However, effective surgical treatments have been developed, and diagnosis is now much more precise. At the center, the most common treatment is hip arthroscopy, a procedure in which a fiber-optic camera is inserted through a small incision, allowing the surgeon to visualize the hip. Specialized instruments facilitate repair and some recontouring of the natural bones. In more complex cases, open surgery may be called for, to correct major deformities that are not accessible with arthroscopic techniques. Both arthroscopic and open surgical techniques can be very effective in relieving the impingement and improving hip function.
The purpose of these rapidly advancing approaches and techniques is universally to relieve pain, improve function and delay or perhaps even prevent the onset of arthritis, according to Clohisy. Taken collectively, they go by the name “hip preservation surgery.”
But that goal is not always possible. Rachel Van Winkle was only 9 years old when she was diagnosed with systemic juvenile rheumatoid arthritis, a chronic autoimmune disease that causes inflammation of the joints and their protective tissues. A progressive illness, it leads to destruction of the joint.
Van Winkle was 14 when she had gotten as much use as possible out of her hips, and pain told her and her physicians that something had to be done. At the center, the physicians found her arthritis was advanced and the natural hip joints were ruined. They determined that complete hip replacements were called for — the right hip at age 14 and the left three years later.
"The purpose of these rapidly advancing approaches and techniques is universally to relieve pain, improve function and delay or perhaps even prevent the onset of arthritis."
—John C. Clohisy, MD
Van Winkle’s hip replacements are five years in her past, and she is preparing to graduate from college. She now sees Clohisy on a two-year schedule, and together they expect that she will get 20, or even more, years of use out of the joints.
Any decision to replace a young person’s hip joint comes only after careful consideration by the center’s members. According to Heidi Prather, DO, associate professor of orthopaedic surgery and chief of the section in physical medicine and rehabilitation, when Clohisy created the center and invited participation of multiple disciplines, it was not just lip service. “The group is unique; it fully integrates those who are not surgeons. We work together to evaluate, treat and research, looking at each problem from every angle.”
Prather sees all patients, even those referred directly to one of the surgeons and those with undiagnosed hip pain. “There’s a lot of back and forth. In the clinic we share, I often convince surgeons to try something diagnostically,” she says. “We take great care to be specific about the patient’s history and physical exam. We need to be sure that what we see on an image is really the problem; that we are imaging the right thing.” Members’ close cooperation and open communication contributes to the center’s clinical success, she says.
Some young hips do require full replacement. The recipient of two artificial hips after her diagnosis for systemic juvenile rheumatoid arthritis, Rachel Van Winkle can expect another few decades’ use before new hips will be needed.
A third principal, Perry L. Schoenecker, MD, professor of orthopaedic surgery and chief of pediatric orthopaedics at St. Louis Shriners Hospital for Children, performed joint preservation surgery on adults for 30 years and now concentrates on children, rounding out the comprehensiveness of the center and bringing care to that previously underserved population.
He says the collaboration in the group goes well beyond what is common in most such centers. He and Clohisy often work together in the operating suite as co-surgeons and have performed more than 300 periacetabular osteotomies. “It’s synergistic,” he says. “When things get difficult, the combination sees us through. We’re both technically demanding of our craft, and where a lone surgeon might settle for a less-than-perfect solution, one of us often says, ‘I think we can make that better.’”
To push back the number of young patients who need replacements and advance hip preservation treatments, members participate in a range of research projects. A multidisciplinary group studies diagnosis, treatment and outcomes, involving physical therapists, biostatisticians, physiatrists, radiologists and basic scientists looking at the progression of pre-arthritic hip disease.
Center member Linda J. Sandell, PhD, the Mildred B. Simon Research Professor of Orthopaedic Surgery and professor of cell biology and physiology, is an expert in osteoarthritis, studying the mechanisms that mediate joint deterioration. Her clues: tissues removed from affected joints and their proteins and enzymes that lie outside the norm.
Members also lead the eight-center Academic Network of Conservational Hip Outcomes Research (ANCHOR) study group which enrolls more than 500 patients each year in various studies. Clohisy and his multicenter colleagues staff the coordinating center located at Washington University.
“What we’re learning is that there are major advantages to preserving the joint,” he says. “Hip replacement may have to be done, but we don’t want to do it in the patient’s teens, 20s or 30s unless there is no other choice.”