Young Hip Joints

Retirement is no prerequisite for hip surgery



People with hip dysplasia lack a normal hip’s solid “ball and socket” structure: normal (top), hip dysplasia (center) and post-op (bottom).




“Our goal with younger patients is to delay joint replacement surgery and to prolong the life of their true hip joint.”

After osteotomy, patients like Christopher Mackey, above, can return to competition in a variety of sports, including basketball, gymnastics, cycling, swimming, hiking and tennis.

CHRISTOPHER MACKEY DIDN'T REALIZE HE NEEDED HIP SURGERY. For several months, he didn’t really know what was wrong. All he knew was that when he pitched a baseball, a popping sound came from his left hip. At first, there wasn’t really any pain involved, but then his groin muscle stared to hurt. It turned out the groin was being aggravated by a deformity in his hip, the same deformity that was causing it to pop.

Later, when his right hip also popped out of its socket, Mackey experienced significant pain. In fact, he was unable to move, and his baseball coach had to lay him flat on the ground in order to help move the joint back into place.

“That time it hurt!” he says.

Mackey was suffering from a congenital deformity of the hip joint called hip dysplasia. The hip joint is commonly thought of as a “ball and socket” joint. The “ball” is the top of the thighbone, called the femoral head. It rests within the hip’s “socket,” known as the acetabulum. When those two structures are out of sync, problems can develop.

“Most of these patients have an underlying deformity, and many of them have some degree of osteoarthritis in the hip,” says John C. Clohisy, MD, assistant professor of orthopaedic surgery. “As people like Christopher get older, they can begin to experience symptoms. Among people in their 60s and 70s, those symptoms would make us think about total hip replacement, but our goal with younger patients is to delay joint replacement surgery and to prolong the life of their true hip joint.”

Rather than replace the hip joint, orthopaedic surgeon John C. Clohisy, MD, right, radically cuts and repositions the bones in young patients such as Christopher Mackey, returning them to normal, pain-free motion.

To do that, Clohisy and his colleague Perry L. Schoenecker, MD, professor of orthopaedic surgery, radically change the hip joint’s structure. In an operation that takes two to four hours, they cut the bones around the hip socket and reposition them. The patients don’t need a cast, but they do need to stay in the hospital for several days and must walk with the help of crutches for several weeks afterward.

The surgical technique, called the Bernese Peri-Acetabular Osteotomy, isn’t for everybody. Clohisy says it’s designed for relatively young, healthy patients. Those with multiple medical problems or those who are obese are not good candidates.
And while hip replacement surgery can provide pain relief and improved function for patients with advanced hip disease, it’s not a great solution for people under age 50.

“For patients in the 15 to 50 age group, a hip replacement is sub-optimal due to activity restrictions and the fact that the synthetic hip joint is going to wear out with time,” says Clohisy. “A patient who gets a hip replacement at a very young age may require multiple hip surgeries over the course of his or her lifetime.”

Traditionally, treatment for hip disorders in young adults involved little more than restriction of activities, anti-inflammatory medicines and painkillers. But the pain usually gets worse. At first, it occurs during or just after physical activity, but over time, as the pain becomes more frequent, many people may have hip pain even when at rest.

“One way to explain why patients like Christopher don’t get symptoms until they are young adults is that although the cartilage in the hip can function in an adverse environment for a long time, eventually just as the tread on a tire will go bad, the cartilage begins to wear out over time,” Clohisy says.

A person with Mackey’s condition could look forward to pain, difficulty with daily and recreational activities, and doctor’s orders to stop doing things that put stress on the hip joint. There also are problems involving failure to diagnose early hip disease.

That could easily have happened to Mackey.
“I live in Springfield, and a lot of the doctors I saw around here didn’t really know what was wrong with me,” he says.

According to Clohisy, that’s not uncommon. “Very frequently, patients of this age have a deformity or hip joint problem that is not easily recognized,” he says. “Patients don’t get a definite diagnosis, so some go for many years without treatment.”

That’s why Clohisy developed the Young Adult Hip Program at Washington University and Barnes-Jewish Hospital. He treats not only patients who need major rebuilding of the hip joint, but also young people who are candidates for hip arthroscopy or for a process called hip joint debridement, a procedure that involves a trimming of the bones around the joint to correct subtle abnormalities and relieve impingement problems of the hip joint.

Many of these surgical techniques have only been used regularly in the past few years at selected medical centers. As recently as 15 years ago, most of these patients would have been untreated. That would have contributed to the development of osteoarthritis at a young age, and most would have needed a hip replacement by the time they reached their 30s or 40s.

Instead, many of those patients are walking around without pain. Even those who still experience some pain in the hip joint due to underlying arthritis are markedly improved and usually can manage their pain with over-the-counter anti-inflammatory drugs. Most return to full activities after surgery.
Clohisy says some of these young patients may eventually need hip replacement surgery, but even that wouldn’t mean the earlier surgery wasn’t worth it.

“If we have a patient who gets an osteotomy at age 30 and then ends up having a hip replacement at age 50, to me that’s a great success,” he says. “The first surgery will have provided that person with 20 years when the hip wasn’t causing them problems, giving them the opportunity to do many things they couldn’t do if they hadn’t had the operation.”

Luckily, Mackey can look forward to doing many things he would not have been able to do without surgery. Clohisy and Schoenecker surgically repaired his left hip on Valentine’s Day of 2003. When baseball season started in March of that year, Mackey had to watch the Fighting Irish of Springfield Catholic from the dugout. But in spite of pain in his right hip, he came back for his senior season last spring and featured a fastball in the 92-mile-per-hour range. He waited to have that hip operated on in June of this year because he wanted to make it through baseball season first.

Young athletes like Mackey make up a large part of Clohisy’s surgical practice. After osteotomy surgery, they can return to competition, although he discourages them from taking up distance running or other repetitive-impact activities that can damage a diseased hip. Nonetheless, his patients have returned to a variety of sports, including basketball, gymnastics, cycling, swimming, hiking and tennis.

Following the rehabilitation of his right hip, Mackey plans to pitch in college next season for Southwest Missouri State University. He says his hip problems probably cost him a shot at being drafted by a major league baseball team, but even with the injury, he was able to earn a college scholarship. And who knows, if his pitching improves as much as his hips have, he might go a long way.