Healing hips

Doctors are using artest arthroscopy to heal hips.
Doctors are using artest arthroscopy to heal hips.

When it takes you ten minutes to walk up a flight of stairs, something is very wrong.  Well, that's what life was like for a young woman who had a mysterious hip pain.  Doctors are now using arthroscopy to diagnose pain and heal the hips.

Relief at last, for 19-year-old Emily Wander! For five, long years, she suffered horrible pain in her hips.

"Like your sharpest, excruciating pain that you've had and then make that constant and that's what it felt like," Emily Wander, told Ivanhoe.

Emily was active all her life.  You name the sport, she played it!  But by high school, she could barely walk.Finally, Emily found Doctor Keith Kenter at the University Of Cincinnati Health Orthopedics And Sports Medicine.  He discovered bumps, or bone spurs, on her thigh bone, where the ball meets the hip socket.  

"You can imagine as she flexes and rotates, that spur comes in contact with the socket," University of Cincinnati College of Medicine, Orthopedic Surgeon, Doctor Keith Kenter, told Ivanhoe.

To stop the pain, Doctor Kenter tried a high-tech treatment called hip arthroscopy.Through small incisions, he inserts special tools to repair torn cartilage, and shave the bone spur.

"The days where we have to make a big incision, dislocate the hip to address something are going away," Doctor Kenter explained.

Now Emily is pain free and can't wait to go running again.

Doctors say hip arthroscopy is done on an outpatient basis, and patients usually recover more quickly than with major surgery.  Ideal candidates are active patients who have hip pain resulting from bone spurs and tissue tears within the hip.   Doctors say arthroscopy is important because it's helping them see and understand problems within the hip, just as it helped them see and treat the knees and shoulders.


HIP ARTHROSCOPY:  Arthroscopy is a surgical procedure that gives doctors a clear view of the inside of a joint. This helps them diagnose and treat joint problems. During hip arthroscopy, the surgeon inserts a small camera, called an arthroscope, into the hip joint. The camera displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments.


WHEN HIP ARTHROSCOPY IS RECOMMENDED: A doctor may recommend hip arthroscopy if a patient has a painful condition that does not respond to nonsurgical treatment.  Hip arthroscopy may relieve painful symptoms of many problems that damage the labrum, articular cartilage, or other soft tissues surrounding the joint.


COMPLICATIONS: Complications from hip arthroscopy are uncommon. Any surgery in the hip joint carries a small risk of injury to the surrounding nerves or vessels, or the joint itself. The traction needed for the procedure can stretch nerves and cause numbness, but this is usually temporary. There are also small risks of infection, as well as blood clots forming in the legs.


RECOVERY: After surgery, patients typically stay in the recovery room for 1 to 2 hours before being discharged. The patient can also expect to be on crutches, or a walker, for some period of time.


(SOURCE: http://orthoinfo.aaos.org)


Keith Kenter, MD, Associate Professor and Program Director of the Residency at the University of Cincinnati in the Department of Orthopedics and Sports Medicine, talks about a new hip treatment.

What was wrong with Emily? What was causing her pain?  

Dr. Kenter: Emily was presented with a long history of bilateral hip pain and she described this down into the groin region, some mechanical symptoms with popping and catching.  After a detailed history and physical examination as well as review of some of her imaging studies, we made a diagnosis of a labral tear with an impingement component.  

What is a labral tear?  

Dr. Kenter: The labrum is a fibrous tissue that kind of wraps around the socket. Her impingement or a spur that developed on her thigh bone or the neck of the ball was rubbing up against that and resulted in the tear.   

Why did it hurt so much? 

Dr. Kenter: That is a good question. We clearly see these types of tears and spurs radiographically and we know that there are a group of patients that are asymptomatic. We will have to ask Emily, but I think in her case this was kind of a chronic repetitive type of process that just eventually wore and what brought her into our office.

How did you treat this problem?  

Dr. Kenter: Emily had seen several different physicians and had done a variety of different techniques.  I think a lot of times we can try physical therapy; certainly if we can keep somebody out of the operating room that would be great.  We would try modalities through physical therapy.  We may try steroid injections to try to help improve the inflammatory process and I think if that fails then eventually we do have to go to the operating room.  In Emily's case, what we decided to do was to proceed with an arthroscopic type of approach as opposed to an open type of approach.  An open approach is where you would make an incision, dissect down through the muscles into the joint and address the problem. 

Does she have hip dysplasia?

Dr. Kenter: She might have had a component of hip dysplasia which, as a child, and never really diagnosed.  However, her symptoms were not from her dysplasia, could be a result of the dysplasia.

What is hip dysplasia? 

Dr. Kenter: There are a variety of different types of classifications of hip dysplasia. Essentially either the ball or the socket does not form properly and that overall alignment of coverage of the ball different growths of the ball and how that ball and socket develop with time and in her case, she developed some spurring because of the developmental anatomy that took place. 

Emily was active.  Do you think her activities in sports contributed to her problem? 

Dr. Kenter: YES, I am not sure her activity related to it. I would submit or almost think about her activity brought it out. If she wasn't as active as she was or is, she might have never known she had a hip problem.

How did you treat her?  

Dr. Kenter: We talked about options and we decided to do this arthroscopically.  She had failed non-operative treatment and with her chronicity, we decided to go to the operating room.  The arthroscopic procedure is an outpatient procedure.  So Emily came in; had the procedure done and went home that same day. We put a camera into her hip to assess the intraarticular anatomy.  

And what did you find? 

Dr. Kenter: In her case, we found a labral tear as expected.  We ended up repairing that or suturing that back to the socket to kind of recreate that gasket.  Then she also had that spur out on the femoral neck or the neck of the ball where we kind of débrided that or smoothed that down so it would not be hitting against that cartilage tear.

How new is this procedure that you did? 

Dr. Kenter: It has been around for some time.  I think there has been case reports described in literature since the 80s. I think it has come more to a forefront as some of our experts have brought that to our attention; certainly some famous athletes have had surgery and that always helps the media bring this to our attention, so I would say today, I wouldn't say it is uncommon, but I would say, a general orthopedic surgeon today is not doing them. 

What is significant about treating the hip this way, without major surgery?

Dr. Kenter: I think it is less invasive.  I think in an active patient world, and certainly as a Sports Medicine Surgeon, we are less invasive; it is an outpatient procedure, so you can even argue the value and the cost containment is important, but I think it allows our athletes and active individuals or any patient to get back more quickly. I think if they are hurting less and get back to their normal lifestyle, activities of daily living quicker, I think that is a good thing. 

Who is a candidate for this? 

Dr. Kenter: The ideal candidate, at least in my hands would be somebody who is active, has an acute event; tears an anatomic structure such as the labrum.

Who is not a candidate?

Dr. Kenter: Obviously anybody that is medically unstable. Once we start seeing the degenerative process or erosive changes of the cartilage that starts changing overall gliding mechanics and then could be a problem with outcome.   

What are the benefits of hip arthroscopic compared with other standard treatments?  

Dr. Kenter: What makes this exciting for a lot patients because the days where we would have to make a big incision, dislocate the hip to address something are going away and I think just as we evolved around the shoulder, we have evolved around the knee, I think that is this new frontier if you will as far as arthroscopy in joints. 

What about the new frontier as far as treating the hip? 

Dr. Kenter: We are now pushing the envelope.  It has allowed us to understand pathophysiology, pathoanatomy better because we can visualize it easier with the arthroscope.  It has allowed us to visualize the anatomy much better, which allows us to understand the disease process better.  The other advantage is it has allowed us to pursue new technology.  We can now reconstruct cartilage.

What is it about the arthroscopy; that you can see inside?

Dr. Kenter: It is magnified, we can see inside the hip a lot easier.  Now, there are clearly limitations with anything we do, but magnifying the tissue and addressing that with a more magnified view allows us to do more.

What are the concerns of doctors who don't use this procedure? 

Dr. Kenter: Orthopedic surgeons need to be aware of the procedure and then if they don't do that because of the technical demands, transfer that or refer that to one of their colleagues. 

Emily struggled with so much pain.  She went to so many doctors and people would tell her she was, it was just growing pains. Why do you think that was so hard to get to the bottom of her problem? e He He said itw as He said itw as  

Dr. Kenter: It is technically demanding; we did not have the proper equipment, so our industry didn't market or pursue the equipment and it is hard to examine a hip.  The level of accuracy making a diagnosis based on a history and physical exam is a little bit more challenging then say a knee.  

What advice would you have for people who can't get an answer for their pain?

Dr. Kenter: Listen to your patient.  You need to understand what they are trying to relay; a good complete physical examination with good imaging studies.

What advice would you have for a patient who goes from place to place? 

Dr. Kenter: Emily did a good job. She took an active role in her care and communicated her concerns with her physicians and somehow found the right place to go.  With availability of internet and social media, we are a much closer community and society and I applaud Emily.  She took a very active role in trying to figure out what she could do to get her hip better. 




Becca Richter

University of Cincinnati

Department of Orthopaedic Surgery & Sports Medicine