Hip replacement surgery provides pain relief and improved function for patients with advanced hip disease, but it’s not a great solution for young people.
“For an adolescent or young adult patient — really for any patient under 50 — a hip replacement is sub-optimal because of activity restrictions and the fact that the synthetic hip joint is likely to wear out with time,” says John C. Clohisy, M.D., assistant professor of orthopaedic surgery at Washington University School of Medicine in St. Louis. “A patient who gets a hip replacement at a very young age may require multiple hip surgeries over the course of their lifetime.”
Clohisy, who is on staff at Barnes-Jewish Hospital, is one of a growing number of surgeons interested in preserving a person’s natural hip while correcting defects in the joint.
The hip joint is commonly thought of as a “ball and socket.” The “ball” is the top of the thighbone, called the femoral head. It rests within the hip’s “socket,” known as the acetabulum. The hip’s ball and the socket are covered by cartilage, which allows for smooth and painless motion. But if there’s an underlying defect, the cartilage can deteriorate. As that happens, a person may have pain. At first, it occurs after physical activity, but over time, as the pain becomes more frequent, many people have hip pain even at rest.
That’s when they become candidates for osteotomy surgery.
“Most of these patients have an underlying deformity of the hip socket called hip dysplasia, and many have some degree of osteoarthritis,” Clohisy says. “So as they get older, it’s likely that they may need a hip replacement. Our goal is to surgically delay the progression of osteoarthritis and to prolong the life of their true hip joint.”
To do that, Clohisy and colleagues radically change the hip’s structure. In an operation that takes two to four hours, he cuts the bones around the hip socket and repositions them.
The particular technique he uses is called the Bernese Peri-Acetabular Osteotomy. The operation isn’t for everybody. Clohisy says it’s designed for relatively young, healthy patients. Those with multiple medical problems or advanced arthritis are not good candidates. The patients don’t need a cast, but they do need to stay in the hospital for several days and walk with crutches for several weeks.
Christopher Mackey didn’t realize he needed hip surgery. For several months, he didn’t really know what was wrong. All he knew was when he pitched a baseball, there was a popping sound coming from his left hip. At first, there wasn’t really any pain involved, but then his groin muscle started to hurt. It turned out the groin was being aggravated by the deformity in his hip, the same deformity that caused it to pop.
“One way to explain why these patients don’t get symptoms until they are young adults is that the cartilage in the hip can function in an adverse environment for a long time. But eventually, just as the tread on a tire will go bad, when a patient has underlying problems, their cartilage begins to wear out over time, and treatment becomes necessary,” Clohisy says.
Christopher Mackey was diagnosed with congenital hip dysplasia. In the past, treatment for disorders like Christopher’s frequently involved little more than restriction of activities, anti-inflammatory medicines and painkillers.
In the past, an adolescent with hip disease could look forward to pain, difficulty getting around and doctor’s orders to stop doing things that put stress on the hip joint. The patients were too young for hip replacement surgery and too old for the pediatric procedures used to correct deformities in very young children. In fact, 10 to 15 years ago, many young adult patients did not get definitive treatment for their hip problems.
Young athletes make up a significant part of Clohisy’s surgical practice. After osteotomy surgery, many have returned to high-level competition. However, he discourages them from taking up repetitive-impact activities. His patients have returned to cycling, swimming, hiking, golf, tennis and even pitching.
Clohisy and Perry L. Schoenecker, M.D., professor of orthopaedic surgery and chief of pediatric orthopaedics at St. Louis Children’s Hospital and at Shriners Hospital for Children, surgically repaired Christopher Mackey’s left hip on Valentine’s Day of 2003. When baseball season started in March of that year, he had to watch his team from the dugout.
Christopher’s right hip also needed surgery, but he came back to pitch his senior season last spring, during which he featured a 92 mile-per-hour fastball. His right hip was repaired after the season in June.
“With advances in the surgical technique, we can give patients a hip joint that is very functional and can allow them to be active and to enjoy several healthy years of life,” Clohisy says. “Most patients experience major relief and have very little, if any, hip pain after the operation.”
Luckily, Christopher can look forward to doing many things he would not be able to do without surgery. He plans to pitch in college next spring for Southwest Missouri State, where he was able to earn a baseball scholarship. And who knows, if his pitching can improve as much as his hips have, he might go a long way.
Washington University School of Medicine’s full-time and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children’s hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked second in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children’s hospitals, the School of Medicine is linked to BJC HealthCare.