Please review our Terms of Use before proceeding. OSI wishes to repeat and make clear that by reviewing the following, either on a digital screen or in printed format, you (or any reviewer hereof) acknowledge, without exception, that you (or any reviewer hereof) have/has reviewed OSI’s Terms of Use. The information below is not in simple bullet points and represents nothing more than information. Joint preservation cannot be described in one or two structured sentences and simple bullet points. A broader understanding of osteoarthritis is required for a committed surgeon to perform a successful Intraarticular Saucerization. Quick and simple answers and sound bites have been avoided because patients need to be engaged in their healthcare and talk to their doctors. In this regard, a reader hereof may find the information below interesting. Indeed, one is always desirous of immediate relief from pain, and it is for this reason that any reviewer hereof must talk to their doctor. OSI encourages all of us to be informed so that we can avoid ever reaching a point wherein a joint replacement is our only option. Ask questions and be engaged.
To understand hip pain, let’s first describe how the hip bones come together to make the hip joint. The working parts of the hip joint consist of two bones: the hip and the thighbone (femur). Where the thigh bone connects to the hip bone is called the hip joint. The upper end of the thighbone is called the femoral head, and it is covered with cartilage. The hip bone has a cup-like socket where the femoral head connects to the hip bone called the acetabulum. The acetabulum is also covered with cartilage. The outer rim of the acetabulum is outlined with a fibrous structure called the labrum. The labrum helps keep the femoral head in the acetabulum (socket) when the foot is off the ground. The hip joint also has important bands that hold the bones together called ligaments. Additionally, the acetabulum has a central and deep area called the cotyloid (pronounced cot-ta-loid) fossa. This fossa is not covered with cartilage and is present to make room for a large ligament within the hip joint called the ligamentum teres (round ligament). For example, when you swing your RIGHT foot forward to take a step, the round ligament tightens up and requires less space inside your hip joint. When you place your RIGHT foot on the ground and move your LEFT foot forward, the round ligament in the right hip joint becomes bulky and needs more space. The cotyloid fossa provides this space. The hip joint also includes strong ligaments surrounding the joint to increase its stability. The lining of the hip joint capsule produces a lubricant called synovial fluid that helps the femoral head glide against the acetabulum. When the foot is off the ground, gravity tries to pull the femoral head out of the acetabulum. This causes the capsule to compress the labrum against the femoral head, creating the so-called suction seal, like a Chinese finger trap. The most important function of the hip joint is walking.
Hip pain results when the working parts of the hip joint do not operate together smoothly. Often, patients are advised of a labral tear. In some patients, these tears occur because when the foot is on the ground, as described above, the hip partially, not completely, slips out of its socket. With each step, just enough extra pressure is put on the labrum until it tears. This chronic pressure can be called rim loading, which will lead to the development of a pincer lesion, as well. The femoral head slightly slips out of its socket because there is insufficient space in the cotyloid fossa for the round ligament when it becomes bulky. These kinds of labral tears are common and may be identified on an MRI, but why the tear occurred is usually not considered. When its cause is considered, one often looks for a previous traumatic event of current or prior sports-related activity. While this may be the case, how the femoral head rests in the acetabulum while walking must be evaluated. Importantly, congestion of the ligamentum teres and the soft fat (pulvinar) within the cotyloid fossa is not considered nor recognized as contributing to the labral tear. Congestion of the ligamentum teres and the pulvinar reduces the space available for the ligamentum teres, as described above. Any of a number of diseases or changes in body weight can alter how the working parts of the hip joint operate together. The most common disease affecting the working parts of the hip joint is osteoarthritis. In addition to treating pain within the hip joint, treatment should also include making sure that the working parts of the hip joint operate together smoothly. If the treatment only masks the pain within the hip joint with abnormal working parts, things may worsen.
It depends on the cause. The most common cause of hip pain in people over 50 is osteoarthritis. A comprehensive treatment plan for pain due to osteoarthritis of the hip, if saving the joint is desired, may range from non-surgical reassurance with NSAIDs, such as Advil, to minimally invasive two or three micro incisions Intraarticular Saucerization (IA Saucerization), see below. However, arthroscopy is not considered if the hip joint has 2 mm of joint space or less. Nonetheless, if traditional arthroscopy of the hip joint is performed by an expert hip arthroscopy surgeon, the labrum, pincer, and CAM lesions are likely the only structures addressed. No consideration is given to the contents of the cotyloid fossa and how the femoral head may partially slide out of its socket while walking. If cleaning the fossa is considered as part of hip arthroscopy, traditional arthroscopy equipment does NOT allow access to the cotyloid fossa. See the video link below. Frequently, patients complain of the hip feeling unstable or coming out of its socket. This complaint may be attributed to a labral tear, but such tear often results from the femoral head slightly coming out of its socket with each step.
Given the above, the longevity of the hip joint may be adversely affected and when more extensive surgery is required, a joint replacement may be performed. During treatment planning, an x-ray allows the surgeon to see the bones of the hip and how they fit together. An MRI of the hip allows the surgeon to see the labrum, the cartilage, the ligaments, the tendons, and the insides of the bone. A painful hip may experience pain during certain motions, and x-rays and MRIs do not show this relationship. The x-ray and MRI are taken while the hip is not in motion. This is why it is important to explain to your surgeon the specific problem you are having with your hip joint and in what positions the pain worsens or is its worst. All labral tears are not due to sports-related injuries.
When a patient undergoes standard arthroscopy of the hip joint with a labral tear, certain clinical criteria are met, and the surgeon typically performs this procedure without consideration of how the bone spurs, if any, in the hip joint formed nor how these bone spurs may contribute to pain and a labral tear. A typical bone spur that may be missed is the central acetabular osteophyte. This is a bone spur within the cotyloid fossa that may push the femoral head out of its socket while walking. The IA Saucerization is a minimally invasive hip arthroscopy procedure that removes this bone spur and others that cause abnormal contact between the hip structures. The procedure ensures proper labral function by cleaning or repairing the labrum and moving the femoral head back into its anatomic position. X-rays and MRIs do not show how the femoral head moves slightly out of its socket with walking; therefore, the surgeon will test for this while in surgery. In addition to smoothing over the cartilage with a microchondroplasty, well-known CAM or pincer lesions (a type of bone spur) may be removed. Yet here again, how and why the CAM and pincer lesions developed is NOT considered as they relate to a lack of space for the ligamentum teres in the cotyloid fossa. In select cases, autologous bone and bone marrow, obtained through a 2 mm incision at the iliac crest (the top of the hip bone), may then be injected into the bone to replace the fat released to improve the bone’s health and strength. An IA Saucerization of the hip arthroscopically reshapes the structures of the hip joint without replacing the joint. The skilled surgeon performs the procedure through two to three 2 mm incisions while repeatedly motioning the hip during surgery as if the patient were sitting, crossing, or opening their legs. The blood pressure and heart rate are monitored for spikes indicating that the area being cleaned and reshaped is a source of pain. The IA Saucerization considers the limitations of x-rays and MRIs to show the motion relationships between the working parts of the hip joint and how motion brings on pain and deformity. For example, the images of x-rays and MRIs do not show how a bone spur within the cotyloid fossa causes the femoral head to move slightly out of its socket during walking. For a surgeon to perform an IA Saucerization of the hip, specialized equipment developed by OSI must be used. The surgeon must place the arthroscopic instruments into the joint to allow the entire hip joint to be explored. If a treating surgeon concludes that an IA Saucerization is routine hip arthroscopy with a different name or that it can be completed with well-known hospital equipment using a standard fellowship prescribed approach, or the approach of a known hip arthroscopy expert, a good outcome is not likely to be realized at all. The hemi-lithotomy position is recommended and apex triangulation of the instruments must occur in the central compartment of the hip joint. Large capsulotomies should be avoided, and pincer lesions should be addressed after restoring the true acetabulum. See The Q Hip Arthroscopy - Video One.
The following questions should be considered by those interested in understanding an IA Saucerization of the hip joint:
A core decompression track is blind drilling into the femoral head. The purpose of the drilling is to decrease the pressure within the femoral head. The limitation of the core decompression is that the intraosseous blood may not be returned to the femoral head. Thus, many patients may experience immediate relief of symptoms, but the relief is not long-lasting. The real purpose of the core decompression should be relief of the pressure and removal of the dead bone within the femoral head. See references 3 and 4 of the oxLDL White Paper. Specifically, some surgeons report an 84 percent success rate after core decompression, while others report a less than 15% success rate after core decompression. Three additional procedures were created to improve these results. These procedures are the Lightbulb procedure of Rosenwasser, the Trapdoor of Mont, and the free vascularized fibula graft of Urbaniak. Each of these surgeons consistently obtained a greater than 84 percent success rate. However, these procedures are very invasive. What these surgeons do NOT recognize is that in performing their procedures they are essentially achieving thorough debridement of the femoral head. Thorough debridement removes nearly all of the dead bone from the femoral head, leading to a successful outcome. Brannon recognized that thorough debridement of the femoral head is key to the success of core decompression in achieving a lasting outcome. Thus, Brannon developed the Intraosseous Saucerization procedure. An intraosseous Saucerization combines core decompression with endoscopically guided thorough debridement of the femoral head. An arthroscope is placed inside of the core track to identify the dead bone that remains in the femoral head after core decompression. Once identified, the dead bone is removed, which leads to robust bleeding inside of the femoral head. The blood flow into the femoral head is from the outside in and NOT from the inside out. Thus, a vascularized fibula graft, which provides blood flow from the inside out, was not viewed as a requirement because once the dead bone was removed, the arthroscope demonstrated numerous briskly bleeding blood vessels that would supply the bone graft that is used to fill the cavity created by thorough debridement. When an Intraosseous Saucerization is combined with an Intraarticular Saucerization the hip joint can be expected to last 20 years. Nothing in our procedure requires a complex way of understanding hip pain and AVN. At OSI, common sense makes sense.
Joint replacement of the hip is cleaning of the hip that is so extensive an artificial joint must be inserted in the place of the normal hip joint. The surgeon may perform the replacement in a traditional manner or use the assistance of a robot. When cleaning the hip this extensively, the cuts of the bone must follow a particular pattern so that the artificial components can be attached to the femur and the hip bone. The components may be fixed to the bone with or without cement. During a primary total hip replacement, the first time the hip is replaced, the surgeon usually does not treat any condition of the underlying bone. The bone is assumed to be healthy enough to support the artificial components. Additionally, the procedure will attempt to correct any abnormal alignment of the joint.