Sept. 22, 2017
Hip disorders pose significant challenges for young adults, limiting activities and potentially resulting in long-term degenerative joint changes. Complex cases often require both arthroscopy to repair tears inside the hip joint and osteotomy to correct deformities that lead to the recurrence of tears.
To care for increasing numbers of patients with complex hip conditions, Mayo Clinic in Rochester, Minnesota, has a Young Hip Clinic, where orthopedic surgeons with expertise in hip arthroscopy and in open-hip surgery collaborate to treat young people.
"Often we see patients who have had extensive outside work-ups involving multiple physicians in multiple specialties over three to six months. This is costly, inconvenient and unnecessary for patients," says Aaron J. Krych, M.D., consultant in Orthopedic Surgery at Mayo's campus in Minnesota. "The Young Hip Clinic provides a streamlined evaluation for painful hip pathology in young and active patients."
"Especially for patients with the more complex deformities — such as acetabular retroversion, acetabular hip dysplasia or femoral structural abnormalities — our combined subspecialty approach allows us to deliver the best care," adds Rafael J. Sierra, M.D., a consultant in Orthopedic Surgery at Mayo's Minnesota campus.
Arthroscopy and osteotomy in a single procedure
A 30-year-old active male was treated in the Young Hip Clinic for a large cam lesion causing impingement, as well as undercoverage of the femoral head with acetabular dysplasia. A combined open periacetabular osteotomy and arthroscopic cam correction were performed in a single surgery. A. Preoperative pelvis radiograph demonstrates acetabular dysplasia (arrow). B. Preoperative oblique lateral radiograph demonstrates loss of femoral head-neck offset with a cam lesion (arrow). C. Intraoperative view demonstrates correction of the cam lesion (arrow). D. Three-year postoperative image demonstrates correction of dysplasia from the combined open periacetabular osteotomy and arthroscopic cam correction.
In selected patients, Mayo Clinic orthopedic surgeons can perform arthroscopy and osteotomy in a single procedure, sparing those patients a second round of anesthesia and postoperative recovery. Over 150 of these combined procedures have been performed in patients who would have otherwise had an arthroscopic approach to their hip disease prior to femoral or acetabular osteotomy.
"This combined approach is done swiftly by two orthopedic teams," Dr. Sierra says. "The arthroscopic approach allows us to improve the recovery of these patients, as performing labral repairs and femoral head and neck osteochondroplasties through an open approach would require more soft tissue dissection, and potentially prolonged rehabilitation."
Matching patients to procedures
Mayo Clinic is able to treat patients of all ages with hip conditions ranging from mild to severe. Imaging tests can be quickly scheduled and results are typically available within 24 hours, allowing for efficient and accurate diagnosis. Orthopedic surgeons can then collaborate to determine the most beneficial treatment plan for each individual patient.
"There are many factors to consider, involving the degree of correction and amount of arthroscopy work that may be needed," says Bruce A. Levy, M.D., a consultant in Orthopedic Surgery at Mayo's Minnesota campus. "For patients with a very subtle labral tear but who need a significant amount of joint correction, we might do just the osteotomy. For somebody who has a malpositioned socket and also problems on the femoral neck and with the labrum, we might decide to stage the surgeries — fix the labral tear and correct the bony abnormalities on the femoral side, and then do a second-stage osteotomy on the socket."
That level of experience also allows for shorter operating times in selected patients. At Mayo Clinic, pelvic osteotomy can be done in an hour, compared with the four hours typically required. "We're a little bit unique at Mayo Clinic," says Robert T. Trousdale, M.D., a consultant in Orthopedic Surgery at Mayo's Minnesota campus. "Having done many pelvic osteotomies, we can do them well in less time."
Matching patients to the right procedures helps optimize outcomes. In a study published in the October 2016 issue of the American Journal of Sports Medicine, Mayo Clinic researchers found that among patients under the age of 55 who had primary hip arthroscopy for femoroacetabular impingement at Mayo Clinic, modified Harris Hip Score (HHS) improved from a mean score of 59 preoperatively to 81 at one year postoperatively. The mean age of patients studied was 37 years.
A study published in the March 2016 issue of the American Journal of Sports Medicine found improved clinical outcomes for young patients who had reverse (anteverting) periacetabular osteotomy performed at Mayo Clinic to treat isolated acetabular retroversion or retroversion in the setting of dysplasia. Average HHS improved from 58 preoperatively to 93 postoperatively among patients with isolated retroversion, and from 49 to 92 in the dysplastic group. The patients' mean age was 26 years.
"If patients are selected properly for various procedures and the procedures are performed well, the vast majority of both arthroscopies and open surgeries result in dramatic improvement in pain, function and activity levels," Dr. Trousdale says.
Although structural hip deformities are thought to predispose patients to degenerative joint changes, little is known about the natural history of these conditions. Mayo Clinic researchers are working to shed light on the long-term outlook for young people with hip deformities.
In a study published in the February 2017 issue of Clinical Orthopaedics and Related Research, the researchers found that, after mild degenerative change develops in the hip, patients with developmental hip dysplasia have a higher probability of progressing to end-stage osteoarthritis or total hip replacement compared with patients with femoroacetabular impingement or normal morphology.
"Early intervention for patients with dysplasia seems likelier to positively influence the natural history of their hips, compared with patients with impingement," Dr. Trousdale says.
Plans are underway to offer patient appointments at the Young Hip Clinic during designated periods of the week, to further expedite decision-making and patient care. "Because we're all together in one location — as opposed to having an arthroscopist in one hospital and an open surgeon across town, and trying to coordinate two surgeons' schedules — we're able to provide very efficient and effective care," Dr. Levy says. "It's really unique to have surgeons with varied expertise seeing patients together."
"The advantage is harnessing the team approach with experts in multiple areas of intra-articular and extra-articular hip disorders," Dr. Krych adds. "That allows us to perform a timely evaluation to arrive at the correct treatment plan, individualized for each patient."
For more information
Bryan AJ, et al. Are short-term outcomes of hip arthroscopy in patients 55 years and older inferior to those in younger patients? American Journal of Sports Medicine. 2016;44:2526.
Parry JA, et al. Midterm outcomes of reverse (anteverting) periacetabular osteotomy in patients with hip impingement secondary to acetabular retroversion. American Journal of Sports Medicine. 2016;44:672.
Wyles CC, et al. The John Charnley Award: Redefining the natural history of osteoarthritis in patients with hip dysplasia and impingement. Clinical Orthopaedics and Related Research. 2017;475:351.