Surgeons Move From Knees to Hips
Washington Post Staff Writer
Tuesday, April 28, 2009
Since the 1980s, arthroscopic surgery has been a common solution for people suffering pain in the knee or shoulder, providing a minimally invasive way to repair such injuries as torn ACLs and rotator cuffs. But those experiencing hip pain or stiffness have had more-limited options.
"Most people, especially athletes, when they had hip symptoms, usually they just got diagnosed as a chronic groin pull," said J.W. Thomas Byrd, a Nashville orthopedist who specializes in sports medicine and hip injuries. Rest and physical therapy might be prescribed, but no other solutions were available. Byrd also noted that because it's difficult to get standard surgical instruments into the hip safely, it has been "a bit more of a challenging joint to tackle" than the knee or shoulder.
But that's changing. In the past 10 to 15 years, doctors have discovered one specific cause of hip pain: a tear in the acetabular labrum, a condition in which the cartilage that lines the hip socket is damaged. And they've found that it can be fixed using arthroscopic surgery, which uses narrow instruments inserted through smaller incisions than traditional surgery.
New York Yankees star Alex Rodriguez recently made headlines when he opted to have arthroscopy on such a tear in his right hip, a decision that has him sidelined from baseball for weeks.
Derek Ochiai, a surgeon with the Nirschl Orthopaedic Center in Arlington, who began performing hip arthroscopy six years ago, estimates that he did only about a dozen of the procedures that year. Now, he performs more than 100 annually.
Ochiai also occasionally serves as an instructor at the Orthopaedic Learning Center, a surgeon's training lab in Rosemont, Ill., where he said three sessions are offered each year in hip arthroscopy and all are booked solid. This is a marked uptick from a decade ago, when Ochiai said the single course in hip arthroscopy was nearly canceled due to lack of interest.
The labrum is a thin ring of cartilage that lines the acetabulum, or hip socket. It acts as a cushion when the leg bends and provides stability to the joint. Left untreated, labrum tears can lead to arthritis. So, indirectly, "hip arthroscopy may be a way of delaying or even possibly preventing hip arthritis," Ochiai said.
These tears are not detectable by X-ray, and though they usually can be seen by MRI, even those images can sometimes be inconclusive. Ochiai said many patients see three or four orthopedists before getting a proper diagnosis.
There are several causes for labrum tears, but rigorous physical activity or stress is almost always a factor. Also, doctors often find some structural flaw in the hip joint, most commonly femoral acetabular impingement, known as FAI. This means that a bone deformity causes the ball and socket to rub against each other in a way that pinches the labrum. Doctors say FAI is not something a patient is born with; rather, it develops in adolescence, for unknown reasons. Byrd said it is more common in men than in women.
During arthroscopic surgeries on the labrum, doctors can fix the FAI by shaving down the bony defect.
Recovery time varies. When minimal work is done, it can be four to six weeks; when FAI is corrected, it can be more like three to four months.
Why has it taken so long for hip arthroscopy to catch up to its shoulder and knee counterparts?
"The big difference is that with the knee, most of the things we're doing arthroscopically evolved from things we were doing in open surgery," Byrd said. With the hip, however, doctors using arthroscopes discovered a host of conditions, including labrum tears and FAI, that had not been recognized. As a result, surgeons are trying to find remedies for problems that, Byrd said, had received "no treatment at all" in the past.
Plus, surgical techniques have improved. Byrd said that five to 10 years ago, the focus was on "cleaning it up," meaning taking out problem-causing bits of cartilage. While that is still done, restorative techniques have been introduced that allow for the preservation of the labrum instead of its removal.