Hip arthroscopy success and failure rates and non-surgical options

Ross Hauser, MD; Danielle Matias, PA-C

If you are reading this article you likely have a somewhat lengthy medical history of hip problems and you have graduated to the point where the various surgical options are now being discussed with you. You may have just returned from a follow-up visit to your orthopedic surgeon. You may have gotten a prescription for stronger pain medications, cortisone, or hyaluronic acid injections to help hold you over until surgery can be performed.

Over time your orthopedic surgeon may have been exploring conservative care options for you but now you have more pain and more hip instability following these treatments. Your hip may be making a lot of noise such as grinding, clicking, and popping as a signal to you that something is not right.

So now you are in a situation where a hip preserving (not a replacement) arthroscopic surgery may be recommended. Your situation may be a little more concerning in that your surgeon is telling you there is a very good chance the surgery will not work that well and that you may need to be managed along until such time that you can get a hip replacement. But why wouldn’t arthroscopic surgery work for you? Maybe the surgery is not addressing the cause or the pain.

Article summary:

  • One of the reasons that a hip arthroscopic procedure may fail is that the hip arthroscopic procedure did not address the actual cause of the patient’s pain. The surgery is performed, the pain remains.
  • Why was arthroscopic hip surgery recommend to you?

Higher risk factors

  • “Understanding risk factors for conversion to total hip replacement or revision is paramount during discussions with patients.”
  • Who are the high-risk groups for failed hip arthroscopic surgery? People who already had failed hip arthroscopic surgery.
  • Who are the high-risk groups for failed hip arthroscopic surgery? People with bone spurs, hip impingement, and hip instability.
  • Who are the high-risk groups for failed hip arthroscopic surgery? People who had an incomplete surgery.
  • So why are you being recommended to hip arthroscopic surgery?
  • People think it is time for surgery when his/her leg is giving out or gets stuck.
  • “Iatrogenic (surgery causing) gross hip instability following hip arthroscopy is a concerning complication described in the recent orthopedic literature.”

Post-surgical complications

  • A patient case from Caring Medical. Two cortisone injections, two failed arthroscopic procedures.
  • Hip preserving arthroscopic surgery complications and concerns.
  • Does hip preserving arthroscopic surgery lead to hip replacement anyway? The evidence.
  • A study of 1013 patients who had undergone Joint-preserving surgery of the hip.
  • The doctors analyzed the overall failure rates and modes of failure.
  • Opioid-related complications in hip arthroscopy.
  • Doctors warn patients that joint-sparing surgery may complicate the eventual hip replacement in patients over 50.
  • Hip preserving arthroscopic surgery or Hip Replacement?

When you should consider surgery and when it is realistic to expect surgery can be avoided.

  • Hip injections. Can they help you?

One of the reasons that a hip arthroscopic procedure may fail is that the hip arthroscopic procedure did not address the actual cause of the patient’s pain.

Hip arthroscopy success and failure rates and non-surgical options

One of the reasons that a hip arthroscopic procedure may fail is that the hip arthroscopic procedure did not address the actual cause of the patient’s pain. The surgery is performed, the pain remains.

A problem in the hip may commonly manifest itself as groin or inguinal pain. Someone suffering from groin pain should be examined at the pubic symphysis, sacroiliac joint, iliolumbar ligaments, and hip joint. Pain from the hip joint may also be felt locally, directly above the hip joint in the back. When the hip joint becomes loose and unstable, the muscles over the joint compensate for the looseness by tensing or spasming. As is the case with any joint of the body, loose ligaments or ligament laxity initiate muscle tension in an attempt to stabilize the joint.

This compensatory mechanism to stabilize the hip joint eventually causes the gluteus medius, piriformis muscle, and iliotibial band/ tensor fascia lata muscles to tighten because of chronic contraction in an attempt to compensate for a loose hip joint. The contracted gluteus medius can eventually irritate the trochanteric bursa, causing a trochanteric bursitis. A bursa is a fluid-filled sac which helps muscles glide over bony prominences. Patients with chronic hip problems often have had cortisone injected into this bursa, which generally brings temporary relief. But this treatment does not provide permanent relief because the underlying ligament laxity is not being corrected.

Someone suffering from groin pain should be examined at the pubic symphysis, sacroiliac joint, iliolumbar ligaments, and hip joint.

In the image below the various hip, spine and pelvic ligaments are shown.

omeone suffering from groin pain should be examined at the pubic symphysis, sacroiliac joint, iliolumbar ligaments, and hip joint.

Hip arthroscopy may fail because of the complexity of the hip-spine relationship.

The interrelation ship between muscles, ligaments and nerves in the hip is seen in the image below. The muscles, specifically the gluteus medius, piriformis muscle, and iliotibial band/ tensor fascia lata muscles to tighten because of chronic contraction in an attempt to compensate for a loose hip joint. These spasms can interact on the nerve causing sciatica-like symptoms as well.

Hip arthroscopy muscle spasms

Why was arthroscopic hip surgery recommend to you? Diagnosis: Avascular necrosis of the femoral (AVN) head

Many people suffering from bone death (avascular necrosis) may be recommended to arthroscopic surgery as opposed to total hip replacement. This recommendation is based on the good news that the femoral head (the ball of the ball and socket). Please refer to our article Treating avascular necrosis of the femoral head without hip replacement, for a very detailed discussion.

Why was arthroscopic hip surgery recommend to you? Acetabular or Hip Labral Tears

If you have been experiencing symptoms of catching/locking, popping/clicking noises in your hip it is likely that you have been told that you have a hip labrum tear. The labrum is the soft tissue/ cartilage that holds the ball of the hip in the socket of the hip. Arthroscopic surgery will remove tissue that is damaged /torn or try to sew up the tear. In our article Non-surgical Treatment of Acetabular or Hip Labral Tears, we discuss conservative care treatments, regenerative medicine injections, and surgical outcome studies.

Why was arthroscopic hip surgery recommend to you? Femoroacetabular Impingement

In Femoroacetabular Impingement, tissue is impinged. How did the tissue get caught between boney structures which is the impingement? If the cause is some tremendous structural problem with the hip such as a dysmorphic (an anatomic deformity) problem or orientation problem of the femur, then surgical correction may be needed. There are two types of femoroacetabular impingement. Both types of FAI can cause premature osteoarthritis of the hip because both types progress to hip labral and cartilage damage.

“Understanding risk factors for conversion to total hip replacement or revision is paramount during discussions with patients.”

For some people hip arthroscopic surgery can be very beneficial. These are typically not the people we see in our offices. We see the people for whom the surgery did not help as much as had been hoped for and now the patients are trying to figure out their next move. Hip replacement, maybe more arthroscopic surgery, other options.

In the surgical journal Orthopedics (1), researchers wrote in May 2020:

“Hip arthroscopy for femoral and acetabular pathologies has increased dramatically. However, there is little literature analyzing procedures as predictors of revision arthroscopy or arthroplasty.” (In other words, there are a lot of surgeries and there is really no studies that suggest how many of these hip arthroscopes needed to be redone in a “revision surgery,” or how many of these surgeries did not work out and wound up turning into eventual hip replacement surgeries.)

What the researchers in this study did was to go back and look at patients undergoing first-time hip arthroscopy for a labral tear with a minimum 2-year follow-up and between 18 and 60 years old.

  • Follow-up was obtained for 1118 patients (1249 hips) with an average age of 38.7 years (range, youngest patient in the study was 18, the oldest was 60.)
  • Many patients in the study were considered overweight – average body mass index of 26.4
  • The average follow up was about 50 months
  • It took about three years for those patients who had hip arthroscopy that failed, to be sent to total hip replacement
  • It took about 21 months for those patients who had first-time hip arthroscopy that failed to be sent to second-time or revision hip arthroscopy.

Conclusion: “Understanding risk factors for conversion to total hip replacement or revision is paramount during discussions with patients.”

Who are the high-risk groups for failed hip arthroscopic surgery? People who already had failed hip arthroscopic surgery

Many patients we see come in after undergoing an arthroscopic hip surgery that did offer the hope or promise of pain relief that the patient thought would be the outcome of their procedure.

A July 2020 study published in The Bone & Joint Journal (2) and lead by Cambridge University Hospitals in the United Kingdom found that “the most frequently reported risk factor related to a less favorable outcome after hip arthroscopy was older age and preoperative osteoarthritis of the hip. (The more surgeries the higher the risk for failure). . . . Athletes (except for ice hockey players) enjoy a more rapid recovery after hip arthroscopy than non-athletes.

Who are the high-risk groups for failed hip arthroscopic surgery? People with bone spurs, hip impingement, and hip instability

A July 2020 paper in The Journal of the American Academy of Orthopaedic Surgeons (3) stated:

“There has been an exponential increase in the diagnosis and treatment of patients with femoroacetabular impingement, leading to a rise in the number of hip arthroscopies done annually. Despite reliable pain relief and functional improvements after hip arthroscopy in properly indicated patients, and due to these increased numbers, there is a growing number of patients who have persistent pain after surgery.

The etiology of these continued symptoms is multifactorial, and clinicians must have a fundamental understanding of these causes to properly diagnose and manage these patients. Factors contributing to failure after surgery include those related to the patient, the surgeon and the postoperative physical therapy.”

The common causes of failure, residual bony deformity (what’s left of incomplete bone spur removal causing still causing hip impingement) as well as a capsular deficiency (degenerative hip instability).

Who are the high-risk groups for failed hip arthroscopic surgery? People who had an incomplete surgery

In the above study, residual bony deformity is cited as the main problem in failed hip arthroscopic surgery. Five years earlier in 2015, doctors writing in the Clinical Orthopaedics and Related Research (4) suggested that in reviewing patients who had failed hip arthroscopic surgery, they found “marked radiographic evidence of incomplete correction of deformity in patients.”

So why are you being recommended to hip arthroscopic surgery? People think it is time for surgery when his/her leg is giving out or gets stuck

If you went to your surgeon, he/she may explain to you that you are being recommended to hip arthroscopic surgery in an effort to save or preserve your hip. One of the great benefits of this surgery, you are told, is that it will fix the things such as labrum tears and the loss of cartilage through microfracture, which will stop the progression of osteoarthritis and help you avoid hip replacement.

Most people who come to see us for non-surgical hip pain options are recommended to surgery and in some cases get the surgery because their hip gets stuck, and the frequency of their hip freezing up or being stuck increased and so did the pain when it happened. When it does happen, many of these patients, and probably you also, have specific tricks for wiggling or shaking your leg that will free the hip up. At this point the patient, and you, have decided something more needs to be done. Your doctor appointments have now left you with a typical diagnosis of:

  • Hip impingement or  Femoroacetabular Impingement (FAI) was explained to you as a condition where abnormal contact and rubbing of the ball and socket portion of the hip bones creates joint damaging friction. This “bone-on-bone” situation subsequently develops into degenerative osteoarthritis in addition to causing injuries to the labral area. If you are being recommended to arthroscopic surgery for Femoroacetabular Impingement we would like to invite you to read more about this surgery in our article on surgical and non-surgical options for Femoroacetabular Impingement.
  • You have a hip labrum tear. The hip labrum is an important ring of cartilage that holds the femoral head, or top of the thigh bone, securely within the hip anatomy. It also serves as a cushion and shock absorber to protect the hip and thigh bones. Damage or degeneration to the labrum causes pain, hip instability, and bone overgrowth in an attempt to stabilize the area. If you have been recommended to this surgery please see our article Comparing Hip Labrum Surgery and Non-Surgical Prolotherapy | The evidence

 

In this photograph, full thickness cartilage lesions are seen even after arthroscopic hip surgery. The procedure performed was a hip labrum repair with a cadaver graft. This is an example of a "patch" surgery. The goal of the surgery was to patch a hole but the problems that cause the full thickness tear or the "hole," was not addressed. Hip joint instability that continued wearing and tearing at the hip and would make this patient a likely candidate for hip replacement had they not sought regenerative injection therapy.
In this photograph, full-thickness cartilage lesions are seen even after an arthroscopic hip surgery. The procedure performed was a hip labrum repair with a cadaver graft. This is an example of a “patch” surgery. The goal of the surgery was to patch a hole but the problems that caused the full thickness tear, the “hole,” were not addressed. Hip joint instability that continued wearing and tearing at the hip and would make this patient a likely candidate for hip replacement had they not sought regenerative injection therapy.

“Iatrogenic (surgery causing) gross hip instability following hip arthroscopy is a concerning complication described in the recent orthopedic literature.”

Many people do have great success with hip surgery. These are the people we do not see. What we see are the patients trying to avoid the first surgery, we also see the patients trying to figure out what to do to avoid a second or revision surgery. For some of you reading this article, perhaps nothing is as disappointing s a surgery that has failed and that is why you are here.

What is hip instability? Hip instability to you means grabbing for a chair, railing, or anything you can hold onto because your leg just gave way. It can also mean looking at a staircase as if it were a mountain or preparing yourself for the pain by holding onto the car door as you prepare to get in or out of your vehicle. You may be sleeping with a pillow between your legs because sleeping on your hip is painful too.

To the medical community, hip instability is a degenerative hip disease. The steady wear and tear erosion of your hip will eventually lead to hip replacement. Because hip replacement is a big surgery, with long recoveries, and significant complications, medicine is offering a lesser surgery that it is hoped will prevent the need for the larger surgery.

Here is an example of the type of research that discusses hip instability, is a recent study from the journal Knee Surgery, Sports Traumatology, Arthroscopy. (5)

“The increasing use of hip arthroscopy has led to further development in our understanding of hip anatomy and potential post-operative complications. Iatrogenic (surgery causing) gross hip instability following hip arthroscopy is a concerning complication described in the recent orthopaedic literature. Post-arthroscopy hip instability is thought to be multifactorial, related to a variety of patient, surgical and post-operative factors. . . This study reports a case of gross hip instability following hip arthroscopy, describing a (new surgical) technique of management through anterior hip capsuloligamentous reconstruction with Achilles tendon allograft.”

Did you get all that? Follow the path:

  1. The patient has hip pain and instability
  2. The patient is recommended to arthroscopic labral or other clean up and repair surgeries
  3. The surgery that promised repair, stability, and relief of pain, itself caused instability and more pain. (Mostly from dislocation and chronic subluxation (the hip keeps popping out of place)).
  4. One solution was to come up with a surgery to fix the surgery.

These surgeries were designed to save the hip from a hip replacement, but, to do so, the surgeries needed to halt or significantly slow the progression of osteoarthritis. As research points out, surgery many times will not achieve this goal.

A patient case from Caring Medical. Two cortisone injections, two failed arthroscopic procedures.

A reminder that many people have very successful arthroscopic repairs and cortisone treatments. The patient case given below is just one example of the patients we see who did not have a good outcome with two arthroscopic repairs and two cortisone treatments.

This patient was a nurse who came to Caring Medical with horrific pain after several cortisone shots and two arthroscopies for bilateral hip pain. Any doctor with experience with joint instability could tell by physical examination that she had joint hypermobility throughout her body. Surgical procedures most often do not work well long-term in this patient population because their collagen is so stretched out and arthroscopy stretches it further.

This patient had an enormous amount of hip clicking and grinding with motion, especially external rotation of the hip. She was completely disabled and was no longer working as a nurse. At her appointment, we reviewed her medical records. Her MR arthrogram of the left hip five months prior to surgery concluded:

  • Normal acetabular labrum.
  • No arthritic changes of the femoral head or acetabulum.

After this MRI, she underwent two cortisone injections into the left hip and also had undergone a right hip arthroscopy.

In the operative report of her arthroscopy (5 months after her MRA showed a normal labrum and no arthritic changes), the surgeon demonstrated joint instability by distracting the hip joint under fluoroscopic guidance. He also commented on a labral tear. During the surgery, large holes were bore through her iliofemoral ligaments and joint capsule to visualize inside the joint. These same structures were stretched out by the many liters of pressurized fluid pumped inside the joint so that the surgeon could see.

In the report, it bluntly says that the joint was dilated with a dilator and a 5.0 (5.0mm) cannula was placed inside the joint. Basically, to get that in the joint, the hole in the ligaments and capsule had to be slightly bigger than 5.0mm. A capsulotomy was also performed, which again signifies a hold in the joint capsule. The surgeon remarked on significant cartilage degeneration and in places, it was near ‘bone on bone’ (stage 3 cartilage wear).

  • To reiterate, her MRA five months prior remarked on normal cartilage. Even with some margin of error on the images, there was still significant degeneration that occurred on the hip joint within five months, during which time the patient received two cortisone injections.

The arthroscopic evaluation also revealed a non-round, if you will, femoral neck and acetabulum, so the surgeon did a osteochondroplasty to a large section of the femoral head and neck (approximately 2.5mm of bone and cartilage was removed). He felt after he did this, her range of motion was improved. He then procedure to use a high-speed burr to shave off bone from the acetabulum, which was also said to increase her range of motion. He then proceeded to place metal anchors in the joint as a way to ‘repair’ the labrum. We have seen over the years, placing metal anchors in pliable structures make them more likely to re-tear.

Finally, the hip joint was then extensively debrided of any loose material that was present. How much of this loose material came from all of the probing, burring and shaving that was performed during the surgery? The probes were then directed toward the greater trochanter where her bursa was removed and her iliotibial band was released, meaning that the surgeon sliced or removed part of it. Now, after the surgical procedure, she no longer has a bursa to help the tendons glide over her bones and has a weakened iliotibial band. Lastly, at the end of surgery, another steroid shot was injected into the right hip.

In summary, the patient had hip pain but a normal hip MRA. After two cortisone injections, she continued to put excess force on her hip without feeling the pain. Five months later, the patient had significant degeneration and underwent an arthroscopic surgery that further caused injury to many structures in her hip. It is no wonder that she was still left with hip pain and seeking out other alternatives for treatment.

Hip preserving arthroscopic surgery complications and concerns

Hip preserving arthroscopic surgery complications and concerns

At Caring Medical, we see numerous patients whose history is consistent with arthroscopy-induced hip instability (and other joints). The most common reason for doctor-induced instability is arthroscopy and joint replacement. Both procedures involve stretching the joint capsule and depend on the joint tightening after the procedure for joint stability to occur. Most people who have had a hip or knee replacement who now have pain (or they never had full pain relief from the replacement) have instability until proven otherwise. I, and my colleagues at Caring Medical, have treated a myriad of patients successfully with Prolotherapy who have continued pain or new pain after replacement. (Only the surrounding ligaments and tendons are treated as necessary in these cases).

As hip instability can develop from arthroscopic surgery itself, a question that is not often asked is: when a person goes for hip arthroscopy, through what structures does the surgeon insert the arthroscopes, shavers and other instruments? Are these tools big or small? Arthroscopy can cause hip joint instability by several mechanisms including:

  • Blunt trauma and injury to joint capsule by arthroscopic instruments.
  • Blunt trauma and injury to extracapsular ligaments and labrum by arthroscopic instruments.
  • Overstretching of the joint capsule from pumping liters of fluid in the joint to distend the capsule so orthopedic surgeon can insert instruments (a normal hip joint contains less than 3 mL of fluid).
  • Positioning of the patient during surgery, including traction.

During arthroscopic surgery, a probe is placed right through the strongest hip ligament, the iliofemoral ligament. Naturally, a hole then goes through the capsule as well. In a study on revision hip arthroscopies, post-surgical capsular injuries were present in nearly all patients. (11) This included both capsular injuries and iliofemoral ligament defects. Other studies have confirmed the presence of capsular injuries after hip arthroscopic surgeries. It is well known that injury of the iliofemoral ligament causes increased external rotation, extension and anterior translation of the femoral head. Thus, those with iliofemoral ligament injuries after surgery are left with resultant or worsening hip instability.

Research: Handle the iliofemoral ligament with care to avoid post surgical muscle damage and walking difficulties.

In March 2022, doctors wrote in the Orthopaedic journal of sports medicine (12) about the key role the iliofemoral ligament plays in maintaining hip stability.

  • In mechanical testing the researchers found that the when the iliofemoral ligament is strong and undamaged, the impact and strain on the hip flexor muscles, the iliopsoas and sartorius muscles was greatly reduced. Conversely if damaged, as occurs in surgery, the ligament could then cause muscle fatigue and spasms as the muscle would have to work harder to stabilize the hip during walking.

The conclusion of this paper comes with suggests to doctors: “The importance of the contribution of the iliofemoral ligament to the hip flexors warrants careful handling and repair of these ligaments in cases of surgery and structural damage.”

Iatrogenic injuries to both the labrum and cartilage can also happen during hip arthroscopies and relatively common are likely underreported. These labral injuries happen when the superior or anterosuperior labrum is punctured when placing an anterolateral portal into the joint. Associated cartilage injuries often affect the femoral head. Typical traction placed on the leg during hip arthroscopy is 25-50 lbs, meaning this weight is added to the lower leg to distract the hip joint and allow the surgeons better access. Traction injuries can occur to soft tissues surrounding the hip, including nerves, ligaments, and tendons.

  • Labral Debridement and Repair: Debridement refers to the removal of tissue via an arthroscopic blade, shaver, or ablator.  The goal of debridement is to relieve pain by removing any torn or frayed labral tissue from the labrum.

In a recent study published in the journal Knee Surgery, Sports Traumatology, Arthroscopy (6) hip range of motion and adduction strength (the lateral movement of the hip joint)  were associated with weakened and damaged hip labral tears and considered to be important quality-of-life in patients with labral problems. This clearly indicates that patients wantrepair, not tissue removal.

  • Chondroplasty: The removal of damaged cartilage during surgery via shaving, cutting, scraping, laser, or burring away.  The idea is that after the damaged cartilage is removed via chondroplasty, the body may recover the area with new cartilage.
  • Microfracture: A surgical procedure whereby a “pick” is used to spike holes in damaged cartilage to promote bleeding and the migration of bone marrow cells to the joint surface.  The idea is that the blood cells/bone marrow will heal the damaged cartilage.  As aforementioned, microfracture is the only technique performed during this patient’s surgery that may be considered regenerative, in that the technique is applied in an attempt to grow new tissue.  However, a much simpler, less risky, and more cost-effective treatment would be PRP and stem cells to stimulate the growth of new cartilage. A similar technique is Core Decompression
    • Core decompression is considering a “joint sparing” surgery. If it works, there can be avoidance or delay of hip replacement. The core decompression surgical procedure involves drilling a hole(s) into the femoral head of the hip to relieve pressure in the bone and hopefully create new blood vessels to nourish the affected areas of the hip. The overall success of this treatment is unclear. Please see my article Treating hip pain and necrosis without core decompression for more on this subject.
  • Osteoplasty:  The surgical alteration of bone.
  • Synovectomy:  The surgical removal of the entire or partial synovial membrane of a joint.

Does hip preserving arthroscopic surgery lead to hip replacement anyway? The evidence.


A study of 1013 patients who had undergone Joint-preserving surgery of the hip

A 2017 study from surgeons at The Ottawa Hospital published in the Bone and Joint Journal (7made these observations concerning surgical complications.

The doctors reviewed 1013 patients who had undergone Joint-preserving surgery of the hip by a single surgeon between 2005 and 2015. There were 509 men and 504 women with a mean age of 39 years (16 to 78).

Of the 1013 operations:

  • 783 were arthroscopies,
  • 122 surgical dislocations,
  • and 108 peri-acetabular osteotomies. A periacetabular osteotomy seeks to correct hip dysplasia, a condition where the hip socket is not deep enough or anatomically deficient to hold the ball portion of the joint/

The doctors analyzed the overall failure rates and modes of failure. Re-operations were categorized into four groups:

  • Mode 1 was arthritis progression or hip organ failure leading to total hip replacement
  • Mode 2 was an Incorrect diagnosis/procedure
  • Mode 3 resulted from malcorrection (the surgery did not correct the problem) of femur (type A), acetabulum (type B), or labrum (type C) and
  • Mode 4 resulted from an unintended consequence of the initial surgical intervention. (Other complications)

At an average follow-up of 2.5 years, there had been:

  • 104 re-operations (10.2%)
  • There were 64 Mode 1 failures (6.3%) arthritis progression or hip organ failure leading to total hip replacement
  • There were 17 Mode 2 failures (1.7%) Incorrect diagnosis/procedure
  • There were 19 Mode 3 failures (1.9%) malcorrection (the surgery did not correct the problem)
  • There were 4 Mode 4 failures (0.4%). (Other complications).

A November 2023 paper (x) led by California Northstate University College of Medicine and published in the journal Arthroscopy reviewed outcomes of hip joint surgical preservation procedures for chondral lesions of the hip through analysis of survival rates and patient reported outcomes. Simply, patients underwent arthroscopic procedures in an attempt to hold off or prevent the need for total hip replacement.

In reviewing the data of 27 previous studies, the researchers found the most common of these procedures to be:

  • Microfracture was the most common procedure, reported in 17 studies. “The goal with the microfracture is to promote migration of stem cells and growth factors from beneath the subchondral bone plate into the cartilage defect, which eventually heals to form fibrocartilage.” (x) In this procedure, an awl or sharp tool) is pushed into the bone so blood and fluid can fill the cartilage defects.
  • Autologous chondrocyte transplantation (ACT) (five studies). In this procedure, cartilage is harvested, typically from the knee and patched into the hip cartilage defects.
  • Autologous matrix-induced chondrogenesis. In this procedure microfracture is performed, but, to help contain the blood at the point of the defects as opposed to seeping into the whole hip joint, a bio-scaffold is used to contain the blood at the point of the defect.
  • Microfracture in conjunction with CarGel (three studies). As above, CarGel is a specific brand of bio-scaffold.

A successful surgery or “surgery survival” is defined as the patient no needing a revision surgery or had to be moved ono hip replacement.

The researchers reported that the majority of patients across all techniques demonstrated significant improvements in patient reported outcomes, however, isolated Microfracture remained the most commonly performed technique, despite lower survival and higher conversion to hip replacement rates. Other techniques that were performed in conjunction with Microfracture or which avoided Microfracture altogether had higher overall survival rates despite being minimally performed.

Does hip arthroscopy increase risk of hip replacement?

A January 2024 paper  published in the Journal of orthopaedic science (14) examined the previous research on the increased odds of needing hip replacement after hip arthroscopic surgery. Their meta-analysis found that the rates of postoperative complications, including dislocation, revision, and reoperation, were significantly higher in previous hip arthroscopy patients. They also suggested that the higher rate of dislocation in particular may be from arthroscopic surgery, the failure to close the joint capsule after inter-portal capsulotomy. The outcome could be hip joint laxity that will persist, leading to a tendency to dislocate even after total hip replacement.

Opioid-related complications in hip arthroscopy

An October 2017 study published in the American Journal of Sports Medicine (8) comes doctors at the University of Pittsburgh Medical Center and University of Texas Southwestern. In it, the doctors discuss opioid-related complications in hip arthroscopy.

  • Hip arthroscopy is often associated with significant postoperative pain and opioid-associated side effects. Effective pain management after hip arthroscopy improves patient recovery and satisfaction and decreases opioid-related complications.
  • Several methods of pain management have been described for hip arthroscopy.
  • Single-injection femoral nerve blocks and lumbar plexus blocks provided improved analgesia, but increased fall rates were observed.
  • Fascia iliaca blocks do not provide adequate pain relief when compared with surgical site infiltration with local anesthetic and are associated with an increased risk of cutaneous nerve deficits.

The concern is: “There is a lack of high-quality evidence on this topic, and further research is needed to determine the best approach to manage postoperative pain and optimize patient satisfaction.”

Doctors warn patients that joint-sparing surgery may complicate the eventual hip replacement in patients over 50.

A study from the Steadman Philippon Research Institute appearing in the Clinical Orthopaedics and Related Research looked at 96 patients over the age of 50 who had “joint-preserving hip arthroscopy.”(9)

  • Of the 96 patients, 31 went on to have a total hip replacement. That’s approximately one in three patients who had “joint-preserving” surgery that led to replacing the joint.

But the numbers are not what this research was all about. The research sought to predict who would need the hip replacement after the arthroscopy – and the best predictions came after radiographic evidence. If there was a joint space of 2 mm or less (meaning the cartilage had worn down) 80% of those patients would need a total hip replacement. It is all about the joint space.

Hip preserving arthroscopic surgery or Hip Replacement?

As mentioned above, medicine’s way is to seek and find new procedures. As I mentioned above if femoroacetabular impingement and labrum tears are risk factors for later development of hip osteoarthritis and current operations are not halting the development of hip osteoarthritis, then what is needed are newer operations.

The problems of hip arthroscopy have led many to abandon the procedure in favor of total hip replacement. In recent years, however, hip arthroscopy has evolved and returned to prominence. A 2014 study in the Bone and Joint Journal says:

  • The use of joint-preserving surgery of the hip has been largely abandoned since the introduction of total hip replacement.
  • However, with the modification of such techniques as pelvic osteotomy, and the introduction of intracapsular procedures such as surgical hip dislocation and arthroscopy, previously unexpected options for surgical treatment have arisen.
  • Femoroacetabular impingement has been identified as a significant factor in the development of osteoarthritis in many hips previously considered to suffer from primary osteoarthritis. As mechanical causes of degenerative joint disease are now recognized earlier in the disease process, these arthroscopic techniques may be used to decelerate or even prevent progression to osteoarthritis. (10)

When you should consider surgery and when it is realistic to expect surgery can be avoided


Prolotherapy injections. Can they help you?

The purple dots are the map for Prolotherapy injections to be given into this patient’s hip.

Hip prolotherapy injection sites

Prolotherapy is an injection of simple sugar, dextrose. Dozens of research studies have documented Prolotherapy’s effectiveness in treating chronic joint pain.

Below is a typical Prolotherapy procedure note that we use when treating the hip.  Because we see primarily chronic pain, it has to be assumed that by the time we see the patient, there is quite a bit of joint destruction that has occurred and thus the hip joint is treated comprehensively. The decision as to whether or not to use cellular components (such as PRP or stem cells) as part of the Prolotherapy solution depends on many factors. We have found that certain conditions/ tissue injuries heal quicker with cellular versus noncellular (dextrose) Prolotherapy solutions. Fibrocartilage tears, such as occurs in the hip menisci or labrum are ‘glued’ back together better with PRP. Thus, for hip labral tears, we typically use PRP at most of the visits. When a person has significant joint instability, it is important to make sure the emphasis through the treatment is periarticular or extra-articular, meaning that the ligaments and tendons receive most of the injections and solutions. Putting too much of any solution into an already loose joint runs the risk of making the joint temporarily more unstable due to capsular distention, especially if a brace is not used.

We have been offering regenerative medicine injections since 1993 as a service to people who wish to avoid hip surgery. As part of our comprehensive program, we offer Platelet Rich Plasma Therapy, or as we describe it Platelet Rich Plasma Prolotherapy.

  • In Platelet Rich Plasma treatment, your blood is drawn from your arm, it is spun to concentrate the blood platelets which contain concentrated healing elements. The concentrated plasma “rich in healing platelets” solution is then injected into your hip.
  • Using stem cells taken from a patient’s bone marrow is becoming a therapy of interest due to the potential of these mesenchymal stem cells to differentiate into other types of cells such as bone and cartilage.Bone Marrow is the liquid spongy-type tissue found in the hallow (interior) of bones. It is primarily a fatty tissue that houses stem cells that are responsible for the formation of other cells. These mesenchymal stem cells (MSC), also called marrow stromal cells, can differentiate (change) into a variety of cell types including osteoblasts (bone cells)chondrocytes (cartilage cells), myocytes (muscle cells), adipocytes (fat), fibroblasts (ligament and tendon) and others when reintroduced into the body by injection. Bone marrow also contains hematopoietic stem cells that give rise to the white and red blood cells and platelets.Stem cell therapy is a controversial treatment. In some instances, unrealistic expectations and claims may be made in how beneficial this treatment can be. Stem cell therapy does help many people. It does not help everyone. Please see our articles:

The following are cases from  Caring Medical

A 26 year-old college student who had sustained a simple hip injury working out with thera-bands. While many people have successful surgeries, this patient had surgery for a hip labral tear that at best can be described as “ill-advised” He had a surgery that removed cartilage, labrum and other bone fragments.  This of course caused further joint deterioration and led to two more debridement procedures and microfracture, which involves drilling into the bone from the joint surface to try and stimulate cartilage repair. None of these procedures addressed the underlying cause of his hip pain: hip instability from ligament injury. Because his hip pain was stemming from the ligaments outside of the joint, surgeries directed at the inside of the joint will not work in the long run. As expected, the surgeries he underwent were not successful. It was noted on his first visit with us that “he walked like an old man with a degenerated hip, all bent over with limited motion.” The hip instability also caused issues to his lower back (sacroiliac joints and lumbosacral area) as the instability had progressed to these areas. This patient reported a very good outcome.

A seventeen year old female and nineteen year old male need hip replacements

Recently, within a short matter of two days, I saw a seventeen year old female and nineteen year old male that were both recommended by orthopedic surgeons for hip replacements. Both cases had started out as simple athletic injuries, but after undergoing multiple orthopedic surgeries that loosened the joints further by taking out joint stabilizing structures and overstretching them, both young people had severely degenerated hip joints. The seventeen year old female already had collapse of her femoral head and unfortunately I had to send her for joint replacement, as her bony architecture was destroyed. The nineteen year old still had retained some his normal bony architecture, though it was not perfect and his cartilage was all gone. He underwent several Stem Cell Prolotherapy procedures, which will delay his need for a joint replacement for some time. For an excellent Prolotherapy candidate, Prolotherapy can eliminate the need for a joint replacement permanently, but this young man had some bony changes that will make joint replacement necessary at a future date. Isn’t it interesting that many people with hip replacements still waddle like a duck? Why? Surgeries cannot get the joint biomechanics back to normal. There is so much disability long-term even with ‘successful’ hip joint replacements. As a last resort, yes get a hip joint replacement. But it is wise to seek out the opinion of an experienced Prolotherapist before doing so.

Hip joint instability causes significant pressures to be exerted on all hip tissues. It is as if with every step, the unstable hip is receiving the same amount of force of as if it were jumping (many times body weight with each step). As such, it is like the acetabulum is smashing on the femoral head with each step until eventually the femoral head collapses. At this point, the person needs to undergo surgery to get the ball to be round again. A Prolotherapy can’t do this, but an orthopedic surgeon can.

In this video, Ross Hauser, MD demonstrates and describes the Prolotherapy treatment. A summary transcription is below the video.

  • This is a hip procedure on a runner who has hip instability and a lot of clicking and popping in the front of the hip.
  • This patient has been diagnosed with a suspect labral tear and hip ligament injury.
  • The injections are treating the anterior or front part of the hip which includes the hip labrum and the Greater Trochanter area, the interior portion, the gluteus minimus is treated.
  • The Greater Trochanter area is where various attachments of the ligaments and muscle tendons converge, including the gluteus medius.
  • From the front of the hip (1:05), we can treat the pubofemoral ligament and the iliofemoral ligaments.
  • From the here posterior approach I’m going to inject some proliferant within the hip joint itself and then, of course, we’re going to do all the attachments in the posterior part of the hip and that will include the ischiofemoral ligament, the iliofemoral ligaments. We can also target the attachments of the smaller muscles too including the Obturator, the Piriformis attachments onto the Greater Trochanter.
  • Hip problems are ubiquitous, the hip ligament injury or hip instability is a cause of degenerative hip disease and it’s the reason why people have to get to get hip replacements.
  • This athlete is training for a half marathon and did not want to have their training regiment stopped because of this injury and believe it or not within 10 days of this treatment the athlete was back to running. At the time of this video, they were scheduled to have another treatment. One treatment may not resolve a runner’s injury. Depending on the injury we get people sometimes back to their sport really quickly sometimes it takes a few treatments before they’re back to their exercise

Is Prolotherapy an appropriate treatment for you?

When we receive hip x-rays from prospective patients via email, they provide a good assessment of how many Prolotherapy treatments might be needed to achieve the patient’s goals. The best assessment would be an in-office physical examination.

  • Rating a hip Prolotherapy Candidate: We will rate the potential hip pain patient on a sliding scale of being a very good Prolotherapy candidate to a very poor one. In a very good candidate’s x-ray, the ball of the femur will be round, fitting nicely into the socket in the pelvis, with good spacing between these two bones. This space is the cartilage that cushions and allows the femur to rotate freely within the socket.

Published research papers from our doctors at Caring Medical on Hip Disorders

In the Journal of Prolotherapy, we sought to show how Prolotherapy could provide high levels of patient outcome satisfaction while avoiding hip surgery. Here is what we reported:

  • We examined Sixty-one patients, representing 94 hips, who had been in pain an average of 63 months We treated these patients quarterly with Hackett-Hemwall dextrose Prolotherapy.
  • This included a subset of 20 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of eight patients who were told by their doctor(s) that surgery was their only option.

Patients in the study have contacted an average of 19 months following their last Prolotherapy session and asked questions regarding their levels of pain, physical and psychological symptoms, and activities of daily living, before and after their last Prolotherapy treatment.

Results: In these 94 hips,

  • pain levels decreased from 7.0 to 2.4 after Prolotherapy;
  • 89% experienced more than 50% of pain relief with Prolotherapy;
  • more than 84% showed improvements in walking and exercise ability, anxiety, depression, and overall disability;
  • 54% were able to completely stop taking pain medications.

The results confirm that Prolotherapy is a treatment that should be highly considered for people suffering from chronic hip pain.

Summary

When a surgeon reshapes the hip to make the acetabulum and femoral head more round, it likely will temporarily help the joint biomechanics. If underlying hip instability is not addressed, the results will likely not last. Often, patients are subjected to a surgery like this that may provide them with one or two years of relief before symptoms return. Many surgical operations for chronic pain involve removing one or more of the pain-causing structures and will effectively temporarily help joint biomechanics, but because the underlying joint instability is not resolved, the condition comes back. For instance, the precursor operations for chronic hip and knee pain include meniscectomy, arthroscopy, osteochondroplasty, osteotomy, etc. These operations do not make the joint more stable (in fact, they do the opposite) and thus the person’s OA progresses. Interestingly, the same surgeons that perform these procedures may often perform the patient’s joint replacement years later as their condition worsens.

If you have questions about your hip pain, you can get help from our Caring Medical staff

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This article was update September 4, 2022

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