Joel Williams, MD, Assistant Professor at Rush University Medical Center and with a background in Orthopedic Trauma and Hip Preservation Surgery talks about hip replacement surgery and a different option for young patients.
Interview conducted by Ivanhoe Broadcast News in May 2017.
What is your role at Midwest Orthopedics at Rush?
Dr. Williams: I treat fractures all over the body. I am especially interested in fractures of the pelvis, and fractures that have problems healing or fractures that heal in a crooked position. The other focus of my practice is hip preservation, which is geared towards treating patients with hip dysplasia and hip impingement.
What is hip dysplasia?
Dr. Williams: Hip dysplasia is a condition that results in an abnormal or shallow hip socket. Left untreated, hip dysplasia predictably results in early onset arthritis.
Is it a condition that is found in children?
Dr. Williams: Absolutely. Sometimes it is diagnosed very early on and treated in infancy and early childhood. But, there are still a huge number of patients that are not diagnosed until later in life.
Why aren’t they diagnosed?
Dr. Williams: There are potentially a few different explanations. One is perhaps our definition of normal versus abnormal is not sensitive enough, and we should be consider changing our cut-off values. Another is that infants can be born with a normal hip joint and develop dysplasia during development.
Is there some indication or sign that there is hip dysplasia?
Dr. Williams: Pain is commonly localized to the groin. An X-Ray of the pelvis is often all that is needed to establish the diagnosis.
Babies when they’re born, we get a test for hip dysplasia for every baby that is born right?
Dr. Williams: Yes. In the United States, every baby has a hip examination to test for instability of the hip joints. If the hip is very unstable and the dysplasia is severe, it’s diagnosed very early. Initial treatment typically involves a brace or cast. In the severe cases, there are surgeries that can be offered during infancy and early childhood.
Are there cases that are mild that are going undiagnosed?
Dr. Williams: Tons. So that’s the biggest issue I see in my practice.
Why don’t you start out by telling me about that?
Dr. Williams: In addition to severe cases which are diagnosed in the newborn nursery or by the pediatrician very early on, there are still a huge number of cases which go undiagnosed until later in life.
When does it come back to haunt these people?
Dr. Williams: It mainly depends on the severity of the dysplasia. Severe cases, or very active/athletic individuals tend to manifest in middle or high school. Mild cases or less active people sometimes do not develop symptoms until the reach their twenties or thirties. Rarely, dysplasia can be asymptomatic until the arthritis process is underway in their forties.
Do you think there could be more done at a younger age to sort of stop it in its tracks?
Dr. Williams: I think if we potentially re-evaluate what’s a normal hip versus an abnormal hip in infancy that could help. But still there are plenty of patients who are born with a normal hip and at some point during their development they start developing hip dysplasia.
How does it come about, why are there more numbers of it or are we becoming more aware of it?
Dr. Williams: I think the increase in numbers is both an increase in awareness and number of people that develop dysplasia. The treatments that we offer patients today didn’t come about until the 1980’s and become widespread until the 90’s. Prior to modern surgical options, a common recommendation was to bite the bullet and wait until old enough for a hip replacement.
What is hip preservation?
Dr. Williams: Hip preservation is an area orthopedics which focuses on a series of procedures to treat pre-arthritic hip conditions like hip dysplasia or hip impingement.
Are there thousands of cases a year in the United States, are there tens of thousands?
Dr. Williams: The exact number of patients walking around with hip dysplasia is very hard to estimate. We do know though that of all the hip replacements done in the United States roughly ten percent are done for hip dysplasia. So, each year that’s around 35,000 hip replacements in the U.S. done for hip dysplasia.
Ten percent?
Dr. Williams: Correct.
How common is it in men versus women?
Dr. Williams: Much more common in women. The ratio is roughly four or five to one.
Why is that?
Dr. Williams: I think it’s just something about the way women’s hips are built. The other risk factors are someone in the family has or had dysplasia, first born child and breach presentation. Some ethnic groups are at increased risk compared to others. Northern Europeans, for example, are the highest risk.
What about multiple birth?
Dr. Williams: Like twins?
Twins, triplets.
Dr. Williams: Being a twin is a small risk factor.
What about quintuplets and all those I would think that would be even worse.
Dr. Williams: Smaller space in utero, so I could speculate that it would be a higher risk.
So there’s smaller space and what does it do then?
Dr. Williams: It just creates a smaller environment so the baby is more constrained which puts more force on the hip joints and effects the development process.
In terms of the commonality of it you’re seeing more cases now?
Dr. Williams: Yes.
Is there another reason for the rise? Does it have to do not only with women’s childbearing hips but now younger people are more active, can you talk a little bit about that?
Dr. Williams: The increase in women is related to two causes – hip dysplasia is more common in women, and women are more active now than decades ago. The onset of symptoms is absolutely related to physical activity. Being active or athletic will not cause hip dysplasia, but it may make the symptoms present earlier or more severely.
What kind of window of time do they have before arthritis kicks in or before they actually will have to have hip replacement?
Dr. Williams: It depends on the severity of dysplasia. For very severe cases the window is fairly small and can be less than a year. Mild and moderate cases typically have a window that is a few years long. The ideal time point for intervention is the first day after the first day of pain, which is obviously near impossible.
Really, but nobody comes then.
Dr. Williams: No, no. The typical course is they go to the pediatrician or primary care doctor who may or may not get an x-ray, or may or may not generate a referral to an orthopedic surgeon. And then, typically non-operative care is attempted with physical therapy, and perhaps an injection. At some point, whenever an orthopedic surgeon looks at the x-ray and the diagnosis is made, a referral is generated to somebody like me who treats hip dysplasia.
So most of your referrals are from orthopedic surgeons?
Dr. Williams: Yes.
What happens if it goes untreated?
Dr. Williams: Early onset arthritis, early need for hip replacement, early need for revision hip replacement with much higher complication rates such as infection and dislocation.
What are the symptoms that the patients that come to see you what do you typically see?
Dr. Williams: Typically hip pain is the first symptom. Hip pain from within the hip joint itself is in the frequently in the groin, but I see a large number of patients that have pain on the outside of their hip near their pockets or in their buttocks. Classically, pain is improved with sitting or lying down. Symptoms commonly occur with standing, being active or while working. Also, it’s not uncommon to see dysplasia initially present when women are pregnant. Because not only are they carrying more weight demanding more of their hip joints but the hormones while a woman is pregnant cause ligaments and connective tissues to relax and any sort of mild cases of instability become much more symptomatic during pregnancy.
What extent of arthritis do you have that still have hip preservation?
Dr. Williams: Ideally none. Mild arthritis is not a contraindication if the patient is young enough.
Who are the patients that you like to treat?
Dr. Williams: Ideally, somebody that has hip dysplasia without arthritis that might need a periacetabular osteotomy, which is a mouthful, so we have shortened it to “PAO”
Speaking of periacetabular osteotomy tell us what that it and what the treatment is like.
Dr. Williams: A PAO is a procedure designed to reorient the joint. The hip socket (aka, acetabulum) is cut apart from the rest of the pelvis so it’s a freely mobile piece of bone. Its position is changed to a more normal location to create a more stable hip joint. It is then fixed in place with screws. After the operation, patients use crutches and are able to put a very small amount of weight on their leg for about two months. At that point if the x-rays look good and healing is appropriate then the crutches are weaned and physical therapy is started to help re-learn how to walk and initiate strengthening.
What are the risks?
Dr. Williams: There can be problems with bone healing – rarely there’s an issue with getting the hip socket to heal back into the pelvis but it’s very uncommon. With any operation, there is a risk of injuring a nerve or a blood vessel, an infection, or a blood clot. If the hip joint later develops arthritis, there is a risk of needing a hip replacement.
When you go in to do the PAO if you see arthritis, you have to clean that out, how do you deal with the arthritis?
Dr. Williams: If there’s mild arthritis like a bone spur we can remove that at the time of the operation. We do a very thorough job before an operation is offered to be sure that there is not arthritis already taking place.
Do you still have success if there is some arthritis?
Dr. Williams: It still can be a very successful operation and postpone arthritis to the stage where it would need a hip replacement. Outcomes are definitely better if we can get to patients before arthritis starts.
What’s the earliest you can have PAO?
Dr. Williams: There is not a hard cutoff. The earliest age would be somebody that’s just reached skeletal maturity – adolescence for most people. My youngest PAO patient thus far was 14 at the time of surgery.
If you were doing a public service announcement to women about their hips and trying to communicate this problem and there is hope if they get done early, how would you do that?
Dr. Williams: Treat hip pain seriously. The vast majority of patients of all ages that have hip pain will probably have something that’s soft tissue related, an over-use type of problem, or nonstructural abnormalities. If the pain doesn’t improve after activity modification and over the counter Tylenol or NSAIDs (Ibuprofen, Naproxen, Advil, Motrin, Aleve), you should have it checked out. That might be as simple as an examination by a physician, an x-ray, or both. There are plenty of problems which have a delayed diagnosis because people dismiss their symptoms. A delay in diagnosis decreases the success rates of any potential treatments. If it is hip dysplasia, there is a small window to offer a joint preserving procedure and avoid a hip replacement. Joint preserving procedure outcomes are much better if done before the arthritis process starts. If hips have already become arthritic then hip replacement is the only surgical option.
Are there certain characteristics or symptoms that you’ll say, wow you’ve got to get this looked at?
Dr. Williams: Persistent pain that doesn’t seem to get better. Classically, it’s activity related – people that are on their feet all day working or during sports. Symptoms commonly occur while they’re doing the activity, at the end of the day, or the next day they experience rebound pain.
And the treatment options then become?
Dr. Williams: A hip replacement or resurfacing.
And what’s the concern about doing hip replacements so young?
Dr. Williams: Hip replacement is a phenomenal operation for patients that have a painful hip or limited function due to arthritis, and are old enough that are unlikely to require a revision – typically 70+ years old. Problems arise when patients are too young and are likely to need a revision hip replacement. Outcomes for revision hip replacement are not as good as primary hip replacement and commonly require larger and larger metal components and removal of native bone. Each time a joint replacement is revised, the expected longevity of each subsequent procedure is less – in other words, if the first replacement lasts 20 years – the average longevity of modern designs – the revision might last 10 to 15 years, and the revision after that even less. Also, the complication rates – infection and dislocation in particular – are higher with each revision procedure. Patients with hip dysplasia that have a hip replacement at a young age will still have pain relief, but are at a much higher risk of needing multiple revision procedures and associated complications. Further, there is good data that shows hip replacement outcomes are the same whether or not someone has had a PAO.
Tell me about Ashley when she came to see you.
Dr. Williams: Ashley is a twenty-year-old woman that was referred to me in the fall of last year. She had a hip arthroscopy (scope) in 2009 to treat a labral tear – it is not uncommon that patients have had one or more hip surgeries before they are referred. In young patients, there is almost always a structural (aka, bony or skeletal) cause for a labral tear. The most common causes are impingement and dysplasia. Identification and treatment of the underlying bony cause for the labral tear is crucial for healing the labral repair and prevention of a recurrent tear. Her labral tear was fixed in 2009 – but her dysplasia went untreated – which provided a couple of years of pain relief. Predictably, all of her symptoms returned when her labrum re-tore. When I met Ashley, she had recently finished high school and was working two jobs. She had a full time job as a nanny and then in evenings working at a pizza parlor. She was on her feet all day every day.
And what was tough about that?
Dr. Williams: At the end of the day she’d come home and just have unrelenting pain. It would prevent her from sleeping and she was at her wits end with hip pain.
And how was she walking?
Dr. Williams: When I met Ashley she had a noticeable limp, patients tend to favor their good side and decrease the amount of time they have to put weight on their affected hip.
How is she doing now?
Dr. Williams: Now she’s doing great. She’s back to work, she’s walking without crutches, her limp is almost gone and she’s still undergoing physical therapy to strengthen her muscles. I think the next time I see her, the limp will be gone.
In terms of outcomes for patients like Ashley will she be able to do athletics again and which one?
Dr. Williams: Absolutely yes. Growing up she was very active she played soccer, basketball, volleyball and gymnastics. Once she’s healed and she is strong as she needs to be, I’m not going to have any formal limitations on what she can or can’t do athletically or for work. I will be sure she understands that avoiding funny positions like gymnastics, squats, lunges, and impact activities like running and jumping will make her hip joint last longer.
So you gave her a new lease on life?
Dr. Williams: In a way, yes.
That’s kind of a cool feeling I bet that you know that you made a difference.
Dr. Williams: It’s an incredibly rewarding feeling and I’m incredibly privileged to be able to offer patients and operation like this and prevent them from getting arthritis and a hip replacement at a young age.
Can it actually prevent hip arthritis too?
Dr. Williams: Absolutely.
So there’s some cases that you’ve seen or documented that you get hip preservation and you won’t ever need anything again?
Dr. Williams: The goal of all operations within hip preservation is to avoid hip replacement altogether – or at least postpone the procedure until patients are older. There are plenty of patients, which have hip dysplasia diagnosed early, who have a PAO before the arthritis process starts and will never get hip arthritis or need a hip replacement.
Do you tell all your patients that?
Dr. Williams: I tell all patients that that is the ideal scenario. It is sometimes hard to predict when the diagnosis or referral is delayed, and the arthritis process has already started whether the outcome will be avoidance versus postponing a hip replacement. If we can buy that patient multiple years until they need a hip replacement I think it’s a tremendous win.
What’s your wish for Ashley?
Dr. Williams: I’m hopeful and confident she’ll be able to go back to working as hard as she wants to and she will be able to get back to the gym.
I know you can do hip replacement too and you can do the direct anterior approach, tell us a little bit about that.
Dr. Williams: Hip replacement can be done through a variety of approaches. I perform both posterior and direct anterior approaches — depending on numerous factors. The advantage to the direct anterior approach is that it’s more friendly to the soft tissues – doesn’t go through the gluteus maximus – and patients tend to have less pain and a faster recovery after the operation.
How about complications?
Dr. Williams: The complication rates are similar to the conventional posterior approach.
END OF INTERVIEW
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