Transcription:
Hip Preservation Surgeries at Northwestern Medicine

Melanie Cole, MS (host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole, and we have a panel for you today with two Northwestern Medicine Physicians. Dr. Michael Stover is a Professor of Orthopedic Surgery and Dr. Sanjeez Bhatia is an orthopedic surgeon and they're here to highlight hip preservation for us today.

Doctors, thank you so much for joining us. And Dr. Bhatia, I'd like to start with you. I'd like you to kind of set the table for us about the causes of hip osteoarthritis, dysplasia, femoral acetabular impingement. Just speak to us a little bit about what you see in the trends and the prevalence of this.

Dr. Sanjev Bhatia: Thanks very much, Melanie. It's a huge honor to be with you today and I think it's really neat, that we're able to highlight this very exciting and emerging field of orthopedic surgery. From a 50,000-foot view in general, the field of hip preservation is really based on the concept of trying to help reduce the onset of hip osteoarthritis, which is one of the most common joints that gets afflicted with degenerative disease.

And one thing that's very unique about the hip is that it's a ball and socket joint that in general is actually a pretty durable joint. I think Dr. Stover and I will both agree that it's one of the joints in the body that complains the least for the most part, except when certain conditions develop. And a lot of the arthritis in the hip often occurs because of some type of pre-arthritic bone abnormality They kind of are classified into kind of two camps. One is hip impingement, which is one of the leading causes of hip osteoarthritis. It occurs essentially when the ball and the socket kind of have an incongruency or the ball doesn't fully fit into the socket due to some bone spurs. And then, the other condition that often can lead to hip osteoarthritis is hip dysplasia, which is when the socket is shallower and it can lead to hip instability as well as some cartilage wear, you know, mechanics. So, it's a very neat field and grateful to partner with Dr. Stover on this.

Dr. Mike Strover: I would agree. I think that, from a standpoint of development of osteoarthritis, that can usually be found to have some associated shape abnormalities of the hip that cause the cartilage wear and tear over time. And the two categories of impingement and instability are what we see in the younger patient population. They can be a number of different diagnoses that lead to these conflicts or these issues in the hip. That's our job, is to try to figure out exactly what the shape abnormalities are and how they affect the hips' longevity and how we can intervene to improve the longevity of the hip or to decrease the risk of progression to arthritis.

Melanie Cole, MS (host): This is such a great topic and it's so important. As you say, the prevalence of hip issues is really growing, but this is a very specific patient criteria. Dr. Stover, I'd like you to speak a little bit about the rationale, any research for hip preservation. And really speak a little bit about the different types that are available and what you're doing at Northwestern.

Dr. Mike Strover: I think that there's a lot of interest in hip preservation, and its research that probably began more in the 1980s and beyond. The idea of this femoral acetabular impingement became more of a common discussion point regarding the etiology or the cause of hip arthritis. Initially, we did relatively big surgeries in order to address the abnormalities that come with the hip impingement. But that has since been refined and now can be done with the use of hip arthroscopy with less incisions, but still quite a bit of work done within the hip. So through two or three small incisions, a lot of work can be done using a lighted camera and arthroscopy tools to help take away bone or repair labrum and soft tissues. So, that's been a real revolution, an evolution over time with regards to treating a lot of intraarticular hip problems.

With regards to dysplasia or instability of the hip, still we have some limited less invasive procedures that are done. And I think the application of some hip arthroscopy to this diagnosis of hip instability or hip dysplasia initially had a lot of interest. But since it has probably been proven that it doesn't work out quite as well in the unstable hip patient and that maybe a more extensive surgery where we do corrective osteotomies around the hip is more reliable with regards to outcomes in that patient population. So, there has been a lot of research looking at the role of hip arthroscopy in different hip conditions and then also in the long-term outcomes of osteotomy surgery for hip preservation for the unstable hip patient or the dysplastic patient. So, Dr. Bhatia can probably speak a little bit more on the role of hip arthroscopy in today's patient.

Dr. Sanjev Bhatia: Thanks, Dr. Stover. That's a very good overview. And as he was saying, one thing that's really happened over the last couple of decades, two to three decades, which has been really remarkable is the tools and the instrumentation that we have to minimally invasively get into the hip has really been transformative. And now, we're able to do things arthroscopically that we weren't able to decades ago, which now enabled us to treat bony pathologies that are accelerating the onset of some degenerative conditions and causing a lot of pain in a manner we couldn't do before.

So, as I mentioned earlier, there's kind of two camps of conditions that can increase the risk of arthritis. And one of those camps, which is the one that I primarily deal with arthroscopically is this condition of hip impingement, FAI, which is when certain bone spurs develop that cause pain, can cause labral tears, and in some cases can cause early degeneration of acetabular cartilage.

So, nowadays arthroscopically, we can access most of those bone spurs. And really do some remarkable work in terms of helping get patients back on track, relieve pain, and really give them a durable hip that'll last for over 10 years or longer. And in some cases, as Dr. Stover was saying, the hip socket itself has a congenital deformity or a congenital shape that makes it predisposed to having early osteoarthritis because a socket is very shallow. And in those settings, arthroscopically, we can go in and correct the soft tissue abnormalities or the cartilage abnormalities with labral tears. But in many cases, we also need to do a procedure that reorients the socket. And that's where Dr. Stover's expertise is really tremendous for our system here at Northwestern. He's a very humble guy, but he's one of the nation's leaders in helping correct these acetabular osteotomies. It's a very difficult operation to do, but he makes it look easy. And it's very neat that here at our center, we have a hip and knee joint preservation center. He's an integral part of that and he really helps us help those patients.

Melanie Cole, MS (host): Dr. Bhatia, thank you for that. And Dr. Stover, as you are more of a humble man, but an excellent surgeon, and as we're talking about this, and some are obviously the result of athletics, some might be the result of genetics or age as we were just discussing, I'd like you to speak about the ideal patient for these hip preservation surgeries. Is there a correlation with sports and patient cases? And do you see better outcomes from this procedure because of certain athletic training abilities?

Dr. Mike Strover: I think number one is that we don't know how much this comes from the genes, but a lot of it is probably also developmental. There seems to be some link between patients and their families and development of arthritis, but a lot of it does have to do with how we develop and how we're nurtured and how people participate in athletics or in certain activities of our life. Especially in the adolescent years, there can be areas of the hip that develop differently secondary to the type of activity that people participate in, and this can lead especially to hip impingement. In some areas also, it's felt that the hip socket may not develop quite as sufficiently in the way that you are brought up. So, there are things that impact the hip and its shapes during development that can end up with a more pathologic condition.

As far as our treatment of the hip condition is concerned, for us, early diagnosis and treatment are important. Because when we start to look at our outcomes, number one is trying to get to the patient, and give them the proper diagnosis or the correct diagnosis, because sometimes the ideas of what the shapes and their impacts can be on the hip overlap. And so, it may not be that easy to discern exactly what is causing the symptoms, but to try to make the correct diagnosis and then, perform the correct surgery as early as possible once the patient becomes symptomatic. I don't mean that this is an emergent or urgent situation, but it's a situation where if they start to have pain in their hip and we identify some abnormalities, the earlier that we get to the hip to correct those mechanical difficulties, the better the patients do long term. So, the younger hip, the ability to recover and the ability to adapt to the changes that are provided in the hip do have an impact on how long and how well patients do after surgery. So, age is definitely a factor in outcomes with regards to intervention.

With regards to sports, I think it depends on the type of hip that you're dealing with. A lot of impingement type of activities come and are developed through sporting activities. They can result in groin pain and pain around the hip during activity. And this is because this is a type of collision, femolar acetabular impingement, is a type of collision between the femur bone and the head and neck junction of the femur bone and the acetabular socket. So, you can imagine that athletes put their selves and their hips in more extreme positions with a more violent or a higher velocity of motion that can bring on some of the symptoms along the hip from this collision that occurs. So, I think there definitely is a relationship between development and symptomatic onset in patients with hip femoral acetabular impingement.

Same with instability, we know that the more severe their dysplasia is, the younger time at which they present for symptoms. So, the younger they are, the more active they are, if they have a more severe dysplasia, they present earlier in life. Rather than some patients with a more transitional or a lower volume socket but that is not severely dysplastic, which will present later on in life. Dr. Bhatia has a lot of experience in treating athletes and I think that he can give some insight as to development and also the treatment of these patients and their outcomes at an earlier age.

Dr. Sanjev Bhatia: Thanks, Dr. Stover. Yeah, I mean, one of the interesting things about athletes, and there's some really interesting research that's come out over the last few years, and there's a few properties of bone that kind of play a role in the development of hip impingement. So, this is more pertinent to, the impingement side of things. One thing that happens with bone is that if it starts to receive repetitive stress, that specific area of bone starts to overgrow or hypertrophy. It's actually a defense mechanism that bone has. But in cases of impingement, if there's a stress spot on that ball and socket joint, that area where the body starts to lay down more bone actually can be more harmful and actually can lead to some of these early degenerative conditions, namely with hip impingement.

Other things that happened and there's been some interesting research that shows that younger adolescent athletes that are involved in certain sports, whether it's hockey, whether it's other hip-intensive sports in the adolescent phase, this is the phase with which the proximal femoral growth plate is starting to close. In some cases, there actually can be some abnormalities that develop around the growth plates, which then lead to what are called CAM lesions, which then lead to the development of hip femoral acetabular impingement, which then subsequently later on in adulthood can lead to labral tears and, in some cases, early arthritis about the hip. So, it's really a fascinating area. It's probably one of the most fascinating and fastest growing area of orthopedic research right now. And much of this is related to our understanding, our developing knowledge about all these topics.

Melanie Cole, MS (host): It is such an exciting time in your field. I'd like to give you each a chance for a final thought here. Dr. Bhatia, how did you start working together on joint cases? Tell us a little bit more about arthritis being addressed at the Northwestern Medicine Joint Preservation Program. A little bit about your outcomes and certainly your multidisciplinary approach.

Dr. Sanjev Bhatia: It was a very exciting thing and it's one of the main reasons why I came to Northwestern to be a part of our hip-knee joint preservation center. So, it all kind of began after my fellowship in Vail, Colorado. I was working with the hip preservation center in Cincinnati. And one of my friends out there, Dr. Michael Archdeacon, actually was good friends with Dr. Mike Stover. And right around the time when I was considering a move to Chicago, my wife's actually from the Chicago area, Dr. Archdeacon, he connected Dr. Stover and I. And since that point, we've had a really good time working together. We've been able to help lots and lots of patients from several different states. So, it's been a really cool journey and we're very proud of our outcomes. I think we have some of the best outcomes in the country. We have one of the lowest revision rates in published literature. So, we're very grateful to have a lot of the resources that we have here at Northwestern.

Melanie Cole, MS (host): And Dr. Stover, last word to you. I'd like you to speak about when it's important that physicians refer hip preservation patient candidates to Northwestern Medicine and anything else you would like other providers to know about this exciting procedure and the future of hip preservation.

Dr. Mike Strover: I think that primary care physicians and first line medical providers, I think the important thing to know is that commonly when a patient presents with a hip problem, 85% of the time, a component of their pain complaint is in the groin or almost in a C-shape distribution around the front side and back of the hip. And so when this occurs, I think everybody should have in mind that the hip may be part of the problem with regards to a patient's pain. So, getting an x-ray is fine, making sure that there's no arthritis and everything is fine. But we're happy to see all those patients, especially patients under the age of 40, where I think that we can have a real impact on longevity of their joint and on symptomatic improvement with the procedures that we provide, and we can help to make that diagnosis and then, follow up with the primary care physicians as far as, you know, information and how the patient did.

From a standpoint of where this is going, I think that we do have more and more providers within our system that are interested in hip preservation. I think that we can provide a quality product to the people in the Chicagoland and the rest of the Midwestern area with regards to hip preservation. I can tell you that we will stay on top of what we think are the best reported outcomes so that we are up to date as to what the best surgeries are for patients and what their expectations can be from that. And I think our job is to just make sure that people know that we're here and that we're willing to see these patients and take care of them long term. So, I think that's the job for us to provide, is to give them a cohesive hip care plan that we can follow throughout their life.

Melanie Cole, MS (host): I'd like to thank you both for such an engaging episode, such an interesting procedure. Thank you both for joining us. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/orthopedics. You can also go to nm.org/jointpreservation. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. Thanks so much for joining us today.