7.9 Surgical options excluding total hip replacement for hip pain

This chapter outlines the main surgical options for hip pain excluding total hip replacement. The aim of surgery is to relieve pain and delay or halt further degenerative changes, negating the need for total hip replacement or delaying the age at which it needs to be implanted. The choice of treatment is dictated by the patient symptoms, underlying disease process, hip deformity, past treatment, and future patient expectations.

Due to the myriad of underlying causes of hip pain and arthritis in the young patient (see Chapter 7.7) not all, and likewise, perhaps more than one of the following surgical options may be employed during the course of management of the arthritic hip in the young adult.

For pain relief in patients with rheumatoid arthritis, juvenile idiopathic arthritis, and synovitis of the hip joint in the presence of minimal joint degeneration and absence of mechanical symptoms.

Used in conjunction with arthrogram and examination under anaesthesia to assess range of motion of hip joint and assessment for suitability of osteotomy (femoral, acetabular, or both) as well as verifying intra-articular nature of pain.

Should be performed under strict aseptic conditions with intraoperative fluoroscopy for correct placement of the needle. An anterolateral or direct lateral approach may be used. Injecting Omnipaque 300 dye confirms the needle is in the joint and helps outline the articular surface and aids in assessing joint congruency.

Intra-articular steroid and local anaesthetic do not alter disease progression radiographically and improvements in pain typically last for 12 weeks. Conflicting evidence in the literature exists regarding increased risk of infection in patients who have a subsequent total hip replacement shortly after their injection.

Any condition leading to significant muscle imbalance and spasticity can result in soft tissue contractures. This in turn can result in substantial acetabular erosion, femoral head subluxation/dislocation, and in the skeletally immature increased femoral neck anteversion and coxa valga. Neuromuscular conditions such as cerebral palsy and myelomeningocele result in intrinsic muscle imbalance with resultant contractures.

Spastic hip subluxation and dislocation are common problems in patients with cerebral palsy often leading to a painful joint with difficulties in mobility (in previously ambulating patients), sitting, personal hygiene, and care. The adducted hip can also result in pelvic obliquity and subsequent scoliosis. The adductor longus and variably the iliopsoas are contracted in these patients. Release of adductor longus is performed by a medial open or percutaneous method. Release of iliopsoas at the level of the lesser trochanter or at the pelvic brim (to prevent loss of flexion power) is also performed. Soft tissue releases have proved to be beneficial in the prevention of spastic hip dislocation and progressive hip dysplasia.

In juvenile idiopathic arthritis, inflammatory synovitis leads to pain and muscle spasm with subsequent joint contractures. Effusion of the joint also leads to pain, the joint is then held in the position of maximal joint space, thereby reducing joint pressure, which in the hip joint is 45 degrees of flexion in neutral rotation. In the presence of fixed contractures, surgical release of psoas and the adductors relieves pain and increases mobility and function. More aggressive surgical release, including rectus femoris with or without open synovectomy, may also be indicated.

Hip dysplasia with marked subluxation or dislocation, adult acquired neurological diseases such as stroke or Parkinson’s disease, and patients with longstanding hip pain can all develop muscle contractures around the hip joint. Patients undergoing a total hip replacement in the presence of tight adductors or iliopsoas may also benefit from surgical release to prevent deforming forces and improve range of motion and stability of the hip replacement.

Soft tissue releases have not shown to arrest or prevent degenerative changes in the hip joint radiographically or prevent the marked femoral neck anteversion seen in patients with juvenile idiopathic arthritis.

Only a few conditions exist which solely affect the synovium around the hip joint, resulting in pain with or without mechanical symptoms. Juvenile idiopathic arthritis can lead to severe synovitis resulting in debilitating pain and decreased function. Open synovectomy results in significant improvements in pain, mobility, and walking ability.

Primary synovial osteochondromatosis of the hip is a rare benign condition characterised by multiple intra-articular osteochondral loose bodies and synovial hyperplasia, which may result in mechanical symptoms and degenerative arthritis if untreated. Open synovectomy can reliably remove the loose bodies and alleviate symptoms.

Pigmented villonodular synovitis of the hip is a rare disease. Synovectomy is generally accepted as the only surgical treatment for the disorder.

Synovectomy is traditionally performed through a Smith-Petersen approach or open dislocation of the hip. The latter has slightly better results in terms of recurrence of the primary disorder but is associated with increased morbidity. Synovectomy can also be performed arthroscopically.

Reconstructive acetabular osteotomy is indicated in young active adults with symptomatic hip dysplasia and only mild arthritic changes as seen radiographically. Hip joint congruency is essential to the success of the operation and can be confirmed by preoperative imaging with either an anterior-posterior (AP) radiograph of the hip with the leg in abduction, on three-dimensional computed tomography (CT) reconstructed images. The false profile radiograph is a true lateral radiograph of the symptomatic acetabulum taken with the patient standing. The false profile radiograph is important as some patients who have dysplasia of the hip have nearly normal findings on AP radiographs and the lack of anterior coverage of the head is seen only on the false profile radiograph.

Examination under fluoroscopy with radio-opaque dye injected in the hip joint allows for a dynamic assessment of the joint congruency and can also help detect subtle labral pathology. The aim of the osteotomy is to return the hip joint to as near as normal anatomy and biomechanics, with improvements in pain and prevention of further degenerative changes. Reconstructive osteotomies include the Bernese periacetabular osteotomy, triple osteotomy and dial osteotomy. Where the hip joint is not congruent because of severely distorted anatomy, a salvage osteotomy is undertaken. These procedures rely on metaplasia of the capsule to fibrocartilage and therefore do not provide a long-lasting reconstruction. Common salvage procedures include the Chiari and shelf osteotomy.

Patients with inflammatory conditions; patients older than 50 years; the presence of arthritis or marked obesity. The presence of joint incongruence precludes any reconstructive osteotomy. Smokers should be cautioned of an increased risk of non-union.

The Bernese periacetabular osteotomy developed by Ganz and colleagues in the early 1980s is currently the most popular reconstructive pelvis osteotomy. The numerous advantages of this procedure include the need for only one incision, the use of three straight and reproducible bony cuts, the large range of correction possible with medialization of the hip joint centre, anterior and lateral rotation, version correction, preservation of a portion of the posterior column allowing for early partial weight bearing, and minimal internal fixation and no change in the diameter of the true pelvis therefore not interfering with child birth. The risk of non-union of the osteotomized fragment is negligible due to preservation of its blood supply. The procedure also allows for intra-articular assessment and repair if required of the labrum, as well as treatment of femoroacetabular impingement.

The longest follow-up to date by Ganz and colleagues at a mean 20 years, reports joint preservation of 60% at latest follow-up. Poor outcome was associated with pain and low functional scores preoperatively, severity of arthritis, positive anterior impingement test, limp, and age at surgery. Patient selection is therefore key to the success of this procedure. Previous Bernese periacetabular osteotomy does not compromise the results of subsequent total hip replacement.

The periacetabular osteotomy is performed through an abductor-sparing Smith-Petersen approach. Sequential soft tissue and bony steps as described by Ganz are performed which then allow for mobilization and correction of the acetabulum. The key aims in correction are:

The triple osteotomy includes cuts of the ilium, ischium, and pubis through three separate incisions. The acetabulum is then rotated to provide increased femoral head coverage. Although this is technically easier to perform than the dial or Ganz periacetabular osteotomy, the coverage it provides is less adequate (since the cuts are farther away from the acetabulum) and has the potential for non-union at the osteotomy sites because of inability to achieve adequate internal fixation. Steels osteotomy involves ischial cuts at a distance from the joint. The modified Tonnis osteotomy (see Figure 7.9.1) involves bony cuts closer to the joint. As the sacrotuberous and spinous ligaments are not violated, the mobility of the osteotomized fragment is limited. Large corrections with a triple osteotomy can result in pelvic deformity and as the posterior column is disrupted fixation of the osteotomized fragment can be compromised.

The dial osteotomy described by Eppright is one of a number of spherical osteotomies, mainly favoured in the Far East. It provides for excellent coverage with complete redirection of the acetabular articular surface. It is rarely used because it is extremely technically demanding and carries a high risk of penetration into the hip joint and resultant damage of the acetabular articular cartilage. Alternative surgical procedures, such as the Ganz periacetabular osteotomy, can achieve the same result with a less technically demanding and reproducible procedure.

This procedure is reserved for non-congruent joints. The iliac bone is osteotomized just above the hip joint surface to the inferior part of the sciatic notch. The inferior segment of the pelvis is then displaced medially, resulting in increased femoral head coverage and medialization of the hip centre. Capsule is interposed between the femoral head and the proximal shelf of bone. This capsular tissue undergoes metaplasia into fibrocartilage. Long-term review of the Chiari pelvic osteotomy found that most patients had progressive degenerative changes and almost a third had severe pain at follow-up at 14 years. Outcome was enhanced when no preoperative arthritic changes were present, in younger patients, and a hip that was painless at the time of surgery.

Chiari osteotomy has no adverse effect clinically or radiographically on later hip replacement. It did, however, require less bone grafting and achieved better coverage by host bone when compared with hip replacements in dysplastic hips.

This procedure involves using a corticocancellous graft to augment the anterolateral aspect of the acetabulum and to act as a buttress, increasing joint stability. The hip joint centre is unaffected as is the relationship of the femoral head with the acetabulum. This procedure is typically used in children with incongruent joints. Recent study in adults who underwent shelf osteotomy for symptomatic hip dysplasia revealed a survivorship with conversion to hip replacement as an end-point of 86% at 5 years and 46% at 10 years. In patients who had slight or no narrowing of the joint space preoperatively, the survival rose to 97% at 5 and 75% at 10 years.

One of the original and, to this day, main indications for proximal femoral osteotomy is the treatment of non-union of femoral neck fractures. A valgus osteotomy converts a shear force across the non-union site into a compressive force and this induces healing. In one study, 93% of hips went on to heal using this technique.

Pauwel is credited for introducing the concept of varus and valgus proximal femoral osteotomies as a method of increasing the weight-bearing surface across the femoral head. He believed that ‘osteoarthritis results when abnormal forces act on normal tissue, or when normal forces act on damaged tissues’ and treatment should therefore be directed at increasing joint congruency, which in turn results in a greater surface area and decreased load per unit area of the articular cartilage. Bombelli later added flexion and extension osteotomy in the sagittal plane to further optimize joint congruency.

Other indications for the use of proximal femoral osteotomy include correcting post-traumatic deformity, and treating healed slipped upper femoral epiphysis (SUFE) using a flexion with or without rotation osteotomy. Acquired varus deformity with hinge abduction following Legg–Calve–Perthes disease is corrected with a valgus extension osteotomy. The treatment of hip dysplasia with a varus (derotation) osteotomy is usually performed in conjunction with a pelvic osteotomy.

In the management of osteonecrosis a variety of osteotomies have been described, varus, valgus, flexion, extension, combined, or rotational all with the intention of moving the osteonecrotic area away from where it would transmit weight.

Careful and meticulous preoperative planning is required to ensure a successful result. The position of ‘best fit’ and ‘improved patient comfort’ is key to achieving this. During preoperative examination it is important to assess the degree of passive movement, in particular adduction and abduction across the hip. Following a varus osteotomy there will be loss of abduction, the minimum amount of abduction required prior to surgery is the amount of varus required plus 10 degrees, otherwise a fixed adduction contracture will ensue. Likewise, a valgus osteotomy will result in loss of adduction; therefore to avoid any abduction contracture postoperatively the patient should have at least the required angle in adduction.

Preoperative imaging with an AP of the hip taken in adduction/abduction is necessary. A false profile lateral view also reveals any anterior uncovering which may require correction. Magnetic resonance (MRI) scans are useful in isolating the osteonecrotic area in a patient with osteonecrosis of the hip. CT scans and hip arthrograms are also extremely useful in planning the corrective osteotomy and used according to surgeon preference. The latter, however, gives a dynamic understanding of the hip joint and allows for accurate assessment of position of ‘best fit’.

Patients undergoing a varus osteotomy typically have lateral subluxation of the femoral head, associated with coxa valga. Following the osteotomy, the affected limb will be shortened and patients should be informed of this. Valgus osteotomy should result in reduced lateral impingement and an improvement in joint space on AP pelvis with the hip in adduction. It should also result in normalization of the relationship between the tip of the greater trochanter and the centre of the femoral head. In varus osteotomy the femoral shaft should be medialized, and in a valgus osteotomy the femoral shaft requires lateralization to avoid any alteration to the mechanical axis of the limb.

The affect on limb length and any resulting discrepancy following an osteotomy should be discussed in depth with patients preoperatively to ensure patient satisfaction.

Femoral osteotomy may distort the local anatomy which may jeopardize any future total hip replacement and this has to be taken into consideration by the operating surgeon. Best results are typically found in the young, non-obese patient with a good range of motion preoperatively.

A study of 26 varus proximal femoral osteotomies for hip dysplasia in adults with a mean follow-up of 5 years reported no conversions to total hip replacement in the review period. There was significant improvement in symptoms and function with one case of non-union which was successfully revised. Best results were obtained in patients with long-leg dysplasia.

A review of intertrochanteric valgus-extension osteotomy performed for osteoarthritis reported 67% of the hips were good or excellent at final review. Better results were obtained in patients under 40 years of age with unilateral involvement and a mechanical (secondary) aetiology.

Rotational proximal femoral osteotomy for the treatment of osteonecrosis is associated with a high incidence of complications (55%). Another study of rotational osteotomy carried out in 18 hips in 17 patients at a mean follow-up of 5 years for osteonecrosis revealed satisfactory results in only three hips (17%) and 12 hips had been revised to total hip replacement; 83% of the patients had additional collapse. Varus and valgus osteotomies performed better with 74% and 85% good or excellent results respectively at medium-term review.

A previously osteotomized hip may be difficult to convert to a total hip replacement. Complicating factors include hardware removal, deformity of the proximal femur leading to inadequate prosthetic fit and fixation, or to intraoperative femoral fracture and risk of infection. In one large series of 305 total hip replacements in 290 patients who had a previous intertrochanteric osteotomy, it was noted that the operative time was longer and blood loss was somewhat greater than for primary total hip replacement. Technical difficulties were encountered in 23% of cases. The overall probability of failure at 10 years was 20.6%. The incidence of positive tissue cultures from the osteotomy site was 9%, and that of broken plates or screws 24.3% at the time of total hip replacement. Removing hardware as soon as bony union has been obtained as well as maintaining proximal femoral alignment with the femoral shaft on coronal and sagittal planes may facilitate and improve results of subsequent total hip replacement.

See Chapter 7.18.

See Chapter 7.7.

Once the preferred treatment of choice for end-stage osteoarthritis, the popularity of this procedure has faded as that of total hip replacement has risen since the early 1970s. The procedure is rarely performed today and most orthopaedic surgeons are inexperienced in its use, making it even less of an attractive option.

In adolescents and young adults with severe end-stage arthritis affecting a single joint, reconstructive and salvage procedures as discussed earlier may not be suitable. While total hip replacement offers the potential for immediate pain relief and good results in the short to medium term with regards to function, there remains considerable concern and reservation about the long-term outcome and durability of its use in the young active patient. Several long-term studies have shown that hip arthrodesis successfully relieves pain and allows patients to lead active lives.

The ideal patient is classically described as a young active male manual labourer who wants to return to work. In general, patients should be younger than 30 years of age and have end-stage monoarticular osteoarthritis. Ideal candidates are those with post-traumatic arthritis, osteonecrosis, and patients who have had sepsis such as tuberculosis. Patients should not have low back pain, ipsilateral knee pain, or contralateral hip pathology. MRI screening of the contralateral hip should be performed in patients with osteonecrosis to rule out early disease.

Hip arthrodesis can be achieved with the use of a Cobra plate applied to the lateral aspect of the femur and ilium. To gain access to the femoral head and acetabulum, a trochanteric osteotomy is performed which is then fixed over the plate. The Iowa technique involves performing a Chiari type osteotomy while the Vancouver technique avoids the need for this by medializing the socket.

Further techniques have been developed to avoid violation of the abductor mechanism which occurs using the earlier described techniques. Preservation of the abductors is important as the arthrodesed hip may be a stop-gap measure to delay a total hip replacement or a patient may choose to have a fused hip converted to a total hip replacement. Abductor-sparing techniques include the use of a dynamic compression screw and anterior plating (Figure 7.9.5). The hip should be arthrodesed in a position of 30 degrees of flexion, 5–10 degrees of adduction, and 10 degrees of external rotation. Abduction and internal rotation are associated with poor results.

The functional limitations of hip arthrodesis relate to the loss of hip flexion, with difficulty in prolonged sitting in confined spaces, bending, putting on socks, and sexual activity. It is unclear whether patients today are willing to accept these limitations. The main long-term complication of hip arthrodesis is associated low back pain in up to two-thirds of patients, ipsilateral knee pain in half, and contralateral hip pain in a fifth of patients. Patients fatigue more easily due to the increased energy expenditure when walking. The main advantage is the relief of pain, return to active lifestyle, and preservation of bone stock.

Conversion of a fused hip to a total hip arthroplasty is generally associated with a favourable outcome. However, the technically demanding nature of the procedure should not be underestimated. Patients should be informed preoperatively of the possibility of a higher complication rate than that seen with primary total hip replacement.