Do all patients with hip dysplasia need two surgeries, or can just one surgery relieve hip pain and preserve the hip? It’s a highly debated question among orthopaedic surgeons.
Robert Kollmorgen, DO, associate clinical professor of Orthopaedic Surgery at UCSF Fresno, research director for the Department of Orthopaedic Surgery, and Inspire Health Medical Group provider, was asked recently to write an editorial about the topic for The Journal of Arthroscopic & Related Surgery.
The journal is the global leader in sports medicine and orthopaedics, and Dr. Kollmorgen, the journal's associate editor, is a fellowship-trained hip preservation specialist. For the editorial, he reviewed the literature on the role of hip arthroscopy combined with periacetabular osteotomy in patients aged 13 to 30 with dysplasia.
Patients with hip dysplasia have shallow or abnormally formed hip sockets, which can cause hip pain. Most patients with hip dysplasia are born with the condition and may not even know they have it until they experience pain.
Hip preservation surgery began in 1986, when total hip replacements wore out relatively quickly, Kollmorgen said. Today, hip replacements last much longer, but hip preservation is a viable option for a young adult instead of a lifetime with an artificial hip.
Hip preservation surgery for hip dysplasia, periacetabular Osteotomy or PAO, involves an open surgery to cut into the pelvic bone around the hip socket (acetabulum), turn the socket to cover the femoral head, and secure it with screws. A second surgery, hip arthroscopy (HA), is performed by some surgeons, in which a camera is inserted into the hip joint and special instruments are used to repair soft tissue (labral tears) and shave bone to correct hip impingement.
“Some surgeons do the camera surgery first and then do the PAO at the same time,” Kollmorgen said. “And then others will just do the PAO – and there is your controversy. Do they need to have this other surgery or not?”
The question is controversial among orthopaedic surgeons. “I sit on these international panels, and it’s a very hot topic of discussion,” Kollmorgen said. “It’s very pertinent to my world where I operate and take care of patients with young hips.”
Many open-hip surgeons argue that hip arthroscopy is unnecessary, adds no clinical benefit, introduces unnecessary scarring, and could add undue cost and risk to patients, Kollmorgen noted in his editorial. However, the literature review also showed the addition of HA to PAO to be safe, returns patients to sports, and provides revision rates similar to those of PAO alone at two to five years, he wrote.
He added that reviews of the available literature comparing an isolated PAO to HA+PAO showed the safety and efficacy of adding hip arthroscopy. “Diving into the included studies, there was no difference between the groups in outcomes, complications, and revision rates,” he wrote. “The HA+PAO group, in a pooled analysis, showed some improved clinical outcomes versus PAO alone, and there was no inferiority among the groups.”
Not all orthopaedic surgeons can perform hip arthroscopy. For example, Kollmorgen is the only adult HA fellowship-trained orthopaedic surgeon in Fresno, and that must be considered. “You have to be really skillful and thoughtful in your decision-making,” he said. “Look at the patients individually and do whatever surgeries they need. You don’t have to do a camera surgery if they don’t need it, but if they need it, offer it to your patients; and if you can’t do it, then you have to figure out how to help them some way.”
His conclusion, the literature does not clearly define whether the addition of HA to PAO is necessary in all, some, or any patients, and more research is needed.
This leaves the subject open to further debate, which Kollmorgen welcomes. “If it leads to more research and more discussion, I think we’ve won.”
