Decision Making in Borderline Cases between Hip Preservation and Reconstruction Surgery

*Munif Hatem, Richard Feng, Srino Bharam and Hal David Martin*

### **Abstract**

The hip joint is the center of human body movement. An optimal hip function is critical for general health, mental health and well-being. A frequent dilemma in orthopedic practice is what to recommend to a patient with hip pain who is neither the ideal candidate for hip preservation surgery nor for total hip arthroplasty. What are the factors to be considered when deciding between a hip preservation or replacement surgery? This chapter aims to help orthopedic surgeons to decide between hip preservation or total hip arthroplasty as the primary surgery for borderline cases. Chondral damage, age, acetabular dysplasia, femoral torsion abnormality, lumbar spine disease, patient expectation, abnormalities in more than one hip layer, comorbidities, and psycho-social determinants are the main factors to be considered on decision-making for hip surgery. Conservative management, hip arthroscopy, hip osteotomy, and total hip arthroplasty can also be seen as a continuum of treatment.

**Keywords:** hip preservation surgery, surgery indication, hip arthroplasty, hip arthroscopy, hip osteotomy

### **1. Introduction**

Orthopedic surgeons treating patients with hip disorders often see borderline cases between hip preservation surgery and total hip arthroplasty (THA). This scenario is becoming more frequent following the advancements in hip preservation surgery techniques in the last 3 decades.

Hip preservation surgery and THA may also be seen as a continuum of treatment. This approach is utilized in many clinical disorders in different medical fields. When treating heart failure, for example, cardiologists will try less invasive clinical and surgical approaches before proceeding with a heart transplant. As in prior times of technological advancement, hip preservation surgery and THA have progressed allowing for a better understanding of the complex hip-spine-pelvic-CORE anatomy and biomechanics of each of the five hip layers: the osteochondral, capsulolabral, musculotendinous, neurovascular, and kinematic chain, the interpretation of which is dependent on a comprehensive history and physical examination, with triplanar

	- Acetabular dysplasia
	- Femoral torsion and acetabular version abnormalities
	- Ischiofemoral impingement

#### **Table 1.**

*Factors to take into consideration to decide between hip preservation versus reconstruction surgery.*

imaging assessment. Osseous conditions of the hip affect other hip layers in a cascading fashion.

The decision for borderline cases between preservation and reconstruction is complex, and the physician is intuitively considering multiple factors to be shared with patient. Frequently, a patient prefers the risk of a failed hip arthroscopy than the potential complications of a total hip arthroplasty. Therefore, the role of the orthopedic surgeon is to be well informed and make the decision with his patient. Similar cases based on imaging findings may require different approaches (conservative, hip preservation or THA) based on patient's expectations.

The goal of this chapter is to organize factors and evidence to help the reader on the decision-making process for borderline cases between preservation and THA. This chapter does not aim to say what is right and what is wrong, it aims to help the reader to make the best decision for the patient based on the patient expectations. As an important reminder, the orthopedic surgeon is not required to make the decision in a single appointment, and repeat assessments are often the best way to define the most appropriate treatment approach for each patient. Repeat visits also helps to build relationship with patients, which is a key component in outcomes. The elements to be discussed in the current chapter are organized as in **Table 1**.
