If you follow this blog, you now know that except for a few select patients, the routine use of knee meniscus surgery in middle-aged and older patients is an invasive waste of time. In my opinion, the next big orthopedic surgery bubble to pop will be hip arthroscopy. There are multiple randomized controlled trials underway, and I predict none of them show superior results to physical therapy or a sham procedure. This morning’s study focuses on the other side of the efficacy and safety calculus, just how invasive this now common hip procedure can be.
Defining Hip Arthroscopy
The hip joint is a ball-and-socket structure in which the head of the long upper-leg bone (the femur) fits into a socket (the acetabulum) in the pelvic bone. The joint contains structures to protect and cushion the bones, including the labrum, which forms the lip of the acetabulum, and cartilage, which lines the socket and covers the femoral head. Conditions that might generate a recommendation from an orthopedic surgeon for hip arthroscopy include a torn or degenerated labrum or a hip impingement, which can result when hip bones are misshapen, either due to an injury or a congenital deformity.
See my video below on hip impingement to learn more:
In order to perform a hip arthroscopy, first an incision is made through the skin and tissue and then to visualize the joint, a scope is inserted into the hip. Once this is accomplished, portals, or tunnels, are then created through the skin and soft tissues that will allow surgical instruments to pass through and access the area to be treated. As the surgeon visualizes the surgical site through the scope, he or she then makes repairs through the portals.
In order to get into the joint, the surgeon must pull a massive amount of traction, often equivalent to half or more of a patient’s body weight. One of the problems that we witnessed in cadaver hips using this traction machine for knee injection research was that it quickly and irreversibly stretched out the stabilizing ligaments. Turns out, based on this new research, that this may have been foreshadowing…
To learn more about loose hip joints, see my video below:
What We Already Know About Hip Arthroscopy
You would think that since hip arthroscopy has become the most common hip procedure performed worldwide that this decision to operate on all of these hips was based on high-level research showing that this procedure worked. Nope. In fact, despite hundreds of thousands of procedures a year paid by insurance companies, high-level research supporting hip arthroscopy is sorely lacking.
One of the things that doomed knee meniscus surgery was the fact that many government studies began to show that meniscus tears were common in patients who had no pain. While we have no high-level research that hip arthroscopy works, we do have research showing the opposite, that the reason hip arthroscopy is often performed is not well grounded as an abnormality that needs to be fixed. Let me explain.
For example, one study found that bone spurs aren’t the cause of hip arthritis but actually form to protect the joint from worsening arthritis—so removing them to treat hip impingement leaves the joint more vulnerable. We also know that hip impingement seen on MRI may not even be the source of hip pain. In addition, hip labrum tears seen on MRI also may not be the source of hip pain. We know this because many patients have these conditions seen on MRI yet have no hip pain.
So it makes no sense to assume a connection between these MRI hip findings without further study. What good will a hip arthroscopy do to address pain if the labral tear isn’t the true source of the pain? If not the hip, however, then what would be causing hip pain? Any number of things, including an injury to the spine, muscles, or nerves in the back. See my infographic on chronic hip pain for more information on this.
We’ve also seen problems created by those portals used to pass instruments through to perform the hip arthroscopy. I’ve termed this the “portal syndrome” because I see patients with chronic pain and other issues due to these unhealed portals. Speaking of the instruments used, another study found that metal debris created as the hip bone is shaved is often left behind, and these metal particles not only kill cells but can be toxic to the joint.
Now, a new study throws even more fuel on the hip arthroscopy fire finding a surprising incidence of conditions not previously associated with the surgery. Let’s take a look.
New Hip Arthroscopy Complications: Chronic Pain, Mental Health Issues, Sleep Disorders…
The new study investigated the occurrence of seven conditions during the two-year period following (and any history one year prior to) a hip arthroscopy in 1,870 patients. Specifically, they were looking for the rates of increase compared to presurgery status in these conditions during that time, and all conditions increased substantially, as follows:
- Chronic pain—166%
- Substance abuse—57%
- Heart conditions—71%
- Sleep issues—111%
- Mental health conditions—84%
- Joint problems—132%
- Metabolic syndrome—86%
Remember, this wasn’t a decade, or even five years, later; these drastic increases in these conditions occurred within only two years following hip arthroscopy! This led researchers to conclude that the only explanation is that these findings must have been “overlooked” in prior major studies on hip arthroscopy. Keep in mind, too, many of these conditions contribute to and build off of each other. For example, chronic pain and sleep disturbances often go hand in hand; chronic pain can also lead to the abuse of painkillers, such as opioids; and metabolic syndrome increases the risk for heart conditions and stresses the joints.
So if hip arthroscopy isn’t the answer, what will help? We have been treating labral tears that are causing hip pain (the minority of tears) with precisely guided injections of platelets and stem cells for many years. To learn more, see my video below:
The upshot? Turns out that hip arthroscopy likely has many more complications than were previously reported. In the clinic, we’ve seen firsthand the patients in chronic pain due to these procedures. Now, the research is beginning to support what we have observed, that surgeons often don’t consider a connection between health problems after the surgery and the procedure. So for me, it’s just a matter of time before the other research shoe drops and shows that hip arthroscopy is no better than a sham procedure.