The search for an answer to hip osteoarthritis pain usually starts with an MRI. For many patients this is the wrong start. Why? Because the MRI has a notorious habit of sending patients to surgery they do not need. This includes arthroscopy for hip labrum and cartilage damage.

Marc Darrow MD, JD. Thank you for reading my article. You can ask me your questions about hip arthroscopy using the contact form below. 

A new study in the European journal of orthopaedic surgery & traumatology says: “The assessment of a patient with chronic hip pain can be challenging. The differential diagnosis of intra-articular pathology causing hip pain can be diverse. These includes conditions such as osteoarthritis, fracture, and avascular necrosis, synovitis, loose bodies, labral tears, articular pathology and, femoro-acetabular impingement. Magnetic resonance imaging (MRI) arthrography of the hip has been widely used now for diagnosis of articular pathology of the hip. . . Our study conclusions are MRI arthrogram is a useful investigation tool in detecting labral tears, it is also helpful in the diagnosis of femoro-acetabular impingement. However, when it comes to the diagnosis of chondral changes, defects and cartilage delamination, the sensitivity and accuracy are low.”1 Chondral changes, defects and cartilage delamination are the key characteristics of hip osteoarthritis degeneration.

A research team at the University of Utah looked at conditions in the hip that would lead to degenerative osteoarthritis. What they examined is a condition we see in our office very frequently and mentioned in the above research – focal chondral defects – localized damage to the articular cartilage of the hip.

Here is what the Utah team wrote: The relationship between chondral defects and subsequent development of osteoarthritis has led to substantial efforts to develop effective procedures for surgical cartilage repair. Focal chondral defects increased maximum shear stress on the osteochondral surface of the acetabular (socket) cartilage. This effect was amplified with labral delamination.2 

Why are the doctors looking for a surgical answer? Because doctors believe that a hip arthroscopic procedure will be able to stop the progression of osteoarthritis by surgically repair defects in the cartilage and the hip labrum.

Here is a study from 2015 presenting a more optimistic surgical picture:

Damage to the labrum runs a broad spectrum, and the treatments are individualized, but span from debridement to repair and reconstruction. The overarching goal of labral treatment is to restore the native functions of the labrum to allow for more normal biomechanical function. Similarly, cartilage injuries can be managed a number of different ways, including with debridement, microfracture or drilling, cartilage transplants.3

 

But is this the case?

Doctors in Japan reported these findings in January 2017. These finding present a more pessimistic outlook:

Many studies have examined the clinical outcomes of arthroscopic surgery for treatment of hip labral tear and/or osteoarthritis in patients over 50 years of age. Overall these studies show that clinical outcomes generally improved, however they contained cases in which conversion to total hip replacement occurred at a constant rate. In the current study, 34.8% of the patients showed a  progression to osteoarthritis AFTER arthroscopic procedures.4

In March 2017, American Hip Institute researchers presented a paper that says:

Currently, three commonly practiced labral treatments are available: repair (surgical), débridement, and reconstruction. Arguments for and against each treatment option exist in the literature. Reviewing the currently proposed indicators for labral tear treatments in conjunction with the treatment procedures yields a thorough decision-making guide for choosing the appropriate labral procedure.There are no clear cut choices in surgery.

Recently, doctors presented their findings at the annual meeting of the Association of Academic Physiatrists. In this research, ultrasound guided platelet rich plasma (PRP) injections is presented as a non-operative treatment for acetabular hip labral tears.

“Our research demonstrates that single injection of autologous platelet rich plasma under ultrasound guidance can significantly reduce hip pain and improve patient function in as little as 2 weeks,” Lead author Andrew H. Gordon, MD, PhD, commented. “As opposed to open or arthroscopic surgical repair, this study suggests a minimally invasive and lower risk procedure by which pain and functional limitations in hip labral tears may be addressed.”5

Ask Dr. Darrow about hip labrum injuries

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1 Rajeev A, Tuinebreijer W, Mohamed A, Newby M. The validity and accuracy of MRI arthrogram in the assessment of painful articular disorders of the hip. European Journal of Orthopaedic Surgery & Traumatology. 2017 Jul 31:1-7.

2 Klennert BJ, Ellis BJ, Maak TG, Kapron AL, Weiss JA. The mechanics of focal chondral defects in the hip. J Biomech. 2017 Feb 8;52:31-37. doi: 10.1016/j.jbiomech.2016.11.056. Epub 2016 Nov 29.

3 Salata MJ, Vasileff WK. Management of Labral and Chondral Disease in Hip Preservation Surgery. Sports Med Arthrosc. 2015 Dec;23(4):200-4. doi: 10.1097/JSA.0000000000000093.

4 Moriya M, Fukushima K, Uchiyama K, et al. Clinical results of arthroscopic surgery in patients over 50 years of age—what viability does it have as a joint preservative surgery? Journal of Orthopaedic Surgery and Research. 2017;12:2. doi:10.1186/s13018-016-0504-9.

5 Gordon A, Karam C, Blatz D, Gustin Z, DeLuigi AJ. Administration of Platelet Rich Plasma to Hip Labral Tears Reduces Pain and Improves Function, presented on March 12, 2015, at the Annual Meeting of the Association of Academic Physiatrists, March 10-14, 2015, in San Antonio, Texas.