Hip pain in the young, active patient: surgical strategies

Hip disorders in young patients likely exist as a spectrum of prearthritic and arthritic conditions. With the increasing recognition of these disorders, surgical options are being popularized and more patients are being treated at a younger age. Hip surgeons must develop a careful set of evidenced-based indications and follow surgical outcomes in a rigorous, scientific manner. Hip arthroscopy can be used to successfully treat some hip disorders, including labral tears, with or without femoroacetabular impingement, resulting in mechanical symptoms. Long-term outcomes after arthroscopy are determined by the condition of the cartilage at the time of surgery. Patients with preoperative radiographic evidence of moderate to severe arthritis have poor outcomes when treated with arthroscopy. Open joint preservation procedures (including periacetabular osteotomy and surgical hip dislocation with osteochondroplasty) can be done in the absence of substantial arthritis to treat hip dysplasia, femoroacetabular impingement, and related conditions. The results of these procedures are good in appropriately selected patients at short-term to midterm follow-ups. In the presence of severe arthritis, joint replacement is the treatment of choice. Total hip arthroplasty using uncemented acetabular and femoral fixation provides reliable osseointegration; however, long-term results in young patients have historically been compromised by bearing surface wear, osteolysis, and component loosening. Contemporary, highly cross-linked polyethylene and ceramic-on-ceramic bearings have durable results, low complication rates, and offer the potential of long-term survivorship in this high-demand population. In general, metal-on-metal implants have higher complication rates versus other bearing surface options and should be avoided. The best results of hip resurfacing are seen in men younger than 55 years with large femoral head sizes. Although implant survivorship is comparable to that of total hip arthroplasty, the sequelae of metal wear debris continue to cause concern.