Courtesy: Sports Kongres, Copenhagen, Denmark

Hip arthroscopy for osteoarthritis?
-Dr. Bent Lund, Denmark.

Surgical treatment of hip dysplasia
-Prof. Kjeld Søballe, Denmark.

Hip arthroplasty in young active adults. Last option?
-Prof. Fares Haddad, UK.

Hip Preservation and Arthroplasty: Hip Arthroscopy, Dysplasia and the Young Active Patient

Introduction

This symposium brings together three experienced hip surgeons to discuss the management of patients with hip pain across the spectrum—from joint-preserving procedures to total hip arthroplasty.

The discussion emphasizes an important clinical principle: not every patient with hip pain requires surgery. The decision-making process should include appropriate imaging, careful assessment of pathology, patient age and activity level, and consideration of non-operative treatment.

The symposium covers three major areas:

Hip arthroscopy in the presence of osteoarthritis and femoroacetabular impingement
Hip dysplasia and periacetabular osteotomy (PAO)
Hip arthroplasty in young and active patients

1. Hip Arthroscopy in the Presence of Osteoarthritis

Assessing Osteoarthritis on Radiographs

When considering hip arthroscopy in a patient with possible osteoarthritis, careful assessment of the radiographs is essential.

The speaker uses the Tönnis classification to grade osteoarthritis.

Tönnis Grade 0

No radiographic signs of osteoarthritis.

Tönnis Grade 1

Mild sclerosis.
Minimal joint-space narrowing.
Early osteophyte formation.

Tönnis Grade 2

Further joint-space narrowing.
Small cystic changes in the femoral head or acetabular roof.
More obvious radiographic evidence of osteoarthritis.

Tönnis Grade 3

Advanced osteoarthritis.
Severe joint-space narrowing or complete loss of joint space.
Severe deformity.

A severely arthritic hip with essentially no remaining joint space is not considered an appropriate situation for hip arthroscopy.

Importance of Joint-Space Width

The standing AP pelvis radiograph is particularly important when evaluating a patient for hip arthroscopy.

The assessment should include:

Joint-space width, particularly in the weight-bearing portion of the joint.
Acetabular cysts.
Other radiographic evidence of degenerative change.
Overall severity of osteoarthritis.

The speaker notes that, in his practice, a lateral joint-space width of less than 3 mm is considered a relative contraindication to hip arthroscopy.

MRI or CT may be useful when the radiographic assessment is uncertain.

2. Cartilage Damage in Hip Arthroscopy

The Danish Hip Arthroscopy Registry provides substantial clinical data regarding patients undergoing hip arthroscopy.

The registry was established in 2012 and collects:

Preoperative patient-reported outcome measures.
Surgical data.
One-year outcomes.
Two-year outcomes.
Five-year outcomes.

Cartilage damage is graded using specific classifications for the femoral head and acetabulum.

Acetabular Cartilage Changes

The progression of acetabular cartilage damage includes:

Grade 0: Normal cartilage.
Grade 1: Mild fibrillation.
Grade 2: Delamination or the “wave sign.”
Grade 3: Cleavage.
Grade 4: Full-thickness cartilage defect.

The progression may therefore range from relatively normal cartilage to delamination, cleavage and ultimately full-thickness cartilage loss.

3. Femoroacetabular Impingement

One of the major causes of cartilage and labral pathology in younger patients is femoroacetabular impingement (FAI).

The concept of FAI was originally described in the early 2000s and has significantly influenced the understanding of hip pathology.

FAI is broadly divided into:

Pincer morphology
Cam morphology
Mixed morphology

Most patients have a combination of cam and pincer morphology.

Pincer Morphology

Pincer-type impingement is characterized by excessive acetabular coverage.

This may be:

Generalized or focal.
Related to acetabular overcoverage.
Associated with anterior or posterior acetabular prominence.
Related to acetabular retroversion or other morphological abnormalities.

The repetitive contact may produce:

Labral pathology.
Cartilage injury.
Changes at the chondrolabral junction.

Cam Morphology

Cam morphology is characterized by an abnormal bony prominence at the femoral head-neck junction.

It may be associated with:

Loss of the normal femoral head-neck offset.
Pistol-grip morphology.
Femoral version abnormalities.

During hip motion, the cam lesion can contact the acetabulum and produce characteristic chondrolabral injury and cartilage delamination.

4. Can Hip Arthroscopy Be Performed in Patients With Osteoarthritis?

The central question is whether patients with radiographic osteoarthritis can still benefit from hip arthroscopy.

The evidence remains limited, particularly because there are relatively few high-level studies.

A Danish clinical guideline reviewed available evidence regarding outcomes in patients over 40 years of age.

Age

Some studies suggest that appropriately selected patients over 40 can achieve improvements in:

Pain
Function
Patient-reported outcome measures

However, age alone should not determine suitability for arthroscopy.

Radiographic severity and cartilage status are important.

Joint-Space Width as a Predictor

Studies have suggested that patients with a joint-space width of 2 mm or less have poorer outcomes and are less likely to benefit from hip arthroscopy.

The Danish experience has generally used a more conservative threshold, with 3 mm of joint space considered an important relative threshold for proceeding with arthroscopy.

The overall evidence, however, does not establish one universally applicable cutoff.

5. Risk of Conversion to Total Hip Arthroplasty

The risk of subsequent total hip arthroplasty increases with:

Higher preoperative osteoarthritis grade.
Reduced joint-space width.
More severe cartilage damage.
Increasing age.

Data from the Danish Hip Arthroscopy Registry demonstrated significant improvement in patient-reported outcomes following arthroscopy, including measures of:

Pain.
Symptoms.
Activities of daily living.
Sport and recreation.
Quality of life.

However, longer-term follow-up demonstrates that some patients eventually require conversion to total hip arthroplasty.

The risk is particularly important in patients with more advanced osteoarthritis.

6. Cartilage Restoration and Microfracture

Microfracture has been used for focal full-thickness cartilage defects of the hip.

Available studies have generally reported promising early results, but the evidence consists predominantly of small clinical series and lower-level evidence.

The long-term durability of microfracture in the hip remains uncertain.

Other cartilage-restoration strategies, including scaffold-based techniques such as AMIC (autologous matrix-induced chondrogenesis), have also been explored.

These techniques remain areas of ongoing investigation.

7. Practical Approach to Hip Arthroscopy in Osteoarthritis

The speaker’s practical approach is to assess:

The patient’s age.
Tönnis osteoarthritis grade.
Joint-space width on standing radiographs.
Severity and location of cartilage damage.
Underlying morphology, particularly FAI.
Patient symptoms and functional requirements.

Key Principle

Hip arthroscopy may have a role in carefully selected patients with mild degenerative changes, but advanced osteoarthritis with marked joint-space loss is unlikely to benefit.

8. Hip Dysplasia

The second presentation focuses on developmental dysplasia of the hip (DDH) and its surgical management.

Patients with symptomatic hip dysplasia are often young adults.

Typical symptoms include:

Groin pain.
Lateral hip or “C-sign” pain.
Activity-related symptoms.

A standing AP pelvis radiograph is an essential component of the evaluation.

9. The Lateral Center-Edge Angle

The lateral center-edge (LCE) angle of Wiberg is used to assess lateral acetabular coverage.

The measurement involves:

Identifying the center of the femoral head.
Drawing a horizontal reference line.
Drawing a line from the center of the femoral head toward the lateral acetabular edge.
Measuring the resulting angle.

The speaker considers an LCE angle of less than 25° indicative of acetabular dysplasia.

However, acetabular dysplasia is a complex three-dimensional condition, and the LCE angle alone does not capture all aspects of acetabular morphology.

10. Clinical Assessment of Hip Dysplasia

Clinical examination includes assessment for:

Impingement Test

Flexion of the hip.
Adduction.
Internal rotation.
Reproduction of groin pain suggests a positive test.

FABER Test

Flexion.
Abduction.
External rotation.
The knee is gently directed toward the examination table.
Groin pain may indicate hip pathology.

Clinical examination must be interpreted together with radiographic findings and the patient’s symptoms.

11. Indications for Periacetabular Osteotomy

The speaker describes the following factors as important when considering PAO:

Symptomatic hip.
LCE angle less than 25°.
Good joint congruency.
Preserved range of motion.
No or mild osteoarthritis.
Relatively young age.

The procedure is intended to correct the underlying mechanical problem by improving acetabular coverage.

12. Minimally Invasive PAO

The speaker describes the development of a minimally invasive approach to PAO.

The technique involves controlled osteotomies of:

Pubic bone.
Ischium.
Ilium.

An important feature of the procedure is preservation of the posterior column.

Maintaining the posterior column contributes to stability of the acetabular fragment.

The fragment can then be reoriented to improve femoral head coverage and fixed with screws.

Surgical Approach

The described approach uses a relatively small incision extending from the region of the anterior superior iliac spine toward the hip joint.

The surgeon must work in close proximity to:

Femoral vessels.
Obturator nerve and vessels.
Sciatic nerve.
Lateral femoral cutaneous nerve.

Fluoroscopic imaging is used to confirm the position and orientation of the osteotomies.

13. Postoperative Management Following PAO

The described protocol includes:

Mobilization on the day of surgery.
Discharge approximately one day after surgery in most patients.
Approximately 30 kg weight-bearing for six weeks.
Radiographic assessment of healing.
Progression toward full weight-bearing at approximately eight weeks.

The precise rehabilitation protocol may vary according to the surgical technique and individual patient factors.

14. Complications of PAO

Potential complications include:

Nerve injury.
Vascular injury.
Secondary displacement.
Delayed union.
Non-union.
Infection.

In the speaker’s reported series of more than 1,600 procedures, complications were uncommon, and most reported nerve palsies were temporary.

The speaker reports an overall complication rate of less than 0.4% in this series.

15. Outcomes Following PAO

The speaker reports significant improvements following PAO in:

Pain.
Symptoms.
Activities of daily living.
Sports and recreation.
Quality of life.

The procedure increases acetabular coverage and is intended to reduce the mechanical load on the hip joint.

One CT-based analysis demonstrated an increase in femoral head coverage from approximately 54% preoperatively to 87% postoperatively.

16. Factors Affecting PAO Outcomes

Factors associated with poorer outcomes or increased risk of conversion to total hip arthroplasty include:

Increasing age.
More severe dysplasia.
Pre-existing osteoarthritis.
Inadequate correction.
Poor postoperative acetabular orientation.

The speaker emphasizes the importance of achieving an appropriate correction.

In his experience, patients with minimal or no osteoarthritis have the most favorable prognosis.

17. Labral Pathology in Hip Dysplasia

The labrum plays an important role in the dysplastic hip.

Insufficient acetabular coverage increases the load transmitted through the labrum.

Chronic overload may result in:

Labral degeneration.
Labral tearing.
Chondrolabral pathology.
Progressive cartilage damage.

The speaker describes MRI assessment of dysplastic hips demonstrating labral pathology in the vast majority of patients in his series.

18. Arthroscopy in Hip Dysplasia

A major discussion point is whether arthroscopy should be performed in patients with dysplasia.

The speakers emphasize that the underlying mechanical problem of inadequate acetabular coverage must be considered.

For symptomatic patients with an LCE angle below 25°, the speakers favor correction of the dysplasia with PAO rather than isolated arthroscopy.

The concern is that treating the labrum without correcting the underlying instability or inadequate coverage may result in persistent mechanical overload and recurrent pathology.

19. The Borderline Dysplastic Hip

The borderline dysplastic hip represents a challenging area.

An LCE angle between approximately 20° and 30° may not adequately describe the three-dimensional morphology.

Other factors may include:

Anterior coverage.
Posterior coverage.
Acetabular version.
Femoral version.
Three-dimensional acetabular morphology.

CT or other three-dimensional imaging may therefore be useful in selected cases.

The speakers emphasize that the LCE angle should not be interpreted in isolation when dealing with borderline cases.

20. Dysplasia With Femoroacetabular Impingement

Patients may have a combination of:

Acetabular dysplasia.
Cam morphology.
Labral pathology.

These patients represent a particularly challenging group.

Simply removing a cam lesion and trimming or repairing the labrum may fail to address the underlying instability caused by inadequate acetabular coverage.

The speakers therefore caution against treating the morphology in isolation without understanding the underlying biomechanics.

21. The Importance of Diagnosis

An important theme of the discussion is that young patients with groin pain require careful characterization of the underlying pathology.

Patients may spend considerable time:

Reducing activity.
Undergoing physiotherapy.
Living with persistent symptoms.

Obtaining the correct diagnosis is therefore important even when the ultimate treatment is non-operative.

22. Hip Arthroplasty in Young and Active Patients

The third presentation considers the role of hip arthroplasty when joint-preserving procedures are no longer appropriate.

Although arthroplasty is often regarded as the “last option,” modern hip replacement can provide excellent pain relief and functional improvement.

The challenge is particularly important in young and active patients, who have high expectations regarding:

Pain relief.
Function.
Sport.
Longevity of the implant.
Return to normal activities.

23. The Goal of Modern Hip Arthroplasty

The ideal outcome is for the patient to eventually stop thinking about the replaced hip and return to normal life.

The speaker identifies several goals:

Eliminate pain.
Restore function.
Allow meaningful physical activity.
Maintain quality of life.
Minimize the risk of revision surgery.

Patients increasingly expect to return to sports and other demanding activities after arthroplasty.

24. Measuring Success After Hip Arthroplasty

Traditional outcome measures frequently focus on:

Pain.
Patient-reported function.
Need for revision surgery.

However, the speakers emphasize that these measures may not fully capture what matters to younger patients.

For active patients, important outcomes include:

What activities they can perform.
How well they perform them.
Whether they are comfortable doing them.
Whether they are satisfied with their activity level.

Functional testing can therefore provide additional information.

The speaker describes assessment using activities such as:

Single-leg stance.
Stair climbing.
Lateral step-ups.
Forward frog jumps.
Sideways frog jumps.

Gait analysis using force-plate treadmills can also evaluate:

Walking speed.
Contact time.
Loading.
Performance on inclines and declines.

25. Return to Sport After Hip Arthroplasty

Evidence regarding return to sport after hip arthroplasty remains relatively limited.

Young, active patients often want to:

Run.
Jump.
Cycle.
Participate in recreational sports.
Return to higher-level physical activity.

The available evidence suggests that many patients can return to substantial levels of physical activity.

However, activity levels may be influenced not only by physical capacity but also by fear of damaging the implant.

26. Hip Resurfacing Versus Total Hip Arthroplasty

The speaker discusses a 10-year study comparing hip resurfacing with total hip arthroplasty in younger patients.

The study included patients aged approximately 29–55 years.

Functional testing demonstrated differences that were not always apparent using conventional patient-reported outcome scores.

Patients undergoing hip resurfacing demonstrated functional performance that was closer to age-matched individuals with native hips in some measures.

The speaker emphasizes, however, that these findings should not be interpreted as an argument that all young patients should undergo hip resurfacing.

The historical concerns surrounding metal-on-metal bearings remain important.

27. Activity After Hip Arthroplasty

In the reported cohort of young patients undergoing arthroplasty:

Approximately 49% of patients undergoing resurfacing were still running at 10 years.
Approximately 85% were still participating in sport.
Approximately 18% continued manual work.

These figures demonstrate that substantial physical activity can be possible after hip arthroplasty.

However, implant selection, patient characteristics, activity level and bearing technology must all be considered.

28. What Do Patients Actually Do After Arthroplasty?

A larger cohort study examined what patients believed they could do after hip replacement and compared their postoperative activity with their previous activity.

Most patients reported substantial improvement.

Examples included:

Golfers returning to golf.
Runners continuing to run.
Some cyclists choosing not to cycle outdoors because of concerns about protecting the implant.

A key finding was that patients often reduced activities not because of pain, but because they were concerned that certain activities might damage the prosthesis.

The source of these restrictions included:

Surgeons.
Physiotherapists.
Friends and family.
Patient perceptions about implant safety.

29. Patient Satisfaction

Most patients in the reported cohort were:

Satisfied or highly satisfied with their hip replacement.
Willing to recommend the procedure.
Able to participate in activities they considered important.

Many patients reported that they could perform their chosen activities better than before surgery.

Nevertheless, the frequency of participation was often lower than before the onset of hip disease.

30. Activity Restrictions After Hip Arthroplasty

The panel discussion addressed whether formal restrictions should be imposed following hip arthroplasty.

There is considerable variation between surgeons and institutions.

One speaker described a protocol in which patients were allowed to undertake activities relatively freely after the initial postoperative period.

The rationale was that traditional restrictions may not necessarily prevent dislocation in all patients.

The panel also discussed evidence suggesting that many patients do not strictly follow restrictions in daily life.

31. Rehabilitation and Return to Activity After PAO

Following PAO, the described rehabilitation pathway includes:

Protected weight-bearing during the early healing phase.
Gradual progression of weight-bearing after radiographic evidence of healing.
Gradual return to running.
Initial treadmill running.
Progression to outdoor running.
Gradual return to pivoting and higher-demand sports.

The speaker recommends that patients who experience pain during progression should reduce the activity and consider lower-impact alternatives.

32. Rehabilitation Before PAO

The panel discussed the role of preoperative rehabilitation.

Most patients presenting for PAO have already undergone some form of physiotherapy.

However, the optimal physiotherapy program for dysplasia remains incompletely defined.

The speakers recommend maintaining physical conditioning while patients are awaiting surgery.

Patients may be encouraged to:

Exercise under physiotherapist supervision.
Maintain strength and conditioning.
Remain as active as symptoms permit.
Address excess body weight when appropriate.

33. Body Weight and PAO

The panel also discussed body mass index as a consideration in PAO.

The speaker reported a preference for patients to have a BMI below approximately 25 kg/m², based on concerns regarding complications in patients with higher BMI.

However, the discussion acknowledges that BMI should be interpreted in the context of the individual patient and the available evidence.

34. Arthroscopy, PAO and the Dysplastic Labrum

One of the most important discussions concerns patients with dysplasia and labral pathology.

The labrum in a dysplastic hip may become hypertrophic and function as an important load-bearing structure.

Removing or excessively trimming the labrum can therefore have detrimental consequences.

The speakers emphasize that:

Correcting the mechanical abnormality should take priority over simply treating the labral tear.

In patients with clear dysplasia, isolated arthroscopic labral treatment may fail because the underlying acetabular deficiency remains.

35. The Gray Zone: Dysplasia and Impingement

Patients with both dysplasia and impingement represent a particularly difficult clinical problem.

The surgeon must determine whether the dominant problem is:

Instability from inadequate acetabular coverage.
Impingement from excessive coverage or cam morphology.
A combination of both.

Three-dimensional assessment may be necessary in borderline cases.

The panel emphasizes that morphology, symptoms and biomechanics must be considered together.

36. Prophylactic Surgery for Asymptomatic FAI

The panel was asked about patients with bilateral cam or pincer morphology where only one hip is symptomatic.

The speakers do not recommend prophylactic surgery simply because an asymptomatic hip demonstrates radiographic morphology.

Surgery should generally be directed toward symptomatic patients.

The presence of an abnormal radiograph in an asymptomatic hip does not, by itself, establish an indication for surgery.

37. The Role of Sham Surgery and Research

The panel discussed the lack of high-level evidence in some areas of hip arthroscopy.

At the time of the presentation, randomized trials involving sham hip arthroscopy were being developed or undertaken.

The speakers highlighted the need for better evidence regarding:

The true efficacy of hip arthroscopy.
The contribution of the surgical procedure versus placebo effects.
The optimal rehabilitation program.
Management of borderline dysplasia.

These areas remain important subjects for clinical research.

38. Key Take-Home Messages

Hip Arthroscopy

Carefully evaluate osteoarthritis before considering arthroscopy.
Standing AP pelvis radiographs are important.
Assess joint-space width.
Increasing osteoarthritis and cartilage damage are associated with poorer outcomes.
Advanced joint-space loss is a poor setting for hip arthroscopy.
Age is relevant, but should not be considered in isolation.

Hip Dysplasia

Evaluate acetabular coverage systematically.
The LCE angle is an important measurement, but does not describe the entire three-dimensional morphology.
Symptomatic dysplasia with inadequate coverage may be best treated by PAO rather than isolated arthroscopy.
Preserve the labrum whenever possible.
Borderline dysplasia requires careful assessment of three-dimensional morphology, version and coverage.
The quality of correction is an important determinant of outcome.

Hip Arthroplasty

Total hip arthroplasty remains an excellent procedure for appropriately selected patients.
Young and active patients can achieve substantial functional improvement.
Return to sport is possible for many patients.
Patient expectations and concerns about implant longevity strongly influence postoperative activity.
Functional outcome measures may reveal differences that conventional scores miss.
Clear and evidence-based guidance regarding postoperative activity is still needed.

Conclusion

The symposium highlights the importance of appropriate patient selection and understanding the underlying biomechanics of the hip.

Hip arthroscopy can provide meaningful improvement in carefully selected patients, but advanced osteoarthritis substantially reduces the likelihood of success.

In symptomatic hip dysplasia, correcting the underlying acetabular deficiency is fundamental. PAO provides a joint-preserving method of improving femoral head coverage and redistributing load across the hip.

When preservation is no longer possible, modern hip arthroplasty provides excellent pain relief and allows many young patients to return to substantial levels of physical activity.

Across all three treatment strategies, the central message is the same:

The goal is not simply to perform an operation—it is to correctly identify the pathology, select the appropriate patient, address the underlying mechanical problem and restore meaningful function.

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