of post- surgery activity with fewer downside risks than does a traditional, stem-type device. The increased stability is particularly conducive for sports and work activities where a more normal range of motion of the hip is required.
Treatment and Post-Operative Recovery: The patient ambulates the day
following surgery using crutches and under the supervision of a physical
therapist. The patient may not bear full weight on the operated leg for
six weeks. Most patients are discharged four days after the surgery. The
internist to whom you are assigned for medical management during your
hospital stay will order any necessary medications at the time of discharge.
Indications for use: Osteoarthritis
Discussion: In certain situations, the bony anatomy of the proximal femur is so distorted or the femoral head is too damaged such that the femoral part of the hip resurfacing cannot be expected to maintain adequate fixation for more than 5 years. Therefore, these patients are no longer candidates for a bone preserving procedure and total hip replace-ment is the only viable option. The most important factor determining the longevity of a THR implant is the bearing surface (i.e., metal-polyethylene, metal-metal or ceramic-ceramic). In order to select the optimum bearing material we consider three factors: clinical track record, biocompatibility and wear resistance. The most wear-resistant bearing surface is ceramic on ceramic. These bearings are less biologically inflammatory than other bearing combinations. Ceramic-ceramic devices have a greater than 20-year clinical track record in Europe and they have been in clinical use in the U.S. since 1998. The risk of fracture of the ceramic femoral head is extremely low at 1 in 10,000. Although Dr. Beaulé prefers ceramic-ceramic bearings in younger, more active adults who require THR, metal-metal and metal-polyethylene devices are also utilized if they are determined to be a more appropriate option. Dr. Beaulé advocates cementless acetabular fixation and either cemented or cementless stem fixation depending upon the patients bony anatomy.
Treatment and Post-Operative Recovery: Following THR, dislocation is of greater concern as compared with metal-metal resurfacing. However, Dr. Beaulé uses a modified anterior approach that permits the patient to move their hip normally immediately after surgery (e.g., hip flexion, normal weight-bearing). Therefore, the patient may not perform hip flexion greater than 90 degrees during the first six weeks post-op. The patient ambulates the day following surgery using crutches and under the supervision of a physical therapist. Most patients are discharged four days after the surgery. The internist to whom you are assigned for medical management during your hospital stay will order any necessary medications at the time of discharge. At six weeks post-op, the patient can bear full weight and physical therapy is then prescribed for six to eight weeks. Patients typically experience immediate pain relief and they can gradually resume normal activities at eight to twelve weeks following surgery.
Revision Total Hip Replacement
Failure of total hip replacements are often associated with loss of bone stock either in the socket side or femoral side or occasionally both. This loss of bone is secondary to the inflammatory response from the wear debris and the loose implant moving within the bone. There are two ways to reconstruct the defect: a) match the implant to the defect or; b) restore the bone loss and normal hip anatomy. Dr. Beaulé personally favors restoring the bone loss in order to avoid prosthetic escalation. This is achieved by using allograft bone combined with implants favoring incorporation of the bone graft. On the femoral side, Dr Beaulé performs a technique referred to as impaction grafting and on the acetabular side a reinforcement ring is used. This type of reconstruction more closely restores the normal anatomy thereby reducing the risk of dislocation and facilitating any future surgery.