“Hip Preservation” is a subspecialty within orthopedics in which surgeons perform procedures designed specifically to preserve a patient’s natural hip joint, rather than undergoing a hip replacement. These procedures generally are aimed at either re-shaping the hip joint or repairing/replacing damaged tissues.
Why do we strive to preserve the hip joint? For decades, orthopedic surgeons have been very good at diagnosing and treating end-stage arthritis of the hip joint and subsequently treating those hips that have severe arthritis… usually with hip replacement. While hip replacement is a great solution for older patients – relieving pain and improving function for millions, it is not as good a solution for more young, heavier, or more active patients. You see, hip replacements are mechanical… made up of metal, plastic, and sometimes ceramic materials. These materials can wear out over time… especially in younger patients with longer life expectancy and in heavier, more active patients. For this reason, we recommend that those with hip replacements avoid impactful athletic activities… such as running, jogging, or jumping. If a joint replacements parts are worn out prematurely, a patient may have to undergo a second surgery to replace those worn out parts. Obviously, the younger a patient is who receives a
hip replacement, the more likely that he or she will wear out the parts and need to have them replaced in their lifetimes.
For these reasons, whenever possible, we recommend that younger, more active patients consider procedures designed to preserve their native hip joint, rather than replace it.
It is only in recent years that physicians have become more adept at diagnosing conditions early in life that may lead to hip pain and arthritis. Conditions (such as Hip dysplasia, and Femoro-Acetabular impingement (FAI) and labral tears are conditions that we see in younger patients that may cause hip pain and may lead to premature arthritis. These conditions are thankfully correctable, and, if caught before significant arthritis develops, can be addressed to prevent the formation of arthritis in the joint. This helps relieve a patient’s pain and allows patients to be more active with their own hip joints, most often without restrictions.
What can be done to preserve the hip joint? This really depends on what is ailing it. The hip joint is a ball-and-socket shaped joint that consists of the Femoral head (ball), Acetabulum (socket) and a cartilage lining that acts as a cushion between the two. The cartilage cushion within the joint is best treated by a hip arthroscopist.
Labral Tears as a Cause of Hip Pain
When most people think about hip pain, they think of old age and arthritis, but hip pain can happen in younger, active people too.
Hip pain in younger people can be caused by a labral tear. Unfortunately, those who have this condition often go undiagnosed or misdiagnosed for an extended period of time.
Michaela’s Story of Bi-lateral Labral Repair
Individuals with a labral tear usually have pain in the front of the hip or groin, and often times they are diagnosed with a muscle pull or a groin strain that doesn’t get better with rest and anti-inflammatory medication. Some young or middle-aged athletes may be predisposed to labral tears, based on the repetitive motion of their activity or sport, including: runners, tri-athletes, volleyball, soccer and hockey players as well as gymnasts and dancers.
Labral tears are common; in fact, studies show that 67% of all teenage athletes have a labral tear and 93% of youth hockey players have a labral tear in the hip. Fortunately, not everyone with a labral tear has pain or symptoms that need treatment, but when young, active athletic individuals do have pain in the hip there is help available.
Some of the common symptoms of a labral tear can include:
Pain in the front of the hip or groin that gets worse with activity or motion
Decreased range of motion in one hip, when compared with the other
Pain often gets worse with sitting for long periods of time
A locking or catching sensation in the hip
Difficulty putting on socks or shoes
Pain that does not get better with physical therapy
Hip Dysplasia - Another Cause of Hip Pain
It is important to get to the bottom of hip pain because hip dysplasia is the number one cause of arthritis in women less than 50 years old and often it leads to pain and the eventual necessity for early hip replacement. Hip Dysplasia is a condition that is often diagnosed in babies at birth or during exams as they are infants and it can be treated non-operatively usually at that age. However, if diagnosed after the age of two, often surgery is necessary to correct the problem and properly align the bones of the hip joint. Milder cases of hip dysplasia may start causing symptoms as a teenager or young adult when children gain weight through puberty and begin more aggressive athletic pursuits. Today, 9 out of every 10 cases of hip dysplasia are diagnosed during adolescence or early adulthood.
What is Dysplasia?
When the socket does not form in the normal shape and orientation as an infant it is termed dysplasia. Normally, the hip socket (the acetabulum) forms directly over the ball. In patients with dysplasia, the socket is tilted, shallow, and not properly aligned or covering the ball. When the hip socket is misshapen, the ball either rides on the edge of the cup, damaging the labrum, or (in severe cases) is also able to ‘slip out’ of the joint causing pain and cartilage wear.
Over time, this may cause chronic pain and lead to the development of premature arthritis. This happens because the smooth layer of cartilage that lines the joint experiences excess wear and tear in patients with dysplasia because of the abnormal anatomy and forces.
As hip dysplasia damages the lining of the joint, and it can also hurt the soft cartilage – the labrum- that lines the socket portion of the hip joint and this is what leads to a labral tear of the hip. In the normal hip, the labrum is on the edge of the socket. In the dysplastic hip, because the socket is shallow and tilted, the labrum is directly over the ball. The force that the ball exerts on the socket when you stand, run, jump, is far greater than the force is directed at the socket in the normal hip. This is why a in a patient with dysplasia, the labrum takes on more force and is more likely to be damaged and need repair.
Symptoms of Dysplasia
Hip pain caused by dysplasia is frequently associated with activities.
Often people describe the pain as coming from deep inside the groin, but it can also radiate from the side or the back,
Over time, the pain generally becomes more frequent or the intensity more severe.
In some cases, people with this condition may develop a mild limp if they do not address the cause.
In severe cases, one can also develop a leg length difference.
The hip is a ball-and-socket joint, where the upper end of the femur (the ball) fits into the acetabulum (the socket), which is part of the pelvis. The labrum is fibrous tissue that lines the socket, protects the underlying cartilage, and provides a suction seal between the ball and socket joint.
Problems can arise when the ball and socket don’t fit together properly, leading to labral tears or cartilage damage in the hip joint. Hip dysplasia is not the only condition that can cause a labral tear. Femoroacetabular impingement or FAI, as it is commonly called, is often the culprit behind a labral tear.
This type of impingement happens when the ball doesn’t fit quite right in the socket and repetitive motion or extended motion in the hip joint causes the bone to bump or “impinge,” with the labrum pinched between the bones thereby causing a tear in the labrum.
Over time, if FAI is untreated, it exposes the cartilage in the hip joint to excessive wear and tear, which starts the process of arthritis as you age. Untreated hip pain caused by impingement or a labral tear can lead to arthritis, so it is important to address the underlying cause of hip pain. While it is important to note hip arthroscopy is not used to treat arthritis, it can be an important tool in preventing it.
Diagnosing Hip Pain From A Labral Tear
Diagnosing the cause of hip pain can be a challenge because the hip is a complex joint. Hip pain caused by impingement and subsequently a labral tear occurs in both males and females, usually between the ages of 16 – 45. It tends to be more common in females and often affects athletes or individuals with an active lifestyle. Certain sports – from soccer, hockey, ballet, lacrosse, basketball, softball, gymnastics, martial arts, and figure skating – can put individuals at a higher risk for a labral tear and femoroacetabular impingement.
The onset of hip pain can occur gradually over time or it can come on suddenly due to an injury. Younger patients often suffer an acute injury and feel a sudden and sharp pain in the groin area. However, sometimes patients have no idea how the injury occurred but have pain when the hip is flexed forward and internally rotated (when the toes and knees are rotated inward). Older patients often notice pain with activities such as yoga or just sitting.
Pain from a torn labrum is generally felt in the groin in the front of the hip – sometimes described as a “C” sign distribution of pain from the top of the groin in the front of the leg to the back part of the hip. Alternatively, some people describe the pain in the area where they would place their hand in their front pants pocket. Some patients may also have pain radiating to the back or side which often gets worse when flexing the hip forward. The pain is usually worsened with activity and is sharp, sometimes described as a knife stabbing them in the groin. Patients may also experience clicking or popping that is felt deep inside the hip. The pain, caused by impingement and subsequent tearing of the labrum, occurs when the femoral head (ball) and the hip socket (cup) are pinching the labrum in between.
When a patient has hip pain, their diagnosis is often delayed because there are very few doctors who are specifically trained to care for patients with femoroacetabular impingement and labral tears. Often patients see an athletic trainer, a physical therapist, their primary care doctor or even a non-operative sports medicine doctor before they end up with an orthopedic surgeon who is a hip specialist and an expert in diagnosing and treating this injury. Many times this injury is misdiagnosed as a hip flexor strain. Ideally, individuals who are experiencing hip pain should start by getting a referral from their athletic trainer or primary care doctor to see a physical therapist.
If the pain doesn’t resolve or improve after 4 – 6 weeks they should see a hip specialist to be evaluated. If it is suspected that the pain may be a result of a labral tear, the doctor will order a special type of MRI with contrast, called an MR arthrogram, to provide an accurate diagnosis. If a labral tear is found, the doctor may offer an additional course of therapy or provide an injection in the hip to confirm the diagnosis and help with the pain. If these steps do not provide lasting relief, then minimally invasive (arthroscopic) labral repair may be considered.
Dr. Dan Haber, Orthopedic Hip specialist at Panorama’s Westminster offices.
It is important to address the injury, because if left untreated it can lead to micro-instability in the joint, cartilage thinning, or damage to the socket or the ball – all of which may eventually lead to early arthritis. Studies done on hockey players have shown that individuals who leave this injury untreated can have arthritis set in as early as their mid-thirties to late-forties.
Most studies show good to excellent outcomes after hip arthroscopy, with most patients returning to sports at their pre-injury level between 6-7 months after surgery. Additionally, patients tend to have increased range of motion and less discomfort with hip flexion, cutting, and pivoting motions. Surgery generally eliminates the groin pain and gets rid of the clicking, popping and catching in the hip.
If you or someone you know has been suffering with non-arthritic hip pain that is the result of an injury, we recommend seeking out evaluation by an orthopedic surgeon who is trained in sports medicine and specializes in hip preservation.
Dr. Ellman on Labral Tears and FAI
The Panorama Difference - Surgical Expertise
Hip arthroscopy is a technically demanding procedure within orthopedic medicine. Doctors who are the best at diagnosing and treating hip pain in young, active individuals are those doctors who specialize specifically in hip arthroscopy. Because repetition breeds excellence, these are the doctors who have the best outcomes when treating patients with hip pain. Many orthopedic surgeons who specialize in sports medicine may do an occasional hip arthroscopy… you want a surgeon who does hundreds or thousands of hip arthroscopy procedures to ensure that they possess the skills and experience necessary to navigate this difficult procedure.
At Panorama Orthopedics & Spine Center, Dr. Michael Ellman and Dr. Dan Haber were both trained specifically in hip arthroscopy by one of the most prestigious and well known experts in the field of hip arthroscopy, Dr. Marc Philippon, Director of Hip Research at the Steadman Philippon Research Institute in Vail, Colorado.
Meet Dr. Mike Ellman
Meet Dr. Dan Haber
Dr. Ellman and Dr. Haber are experts in this area and performs hundreds of these difficult surgeries every year for patient’s who travel from around the region for this expert care.
Likewise, when it takes more than hip arthroscopy alone to repair a damaged hip, when a bone has to be re-shaped, or moved into a corrected position, doctors who are trained in the complex musculoskeletal techniques necessary to reconstruct the dysplastic hip are few and far between.
Meet Dr. Ron Hugate
Dr. Ron Hugate is one of these highly specialized surgeons and one of only a few in the entire Rocky Mountain region. Dr. Hugate’s special training at the Mayo Clinic in minimal incision hip preservation techniques allows him to perform even the most complicated and complex osteotomies. His experience and expertise is an asset to the entire physician team at Panorama Orthopedics & Spine.
Why is the Panorama Hip Preservation Center special?
Here, both Dr. Ellman and Dr. Hugate work together, each with their own set of specialized skills, to treat patients with hip dysplasia and return them to active and fulfilling lives. While Dr. Hugate specializes in the complex reconstruction of the bones of the pelvis and hip joint, Dr. Ellman, works as a hip arthroscopist to repair the damage to the cartilage and labrum inside the hip joint. Together, they are a highly specialized team of experts when it comes to diagnosing and treating hip pain in young active patients.
Hip Arthroscopy - What to Expect
Your doctor may recommend hip arthroscopy if you have hip pain that has not responded to nonsurgical treatments, including rest, physical therapy, medications and injections.
Hip arthroscopy is a minimally invasive surgery. This means the entire procedure is completed with only two or three 1 cm incisions. This speeds the recovery time and minimizes any scarring. Through these small incisions, the doctor is able to reshape any bone to eliminate FAI and repair or reconstruct the labrum.
“My philosophy is to preserve your own tissue whenever possible, “says Dr. Michael Ellman. In greater than 90% of cases, Dr. Ellman is able to repair the patient’s torn labrum.
When the quality of the labrum is just not good enough for a repair, Dr. Ellman will remove the existing labrum and replace it with a new labrum to provide cushioning in the joint.
After surgery, you’ll be up and moving right away. Patients are usually on crutches for approximately three weeks following their procedure. The surgery has a very high success rate, and most people return to full activities, including athletics, within four to six months.
If you’ve suffered from ongoing hip pain that hasn’t responded to physical therapy or other treatments, you may be a good candidate for hip arthroscopy.
Repairing Hip Dysplasia with Ganz Osteotomy
Osteotomy is a word used to describe shifting or re-aligning the bones. Osteotomy is the preferred procedure in young adults to correct dysplasia of the hip, as it often allows people to either postpone or avoid hip replacement altogether. There are several types of osteotomies depending on the location or area of bone that is misshapen. At Panorama, we offer osteotomies of the femur, pelvis, or acetabulum to correct problems with the hip joint if necessary.
A commonly used osteotomy to correct dysplasia is the “Ganz” osteotomy (also called a peri-acetabular osteotomy, PAO). This is a procedure in which the cup (acetabulum) is moved into a better position to support the hip joint. This procedure was developed in the early 1980’s in Europe and has evolved over the years to meet the needs of patients with dysplastic hips. The Ganz Osteotomy is designed to alleviate the pain and restore proper function of the hip. First developed in the 1980’s for active people with hip pain from dysplasia, the main purpose of the Ganz Osteotomy is to briefly separate the hip socket from the pelvis and re-align it so that it is properly seated over the ball (femoral head). This correction in position of the cup allows the joint to properly function and alleviates excess pressure on the hip cartilage.
The Ganz Osteotomy can be performed in adolescents and young adults after the growth plate around the hip socket is closed. The procedure itself is done through small cuts in the pelvic bone that allow the surgeon to re-align the hip socket and then hold it in place with 2 – 3 screws until it heals. This can most often be performed through an incision only 3-6 inches in length.
Individuals who are a good candidate for Ganz Osteotomy include:
Active individuals with hip pain from dysplasia
Individuals with a round femoral head
Individuals with minimal pre-existing arthritis
Non-smokers
Physically fit patients (with BMI of less than 30)
The goal of a Ganz Osteotomy is to:
Restore the proper shape to the hip joint
Reduce pain in the hip joint
Prolong the life of the hip joint
Delay or eliminate the need for a hip replacement in the future
Allow patients to return to full athletic and daily function.
Learning About Ganz Osteotomy - Patient Resources
Dr Hugate is one of only a few surgeons in the western United States that performs the Ganz Osteotomy. It is a complex orthopedic procedure that can be life-changing for individuals who struggle with hip dysplasia. He has provided these videos as a resource to learn more about hip dysplasia, the Ganz Osteotomy surgery and what to expect in recovery from a Ganz Osteotomy. He goes into detail about what causes hip dysplasia, how it is diagnosed and who is this surgery recommended for.
Correcting Hip Dysplasia with Ganz Osteotomy
Watch Dr Hugate perform a Ganz Osteotomy
Please note this is actual surgical footage and can be graphic in nature
Justin grew up in Winner, SD. He attended college at South Dakota State University in Brookings, SD where he studied Athletic Training as a Richard Miller Leader of Tomorrow. He went on to the University of South Dakota in Vermillion, SD to complete his PA training and subsequently moved to Nebraska where he began practicing in general surgery. In 2004 Justin began his Master of PA Studies at the University of Nebraska at Omaha. Prior to becoming a PA, Justin worked as an EMT, a student athletic trainer and a park ranger. Today, Justin works primarily with Dr. Hugate on the complex orthopedic surgery team. In his spare time she enjoys running, hiking, camping, playing with his dog and going to sporting events.
Brooke Mansfield, Physician Assistant
Brooke is a Colorado native growing up in Broomfield, CO. She attended the University of Colorado Boulder for her undergraduate studies earning a degree in Integrative Physiology and then received her medical training and obtained her graduate degree in Physician Assistant studies from Rocky Mountain College in Billings, MT. Brooke was always passionate about pursuing a career in orthopedic surgery therefore she initially gained experience serving as a PA in Orthopedic Trauma at a level 1 trauma center in Phoenix, AZ. She always knew she wanted to return to her home state of Colorado one day and is happy to be back serving her local community. She primarily works with Dr. Dan Haber in sports medicine and hip preservation. Brooke is always active in her free time and enjoys traveling, skiing, going to sporting events/concerts and spending time with her two nieces.
Barbara Wright, Physician Assistant
Barbara was born and raised in Miami, FL. She obtained her undergraduate degree at the College of Charleston in South Carolina. She went back to Miami to complete her PA training at Barry University, and subsequently traveled to Colorado to begin practicing. Barbara has been working with Dr. Ellman since 2015.
Resources
Please check out this video to help you in you get ready for your hip surgery!
The following videos will help you to understand the recovery process following your hip surgery:
We hope these short videos will aid in your recovery by offering you a resource for information. If you have any questions along the way, please reach out to your doctor or physical therapist. They would be happy to answer them.
