Surgeon experience in young adult hips

I read an interesting article by Omer Mei-Dan about surgeon experience in the field of young adult hips (read it here).  He writes about the growing interest of hip preservation surgery and makes the case for improved training of orthopaedic surgeons in this area.  In sports or orthopaedic fellowships, unlike with paediatric hip conditions, there is very limited training time spent on pathologies in and around the young adult hip and hip preservation procedures.  Surgeons who then make adult hip preservation a part of their practice can often have minimal exposure to this during their residency training (Mei-Dan, 2013). 

It made me think about something which is often spoken about amongst hip dysplasia patients: finding an experienced enough surgeon when pelvic osteotomy surgery is advised.

Just to clarify; pelvic osteotomy involves breaking out a chunk of the pelvis, shifting the broken fragment around to better cover the femoral head and then screwing it into that new position.  The physical effort of moving a chunk of pelvic bone around and the technical difficulty of accurately positioning it is something which requires a high level of experience.  Surgeons who perform large volumes of these surgeries are more likely to be able to achieve consistently good outcomes (Novais et al, 2016; Kraj-Ilik, 2017).  So this article does contribute to explaining why there seem to be so few in orthopaedics who are able to treat young adult hips successfully, and also why hip preservation procedures performed by less experienced surgeons have gained a reputation for being a poor option for treating hips compared to conservative measures.  We can be tempted to begin to see surgery as the Bad Guy in scenarios such as these.

For patients with long term pain, particularly that which doesn’t seem to have a purely medical explanation, undergoing further and further investigations and treatments to find a cause is considered unwise.  We are taught that this may indicate unhelpful beliefs about their pain or that they are looking for a “quick fix” of some sort (Kenyon & Kenyon, 2004).  Against the backdrop of the biopsychosocial model and emerging concepts for treatment of persistent pain, it can be seen as detrimental for young adult hip patients to keep searching for multiple investigations or surgical treatment about their chronic hip pain.

Very often I’ve heard from peers of mine with hip dysplasia who have had labral debridement and who have not seen good outcomes from this because their dysplasia has been missed or misdiagnosed until they eventually find an appropriately experienced surgeon further down the line (Bogunovic et al, 2013).  Meanwhile their condition has been made worse and they have become more and more debilitated.  There are also stories of unsuccessful pelvic osteotomies done by surgeons without adequate experience, or conversion to total hip replacement within just a few years.  I get the impression it is then surmised by health care professionals involved in these patients’ care that pelvic osteotomies are not a worthwhile treatment option for patients.  I wonder about those who don’t manage to find an experienced enough clinician and who have to live with lifelong pain and disability purely because of missed diagnosis or poorly performed surgery.

Another scenario I've heard is when patients with acetabular dysplasia have tried physiotherapy for some months with no success and have been told by an orthopaedic surgeon that pelvic osteotomy surgery is not recommended, or not recommended 'yet,' and that they should continue with conservative management.  We can be forgiven for the boost to our professional ego this gives us.  If an orthopaedic is advocating for physio over jumping into surgery then surely this is a good thing?  However, I would implore physios reading this to reason this treatment pathway cautiously.  We know from the best available evidence and from the trajectory of hip dysplasia, that pelvic osteotomy surgery has better outcomes when performed sooner rather than later (Coobs et al, 2015).  There are many incidences in which this kind of surgery is not the best option for a patient, for a variety of reasons, but these need to be made clear to the patient, and if they haven’t been made clear then it might be necessary to read between the lines of what has been said.

For some patients it is the opposite, of course, and on hearing that a pelvic osteotomy is necessary, they will be out of the clinic door as fast as their acetabularly-challenged hips can carry them.  Most sane people are not keen on having their pelvis cracked open and pinned back together again.

Searching for the right surgeon is something which I all-too-well know the experience of.  After a poorly performed pelvic osteotomy by one clinician & the mental and physical slog of lengthy recovery, I was devasted to discover some years later, and a few orthopaedic surgeons down the line, that the dysplasia in this hip had not been properly corrected & the surgery would ultimately need to be redone.  Not only that, but the previously classified “mild” dysplasia in the opposite side was actually not that mild after all, and the best option going forward was to undergo a pelvic osteotomy on that side too.  I think I spent 3 days in shock, and a lot longer untangling my mental health.  Re-doing a pelvic osteotomy is no mean feat, for the surgeon or the patient. 

Don’t get me wrong, there may well be patients with chronic hip pain (or with pain in any other joint, for that matter) which is medically unexplained; there does not appear to be a structural cause of their pain.  In my understanding this has always been the case in medicine and healthcare, some things we just can’t find a cause for, frustrating as it is to admit.  The issue with hip pain in young adults which we need to be aware of, is that accurate causes of a person’s symptoms are all too often missed by those without adequate knowledge and experience in this area.  This is the point this article strongly puts across.

Remember this is not just about obtaining good treatment outcomes for the sake of it, to prove a point in a debate or to enhance the profile of either surgical or physiotherapy professions.  This is about patients.  We are talking about real people being potentially affected for the rest of their life. 

So this post is a bit of a plea I'm reiterating to my physiotherapy colleagues – as I’ve written in many other posts – to facilitate your young adult hip patients finding the right hip specialist and to understand that they may have to seek a second or even third opinion for accurate diagnosis and treatment of their hip pain.

I leave you with some questions which patients tend to consider when choosing a surgeon.  This is also detailed in a previous post (click here to read it).

• What volume of PAO surgeries does this surgeon undertake?
• What sorts of outcomes do they achieve? For example, how many years after PAOs do their patients tend to undergo THRs?
• Do they liaise effectively with their MDT team during diagnostics, surgery planning, post-op hospital care and rehab?
• Do they consider psychological factors and, if necessary, comorbidites in decisions about surgery?
• Do they encourage physiotherapy input before or as well as opting for surgery, or have they jumped into a surgery decision prematurely?
• Conversely, do they delay a decision about PAO surgery for their patient indefinitely?
• If PAO surgery is not advised for your patient, are they clear on why this is?
• Are they willing to liaise with you, the physiotherapist if there is confusion over diagnosis or complicating factors?
• Does your patient feel they have been listened to and their needs have been considered?

References

Bogunovic, L., Gottlieb, M., Pashos, G., Baca, G. & Clohisy, J. C. (2013) Why Do Hip Arthroscopy Procedures Fail? Clinical Orthopaedics & Related Research, 471. 2523-2529  

Kenyon, K. & Kenyon, J. (2004) The Physiotherapist's Pocketbook: Essential Facts at your fingertips. London: Churchill Livingstone Elsevier

Kralj-Iglic, V. (2017) CORR Insights: Does Surgeon Experience Impact the Risk of Complications After Bernese Periacetabular Osteotomy? Clinical Orthopaedics and Related Research, 475. 1118-1119

Mei-Dan, O. (2013) Hip Preservation: Reality Check on Training. Orthopedics, 36 (4). 244-245

Novais, E. N., Carry, P. M., Kestel, L. A., Ketterman, B., Brusalis, C. M. & Sankar, W. N. (2017) Does Surgeon Experience Impact the Risk of Complications After Bernese Periacetabular Osteotomy? Clinical Orthopaedics & Related Research. 475 (4). 1110 – 1117. Doi: 10.1007/s11999-016-5010-1