A recent review of current evidence found that surgical treatment for hip pain in the middle-aged, active patient population is highly dependent on the type of underlying pathology and condition of the joint. Decisions regarding type of surgery should be made based on the amount of degeneration, bony deformities present, and the ability to repair the labrum and cartilage damage.
The hip joint is a ball and socket joint that has a labrum, or firm piece of tissue that extends out over the socket and makes a deeper pocket to hug the head of the leg bone (femur). In addition to the suctioning of the labrum, the joint is surrounded by ligaments, which hold the bones together, and muscles on top of the ligaments, which are responsible for moving the bones. All of these tissues work in conjunction to allow you to move your leg through space in a controlled manner. If any of these tissues are disrupted, the direction of forces change across the joint and wear and tear can happen at a faster rate. Wear and tear, or arthritis, can also occur from repetitive activities and from bony anomalies that occur either on the ball of the femur or on the socket of the hip joint.
Femoralacetabular impingement (FAI), hip pain due to a torn labrum or disrupted articular cartilage, can be caused by a “cam-lesion”, “pincer-lesion”, or combination of the two. A cam-like lesion is a “speed bump” on the ball of the femur. A pincer-like lesion is a speed bump of bone deposit on the edge of the socket of the hip joint. Either of these lesions results in hip pain and early wearing away of the cartilage protecting the joint which ultimately leads to further break down of the hip joint.
Young, active patients with cam or pincer lesions or labral tears are very successfully treated with arthroscopic surgery. Surgeons are able to make a small incision and remove the extra bone and repair the labrum without disrupting much of the joint. Older, active patients (30 to 50-somethings) with hip pain also have the same lesions or labral tears but additionally often have joint arthritis. When hip joints become so arthritic that it interferes with daily life a total hip joint replacement is indicated. However, a middle-aged active person’s joint arthritis typically does not merit total hip replacement but still requires surgical help.
The surgery that results in very good outcomes for the younger population does not give the same results to the middle-aged population. As many as 25 per cent of the middle-aged hip pain person undergoing the same surgery continue to have hip pain with an increased risk of quick progression to a total hip replacement.
After reviewing the available evidence, authors found people undergoing hip arthroscopic surgery with a decent amount of cartilage damage did not have good pain relief and actually seemed to have an accelerated road towards total hip replacement. Additionally, x-rays do not seem to be a good indicator for estimating how much cartilage damage there is. Authors do point out, however, that the studies reviewed are not ranked highly on the hierarchy of evidence, are a little old in that they mostly only address labral issues, and are not focused on long term outcomes.
Studies that compared labral repairs versus debridement (or removing the extra bony deposits) found that fixing the labrum, even with coexisting cartilage damage (or early arthritis), could possibly prevent or slow down the arthritis. Furthermore, by fixing the labrum the normal joint mobility and tracking is maintained which can also help slow down the joint degeneration by keeping the joint surfaces rolling and gliding as they should and the labral suction seal intact.
Even though the evidence is lacking for the middle age, active patient with hip pain, the general consensus is that the joint is treated in its entirety by repairing the torn tissues and removing the extra bony deposits that potentially caused the tear in the first place. Given time, the research should reflect the current surgical practices that are proving to be effective in this population.