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Hip and knee joint preservation: The new frontier?
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As we enter the fifth and sixth decade of prosthetic hip and knee joint replacement, is there any wonder why our patients and even some of our physician colleagues are exploring options for preservation of native joints? In the United States, the “perfect storm” created by millions of baby boomers entering their 50s and 60s with painful arthritic hips and knees and high functional expectations, and the explosion of information technology has generated strong interest in more kinematically normal joint replacement and nonprosthetic joint preserving alternatives. Add to this the growing numbers of young adults in their 20s and 30s who are seeking, and increasingly receiving, non-prosthetic hip and knee joint restorative procedures, and it becomes easier to understand why we may be entering a new and exciting time for joint reconstruction.
More natural joint function
The movement toward more natural hip and knee joint function is evident in a number of areas. Unicompartmental (tibiofemoral and patellofemoral) knee arthroplasty has increased dramatically due largely to reproduction of more normal knee kinematics. Bicruciate retaining total knee arthroplasty has seen renewed enthusiasm for the same reason. Hyaline cartilage restoration, whether from autologous chondrocytes or transplanted tissue, is of interest for many young active patients who desire improved knee pain and function. In the hip, resurfacing arthroplasty and the rapid increase in the diagnosis and treatment of femoroacetabular impingement are examples of patient and surgeon driven pursuit of restoration of normal function. In addition, more aggressive (usually open surgery) joint preservation treatment of young adults with joint dysfunction resulting from hip dysplasia and sequelae of pediatric hip disease, such as Legg-Calvé-Perthes disease and slipped capital femoral epiphysis, is increasingly more attractive and accepted by patients and surgeons.
Challenges
Evolution, of course, begets challenges and the joint preservation world is not immune. Issues such as optimum surgeon education models, practice/care models, and reimbursement barriers and perverse incentives are particularly germane to the field at this time. Classic orthopedic surgeon training, even after the fellowship year, may not adequately prepare surgeons to manage conventional joint reconstruction or replacement and newer hip and knee joint preservation procedures.
In the hip, recent advances in arthroscopic techniques have led to an exponential increase in the number of hip arthroscopies performed, although there is concern that many of these patients may have unrecognized morphologic abnormalities contributing to joint dysfunction. Perspicacious observers of this trend recognize the need to better define optimum care models for these patients. Although new diagnoses and joint preservation procedures benefit patients, third-party payers are frequently slow to recognize these advances and patients and surgeons are unhappily caught in the vortex. Establishment of new models of care with demonstrable outcome improvement would seem to be in our best interest.
Hip preservation surgery
Our center has had a dedicated hip preservation surgery focus for many years. The field of hip preservation surgery has grown substantially during the past decade coincident with the recognition that most young adult hip problems are associated with altered hip morphology. Although open hip procedures such as surgical dislocation for femoroacetabular impingement and periacetabular osteotomy for acetabular dysplasia have proven efficacy, arthroscopic treatment has increasingly become an attractive alternative to open hip approaches. Arthroscopic treatment of hip disorders, such as labral injury and femoroacetabular impingement has increased dramatically during the past 5 years. Nevertheless substantial questions such as what are the appropriate indications and corresponding efficacy for open vs. arthroscopic interventions for specific intra-articular hip pathologies remain.
In an effort to circumvent the “either/or” approach and attempt to answer some of these questions, our center established a comprehensive service incorporating both arthroscopic and open hip surgery tailored to specific operative indications. Clinical outcome of operatively treated cases was measured with some or all of the following measures: Modified Harris Hip score (HHS), SF-36 (physical and mental components), Lower Extremity Function Score, Rapid Assessment of Physical Activity Score, Hip Outcome score, and conversion to arthroplasty. Demonstrable improvement in these outcome measures reinforced our belief that tailoring appropriate open or arthroscopic treatment for specific diagnoses is preferable to a single operative approach for all forms of hip dysfunction.
Basic science research collaboration
Additional goals of the service were to establish a dedicated hip preservation conference and facilitate clinician – basic science research collaboration. The multidisciplinary conference was effective in establishing a consistent protocol (history, physical examination, imaging, etc.) for the assessment of the non-arthritic painful hip, establishing the appropriate diagnosis, selection of the appropriate treatment methodology, fostering hip preservation education for residents/fellows/medical students, and providing a forum for community participation. An established clinician basic science research relationship focusing on the principles of computational and experimental engineering mechanics, motion analysis and imaging to solve unique problems related to hip joint pathomorphology was similarly improved.
The experience of creating a comprehensive service to address the new and growing demand for joint preservation has raised as many questions as it answered. Going forward, refinement of pathogenetic mechanisms, diagnostic protocols and operative indications is needed. Similarly, defining optimum models of surgical education and training offers great potential for advancement of the field. Other questions will undoubtedly emerge and it seems likely that patients and surgeons will continue the push forward for preservation of the native hip and knee joint.
- Anthony M. DiGioia III, MD, is the editor of Emerging Technology & Innovation. He can be reached at Renaissance Orthopaedics, PC, and Pittsburgh, Pennsylvania Innovation Center, Magee-Women’s Hospital of UPMC, Pittsburgh.
- Christopher L. Peters, MD, is the George S. Eccles Endowed Professor and Chief, Adult Reconstruction, in the Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah. He can be reached at Chris.Peters@hsc.utah.edu.
- Disclosures: DiGioia is a shareholder in Blue Belt Technologies. Peters has no relevant financial disclosures.