Hip Preservation Surgery: Types, Candidates, and Procedures

What are the different types of hip preservation surgery?

Hip preservation surgery encompasses a range of advanced orthopedic procedures, primarily categorized into arthroscopic (minimally invasive) and open surgical techniques, all designed to correct anatomical or pathological issues within the hip joint, thereby aiming to alleviate pain, restore function, and delay or prevent the need for total hip replacement.

Understanding Hip Preservation Surgery

Hip preservation surgery refers to a specialized field of orthopedics focused on maintaining the natural hip joint. Unlike hip replacement, which substitutes the damaged joint with an artificial one, preservation surgery aims to address the root causes of hip pain and dysfunction, often stemming from structural abnormalities or early degenerative changes. The overarching goal is to restore normal hip mechanics, reduce pain, and prevent or postpone the progression of osteoarthritis, thereby improving the patient's long-term quality of life and activity levels. These procedures are grounded in a deep understanding of hip biomechanics and anatomy.

Candidates for Hip Preservation Surgery

Ideal candidates for hip preservation surgery are typically younger, active individuals (often under 50-60 years old) who have not yet developed severe osteoarthritis. They usually present with specific structural abnormalities or conditions that, if left untreated, would likely lead to significant joint degeneration. Common conditions include:

• Femoroacetabular Impingement (FAI)
• Hip Dysplasia (shallow hip socket)
• Labral Tears
• Ligamentum Teres Tears
• Early-stage Avascular Necrosis (AVN)
• Capsular Laxity or Instability

A thorough diagnostic workup, including physical examination, advanced imaging (X-rays, MRI, CT scans), and sometimes diagnostic injections, is crucial to determine candidacy.

Common Types of Hip Preservation Surgery

Hip preservation procedures can be broadly categorized into arthroscopic (minimally invasive) and open (traditional incision) techniques, each suited for different conditions and anatomical corrections.

Arthroscopic Hip Preservation Procedures

These are minimally invasive surgeries performed using a small camera (arthroscope) and specialized instruments inserted through tiny incisions. They are favored for addressing issues within the joint capsule.

• Hip Arthroscopy for Femoroacetabular Impingement (FAI)

  • Description: This is one of the most common arthroscopic hip preservation procedures. FAI occurs when extra bone grows along one or both of the bones that form the hip joint – the femoral head (ball) or the acetabulum (socket) – leading to abnormal contact and impingement during movement.
  • Treatment: The surgeon uses a burr to reshape the bone on the femoral head/neck (cam impingement) and/or the acetabular rim (pincer impingement), a process called osteochondroplasty. Concurrently, associated labral tears are often repaired or, if severely damaged, reconstructed.
  • Goal: To eliminate abnormal bone contact, restore normal hip range of motion, alleviate pain, and protect the labrum and articular cartilage.

• Hip Arthroscopy for Labral Tears (Isolated)

  • Description: The labrum is a ring of cartilage that deepens the hip socket and provides stability. Tears can occur due to trauma, FAI, or degeneration.
  • Treatment: Depending on the tear's nature, the surgeon may perform a labral debridement (removing damaged tissue), repair (suturing the torn labrum back to the bone), or reconstruction (replacing the damaged labrum with a graft).
  • Goal: To reduce pain, restore the sealing function of the labrum, and improve hip stability.

• Hip Arthroscopy for Ligamentum Teres Tears

  • Description: The ligamentum teres is a small but important ligament connecting the femoral head to the acetabulum, contributing to hip stability and proprioception. Tears can cause pain and instability.
  • Treatment: Debridement of the torn ligament or, in select cases, reconstruction.
  • Goal: To alleviate pain and improve hip stability.

• Hip Arthroscopy for Synovitis and Loose Bodies

  • Description: Synovitis (inflammation of the joint lining) or the presence of loose fragments of cartilage or bone within the joint can cause pain, catching, and mechanical symptoms.
  • Treatment: Synovectomy (removal of inflamed synovium) and removal of loose bodies.
  • Goal: To reduce inflammation, eliminate mechanical symptoms, and alleviate pain.

Open Hip Preservation Procedures

These procedures involve a larger incision to gain direct access to the hip joint. They are typically reserved for more complex anatomical corrections, especially those involving significant bone reshaping.

• Periacetabular Osteotomy (PAO)

  • Description: The most common open procedure for hip dysplasia, a condition where the hip socket (acetabulum) is too shallow or improperly oriented, leading to inadequate coverage of the femoral head.
  • Treatment: The surgeon makes precise cuts (osteotomies) around the acetabulum, carefully repositions it to provide better coverage of the femoral head, and then fixes it in the new position with screws.
  • Goal: To improve hip stability, normalize weight-bearing forces, alleviate pain, and prevent or delay the onset of osteoarthritis.

• Surgical Hip Dislocation (Ganz Technique)

  • Description: This highly specialized open procedure involves temporarily dislocating the femoral head from the acetabulum to provide unhindered access to the entire joint. This technique allows for comprehensive treatment of complex FAI, osteonecrosis of the femoral head, or other intra-articular pathologies that cannot be adequately addressed arthroscopically.
  • Treatment: After dislocation, the surgeon performs necessary procedures such as osteochondroplasty for FAI, removal of bone cysts, or treatment of osteonecrosis. The femoral head is then carefully reduced back into the socket.
  • Goal: To address complex intra-articular issues with direct visualization, restore hip anatomy, and preserve the joint.

• Femoral Osteotomy

  • Description: This procedure involves cutting and realigning the femur (thigh bone) itself. It's used to correct deformities in the femoral head or neck, such as excessive femoral anteversion (femur rotated too far forward) or retroversion (femur rotated too far backward).
  • Treatment: A section of the femur is cut, rotated to the correct alignment, and then fixed with plates and screws.
  • Goal: To improve hip mechanics, reduce stress on the joint cartilage, and alleviate pain caused by abnormal rotational alignment.

Emerging and Adjunctive Procedures

Beyond the primary surgical techniques, several other procedures or augmentations may be used in conjunction with or as standalone treatments:

• Biologic Augmentation: The use of platelet-rich plasma (PRP) or mesenchymal stem cells (MSCs) to enhance healing, particularly for labral repairs or cartilage defects.
• Capsular Plication/Repair: For patients with hip instability or capsular laxity, the joint capsule may be tightened or repaired to improve stability.

Post-Operative Rehabilitation and Outcomes

Regardless of the specific procedure, post-operative rehabilitation is a critical component of successful hip preservation surgery. A structured physical therapy program, often lasting several months, is essential to:

• Restore range of motion
• Regain strength and stability
• Improve proprioception and neuromuscular control
• Facilitate a safe return to activity

Outcomes vary depending on the patient's age, the underlying condition, the extent of pre-existing cartilage damage, and adherence to rehabilitation protocols. Many patients experience significant pain relief and improved function, allowing them to return to desired activity levels and potentially avoid or delay total hip replacement for many years.

Conclusion

Hip preservation surgery represents a significant advancement in orthopedic care, offering tailored solutions for complex hip pathologies. By addressing the root causes of hip pain and dysfunction, these procedures aim to maintain the natural hip joint, improve patient quality of life, and extend the lifespan of the native hip. A multidisciplinary approach, involving skilled surgeons, physical therapists, and dedicated patients, is paramount for achieving optimal long-term results.