The Hip in Young Patients: Arthritis, Joint Degeneration and Surgical Interventions with Professor Sam Adie

The podcast presented by Professor Sam Addy focuses on the complex issue of hip arthritis in younger patients. Professor Addy, an expert in orthopaedic and trauma surgery from the University of New South Wales, highlights the unique challenges this demographic faces in managing hip arthritis, differentiating it from cases seen in older patients. His discussion begins with an overview of the epidemiology of hip arthritis, the causes specific to younger individuals, and the assessment methodologies utilized in treatment decision-making.

Throughout the lecture, Professor Addy emphasizes that osteoarthritis remains the most prevalent cause of hip arthritis among younger patients, despite being predominantly a condition that worsens with age. He points out significant demographic insights from the Australian Orthopedic Association joint replacement registry, noting that about 15% of hip replacements are performed on patients younger than 55. He underlines that hip arthritis drastically affects quality of life and increases the burden on healthcare due to its early onset in younger individuals, leading to a longer duration of suffering and disability compared to older patients.

Professor Addy elaborates on the various causative factors for hip arthritis in younger patients. While osteoarthritis is common, he discusses other contributors such as obesity, chronic inflammatory arthritis, avascular necrosis, and developmental issues relating to the hip. Among these, avascular necrosis stands out as a significant concern, often resulting from factors such as alcohol use or corticosteroid treatments, leading to severe long-term consequences. He provides visual aids to help attendees understand the stages and severity of such conditions, emphasizing the importance of recognizing childhood hip problems that could predispose patients to arthritis later in life.

The lecture also covers the critical decision-making process involved in assessing young patients with hip arthritis. Professor Addy stresses the importance of understanding the patient's pain levels, functional status, and previous treatments. He discusses the utility of patient-reported outcome measures like the Oxford hip score to gain insights into how arthritis impacts daily living, especially for those engaged in physically demanding occupations or sports.

When discussing treatment modalities, Professor Addy advocates for a structured approach that begins with non-surgical options, including education, exercise, and weight loss. He underscores the importance of establishing a solid foundation with conservative management before considering surgical interventions. Only after confirming the persistence of significant symptoms and confirming arthritis through imaging does he recommend hip-preserving procedures or arthroplasties, discussing the benefits and risks associated with each surgical option.

Professor Addy provides a thorough overview of surgical treatments, comparing total hip replacements and resurfacing procedures. He acknowledges the advantages of resurfacing for younger patients, particularly in preserving bone structure and facilitating a return to high-impact activities. However, he illustrates the challenges and potential complications associated with metal-on-metal devices traditionally used in resurfacing surgeries, emphasizing the innovations in ceramic materials that promise better long-term outcomes.

As the lecture concludes, Professor Addy encapsulates the critical points regarding the disproportionate impact of hip arthritis on young patients and the multifaceted considerations involved in their treatment. He reiterates the necessity for tailored treatment approaches that address the unique needs of younger individuals experiencing hip arthritis, advocating for ongoing research and development to enhance surgical techniques and materials that could improve patient outcomes in this population.

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It is my great pleasure now to introduce our chairman for today, Professor Sam Addy.

So Sam, or Professor Sam Addy, is a professor of orthopaedic and trauma surgery

at the University of New South Wales.

He specialises in surgery of the hip and knee, including primary and revision

surgeries of the, sorry, primary and

revision hip and knee replacement and arthroscopic surgery of the knee.

He completed his training in Sydney, followed by fellowship training at the

University of Oxford and the University of Toronto.

Professor Addy works at several hospitals across Sydney, including St George

Hospital, which is a Level 1 facility and one of the busiest referral centres in Australia.

He has been awarded approximately $15 million in competitive research grants.

And he has won numerous awards for his research and runs a series of clinical

trials to improve outcomes after joint replacement and injury.

And today Professor Addy will be speaking about hip arthritis in the young patient.

Thank you so much, Jody.

So this talk is about the young patient with arthritis.

There will be a talk a bit later, I think, by Munjid about hip problems in the older patient.

So I'm going to try and focus on issues specifically relating to young patients

who present with hip arthritis.

I mean, there's going to be a little bit of overlap between the two talks,

but hopefully some focus on issues specific to the young patient.

So this is my disclosure. I am a founding surgeon partner at the Orthopedic Institute here.

This is an outline of the talk today. So we're going to talk about the epidemiology of hip arthritis.

What causes it in the younger patient?

How do you assess and what's my decision-making sort of process when it comes

to the younger patient with hip arthritis?

Non-surgical treatments, surgical treatments, and then some questions.

All right. So when we're looking at epidemiology, osteoarthritis is still by

far the most common reason why a young patient will present with hip arthritis.

But it is a disease of age, right?

So the longer you live, the more likely it is that you will get an arthritis

of one joint or other. We all know that.

If you look at, there's going to be quite a lot of, I guess,

figures from the Australian Orthopedic Association joint replacement registry.

This is one of them. So if you look at, for example, the breakdown of age groups

for people having a hip replacement, which is essentially sort of the end result

of someone having severe arthritis,

you can see that the vast majority are in the older patient groups.

But there is a significant portion represented here by the green line of that

younger patient, the less than 55-year-old, who is having surgery for hip arthritis. Okay, so 15%.

The thing is with the younger patient is that there's a disproportionate effect on, I guess,

the life expectancy that they have and the number of years that they have to

live and the quality of life that I guess they have for the remainder of their life expectancy.

So you can see how there's a disproportionate effect in that younger patient age group.

And in fact I'd go further and say arthritis

as you know as a group of

disorders or musculoskeletal problems

is by far the most impactful problem

on our society generally when you're looking at sort of you know metrics like

quality of life years lost right so you know as a researcher all of the you

know the attention gets grabbed by cardiovascular disease and cancer and they

get the bulk of the funding all the time when we're competing for grants, right?

But if you look at the overall impact of these conditions, musculoskeletal problems,

when you're looking at low back pain, knee arthritis, hip arthritis,

by far the most impactful in terms of the number of quality life years lost.

And my point here specifically relating to the young patient is because of their

sort of the longer life expectancy, you're going to have a greater impact on them.

So what are the causes of hip arthritis in the younger patient?

Osteoarthritis is still the most common diagnosis.

And as we know, a lot of the time it is sort of idiopathic, but it's probably

related to people's genetics.

Obesity, there is some association with obesity and hip arthritis,

much more so with knee arthritis.

And I think Samir might be talking about knee arthritis a bit later,

but there is an association with hip arthritis as well.

Probably in association with some lifestyle factors like what sort of work you

do or what sports you do, probably related to some repetitive injuries that

you've had as a younger person, sports injuries that have just,

you know, just, you know, brewed and just gotten worse over time.

And then you get this sort of wear and tear appearance of the hip joint.

But there is a significant portion that are caused by these other things as well.

And I'm going to mention a few of them and maybe just show some images about what they look like.

So, Associate Professor Joshua has just talked about inflammatory arthritis,

definitely an important cause in the younger patient.

Because that inflammatory arthritis is, I guess, a different form of arthritis.

But the end result will be the degeneration of the cartilage and the wearing out of that joint.

And then you get sort of secondary osteoarthritis then

there's other reasons like avascular necrosis has

anyone here had a patient with avascular necrosis yeah

yeah it is it is pretty uncommon we see it disproportionately and we obviously

remember those patients because it is quite a devastating condition for that

younger patient where and i'll show you a picture of what it looks like later, but in our society,

alcoholism and the use of corticosteroids are by far the most common reasons why people get AVN.

But there's a whole laundry list of potential causes of AVN as well that you

can, you know, I remember reading them up as a med student, as a registrar and

sort of committing them to all memory, you know,

we use all of these mnemonics about how to memorize all of these things that caused AVN.

And occasionally you'd get someone who comes along and has one of these sort

of rarer conditions presenting with a case of AVN.

And then you have developmental problems. So if someone presents.

You know, a young patient presents with hip arthritis, one of the first questions

I ask is whether they had any hip problems as a child.

So these are things like developmental dysplasia or clicky hips,

you know, unstable hips as a kid, per-phase disease or slipped epiphyses.

The end result of all of those things is essentially

the patient is left with some sort of abnormal morphology

of their hip joint right so as we all know

the hip joint is essentially a ball and socket joint but

the further we deviate from that shape that simple

ball and socket shape the more likely it is that they're going to have I guess

overloading of certain parts of the hip and more likely it is that they'll present

earlier with arthritis and I guess there is an association with how bad that

dysmorphism is and how early they present.

So you can have someone who had a terrible condition as a kid and the hip is

like totally, you know, it's a totally abnormal shape, right?

But it doesn't mean that they get arthritis like immediately, okay?

So you can have like a square-shaped hip and that hip can sort of last for probably

about 20 or 30 years before they then present to you with symptoms of secondary

arthritis, secondary osteoarthritis, okay?

And then I've listed the femoracetabula impingement.

Has anyone here had a patient with FAI or impingement?

It's quite common and GPs are sort of, yeah, picking up on it much more so.

I've listed it there because we actually don't really know what causes that

abnormal shape with FAI, but we think it is probably a developmental problem

as well and I have a picture about what I mean later.

So this is AVN. This is an MRI of a patient with AVN.

And for one reason or another, essentially what you get is necrosis of this part of the bone.

In this case, quite a large portion of the femoral head is affected.

But it is an important part of the hip joint because it is that subchondral

bone that does a lot of the heavy lifting.

The cartilage itself isn't directly affected but

you can imagine when you have this part of the bone not being

very very healthy right essentially what

that leads to is the cartilage not being supported by that very very important

bone so in this case you've got someone with osteonecrosis of this section but

it hasn't collapsed yet so the next stage of this disease process is For parts

of that bone To just collapse under weight Or physiological.

Movements And then that cartilage then starts Also collapsing and then you get

again Secondary arthritis of that Joint,

So this is a very difficult problem To treat because this itself Is very very

painful Like that process of the patient having,

This bone sort of Slowly dying off Is a very very painful condition.

But the idea from my point of view, I mean, think of me as sort of like a mechanic.

I need to, you know, restore or try and maintain the mechanics of someone's,

you know, joint and their body.

I really want to try and maintain the shape of this for as long as possible.

So the only thing that's left for me

to do is really tell them to not put much weight

on that's probably the best thing that you can tell these patients is to

limit the amount of weight limit the amount of activity that

they do use crutches or a walking aid in order to mitigate that risk of collapse

and then there's other treatments that you can do as well bisphosphonates have

been proposed as um as something that can reduce some of that pain from the

osteonecrosis not sure or if it reduces the risk of collapse though.

And then there's some surgical procedures that have varying levels of evidence

where you decompress this bone and maybe stimulate some healing.

Again, pretty controversial. I have used them in the past when basically I've

got nothing else to offer that patient.

Okay, so that core decompression procedure.

Yeah. Is that true anything on X-ray? Because first we do X-ray. Depending on the stage.

So depending on the stage that you have, but there is a staging system called

FICAT that's commonly, I guess, quoted depending on the stage.

So some, you might have a completely normal x-ray but the MRI is abnormal but

when it proceeds to collapse of the bone and abnormal shape of the bone that

is the time when it shows up on a plain x-ray.

And obviously the arthritis will then show up on a plain x-ray.

So the FICAT stage 3 and 4 will show up on an x-ray if that makes sense.

So this is FAI, so this is.

This is what I'm saying about this being probably some sort of dysmorphism,

but essentially what the patient has is an abnormally shaped proximal femur.

Instead of it being a round ball and a socket, you've got more of an egg-shaped

femoral head, so it stops being round somewhere about here,

and that's essentially how it's diagnosed, by drawing these angles,

which allows you to sort of get this angle about where the femoral head stops

being round. Now you probably don't have to do that.

Radiologists usually do that for us. But it basically gives you an indication

about how severe the FAI is.

But you can imagine if something's not round and this is constantly loading

this area of the hip joint, that's abnormal loading.

It leads to wear and tear of the labrum and then the cartilage and then in this

case, secondary arthritis as well. Okay.

So, how do you assess these patients, all the usual stuff, but specifically

when we're talking about arthritis from a surgical point of view is I want to

know about how severe their pain is.

And I personally use an Oxford hip score, but there's other sort of validated

patient reported measures as well.

It just gives you an overall idea about how much that patient is suffering day

to day with just general sort of activities of daily living.

And then with a younger patient, I want to know a little bit more about what sort of work they do.

So someone who does more manual or physical work and how much the symptoms are impacting on them.

But also, you know, sports and physical activity is going to be very,

very important to these patients.

And again, I want to know about what they do and what's important to them from that point of view.

It's important to know what treatment that they've had so far for their condition.

And I'll see later that that's, I guess, one of the criteria that I use to determine

whether someone should have surgery or not. And of course, their comorbidities.

Examination, look for all the usual stuff, stiffness, irritability, swelling, etc.

And an investigation is usually a plain x-ray, sometimes an MRI.

Okay. So non-surgical treatment. Are you aware of your College of GPs Guidelines

for Management of Arthritis?

I hope you are because they're excellent Basically this is evidence-based approach

To what works best From a non-surgical point of view But first-line therapy.

For arthritis of the hip, knee is these things.

So it's education, basically trying to encourage self-efficacy,

let them take control of their condition, avoid sort of catastrophizing about

the problem, telling them that this is really a normal process a lot of people normally have.

Obviously, in a young patient, maybe not so normal, but arthritis is generally normal.

I tell people that it's a normal part of the human experience to get arthritis

at some point in your life.

So take an active role in their own management and

then land-based exercise and weight

loss so they're the three first line

things so we're not talking about anything else here we're not talking about

injections or fancy you know machines and you know ultrasound therapy and all

of this sort of stuff all of that stuff is like second and third line okay so

often that's not the way we do it.

Often we just like refer people for injections or some sort of interventional treatment.

And it really should be focusing on this first. So I tell people that this is

what they should be focusing on.

And then these things are just trying to, I guess, improve their symptoms a

bit so that they can, again, focus on these things.

Okay. So trying to improve their symptoms with medication or injections or splints

or whatever, to just get them to a happy place so that they can go back to this.

And in terms of surgery, so my criteria for determining whether someone should

have surgery for hip and knee is pretty similar, okay?

So they need to have pain that's significant enough to have a functional impact.

And again, that Oxford score for me is quite helpful because it is quite an

objective way or as objective as possible to get an overall,

I guess, idea about how impacted they are.

But you can imagine in the young patient, it's a different kettle of fish.

So pain for an older patient

who essentially just needs to do some simple day-to-day things like some housework

or walking around the block or going shopping or doing some simple things that

keep them happy is quite different to the 40-year-old who still does CrossFit

and maybe some contact sports.

Okay so that's completely different kettle of fish and when

i say this i'm generalizing but it's very very

much tailored to the individual person and that's

why it's important to understand what their

functional requirements are so right that's part of the history is knowing what

sort of work they do and what sporting activity and all of that sort of stuff

that we inquired about earlier because you want to know about how much they

are impacted by their problem and then you You need some sort of imaging that shows arthritis,

it goes without saying, I think that's a prerequisite.

And then you need to have failure of non-surgical treatment,

so if someone comes to you and they haven't really done anything from a non-surgical

point of view, you need to try and maximize those things first.

Weight-bearing views is what I want, yeah. For a hip, yeah.

I don't think non-weight-bearing x-rays are very useful.

And then I do get specific views later for, you know, once you've decided that

they have surgery, but not to diagnose and for decision-making, right?

So hip preserving procedures just a brief mention

of these i don't want to focus on these too much but hip arthroscopy

is used particularly for fai and it does have some good evidence there's a multi-center

fashion trial that was published in the lancet a few years ago that did show

a benefit over sort of best non-operative treatment so i'd encourage everyone

to at least look at the abstract of that and then you can preserve the hip by

doing these sort of realignment osteotomies.

I don't remember the last time we've done one of those, mostly because hip replacement

and arthroplasty is quite successful.

And you can imagine when you're doing this big procedure like this,

you're preserving the hip, yes, but it's still diseased.

It's still very likely that they'll end up with an arthroplasty at some later stage.

And because arthroplasty has become quite successful, that's probably what we're

focusing on so I'm not going to spend too much time talking about that.

In terms of arthroplasty two main options particularly when we're thinking about

the young patient is a total hip replacement versus a hip resurfacing and this

is what they look like is in the same patient.

Replacement obviously is a removal of a section of the

bone in the proximal femur as well as preparation of

the proximal femur in order to fit a stem whereas a

resurfacing is essentially you're only taking off a

minimal amount of bone and essentially resurfacing the

articulating surfaces i'm not

going to talk too much about total hip replacement because i'm sure that i think

munjid has a talk about it a bit later but most people here would know that

it's a great operation okay like you get headlines like this in the lancet okay

and that's been borne out by amazing outcomes,

patient reported outcomes, satisfaction,

improvement in quality of life,

all very good metrics.

Still by far the most common surgery is a total hip replacement,

97 versus about 3% resurfacing overall.

The problem with a hip replacement, I guess, in a younger patient,

at least in theory, but also some evidence here you can see in the green line,

this is the younger patient group, is because they're younger and more active,

but also younger and more life expectancy, there's going to be a higher revision

rate when it comes to failure of that prosthesis over time.

It's not a huge difference I mean

if you look at the hazard ratios here Which is basically a

comparison Between the younger

group and the older group The long term

hazard ratio is 1.32 Which is a 32% additional risk of revision In that younger

age group But the problem is when it fails It's quite difficult to redo something

like this So if this fails in a significant way,

we're talking about major surgery here and what they're left with after that

sort of revision type hip replacement is never going to be as good as that primary hip replacement.

So that is a real issue for someone who's say in their 40s, you know that at

some point they're likely to have something done.

Not always, but very likely to need something done later on.

Sure. Yeah. But that three months of the revision, I don't quite get it.

That three months, that's a very short time.

Yes. Three months plus. So this data has been divided into hazard ratios for

revision at different time points.

So this represents really, really early complication rates that require revision.

This one sort of represents the medium term. and then more than three months

is sort of the more the longer term right so i focused here on the longer term

hazard ratio of just to make that point of long-term failure but three months,

between two weeks and three months there's actually a

protective effect of being young right and that

sort of makes sense because they're probably less comorbid they're

going to get less infection they're going to you know

be stronger and have less dislocation you know there's lots

of reasons why you can put forward why it's actually better does

that make sense so it's three plus months sorry is

what you're what you might be referring to so it's after

three months sort of more longer term short period i always thought revisions

would happen after a few years it is it is at least so this is at least three

months right but it's eliminating that spike that you get in the early period

in the three months where some people get infections or instability or dislocation,

which often happens in that really, really early period. Yeah?

I'm running out of time so I'm just going to move on because I do want to talk

about hip resurfacing and there is I guess a specific advantage to the younger

patient with hip resurfacing,

if you just look at the prosthesis itself

it preserves the shape and anatomy of the hip okay conserves bone which is really

really important when you're thinking about if there's someone someone needs

a redo procedure later it definitely has better range of motion and there are

studies that show that you get better range of motion with a resurfacing versus a total,

you get faster overall recovery.

So early on it's quite difficult because it is a more invasive surgery versus

a hip replacement, but they recover quicker overall in terms of like,

you know, probably three, six months later, you're getting better functional

outcomes versus a total hip.

And importantly, they get a much higher return to sort of high-level activity, okay?

If you look at the studies, they estimate, you know, about 80% of people can

get to that high level of activity.

And in my mind, what that means is someone who's able to run, essentially, okay?

Like sports that need running, jogging or running, bike riding, etc.

About 80% estimate in a hip resurfacing versus less than 50% for a total hip replacement.

And then you know if it does fail long term

it's relatively easy nobody wants to have a revision don't

get me wrong but it's relatively easy to revise because

you essentially have preserved you know

anatomy and you got a lot of bone left to work

with okay so all we need to do is basically go in

cut this off and then do a stem here

and if that needs revision then it needs to but you

can often just keep the shell if it's stable okay um

very you know famous example you guys

are aware that andy murray had a hip resurfacing he

wanted something done to get him back to that higher level of sport and

he actually did get back and play pretty high level tennis after his

hip resurfacing um i guess

the problem with hip resurfacing is

the metal on metal bearing traditionally it's

been metal on metal and are you guys aware of the

problems with metal on metal it was you know in the

public sphere probably about five or ten years ago where you

do get this thing called metallosis or the wear particles that develop over

over a number of years by these two surfaces articulating can be really really

nasty okay so basically causes this thing called metallosis it is uncommon but

when it does happen it can be quite devastating.

Having said that it's rare and the results of a metal on metal hip resurfacing are very, very good,

but you look at how things have happened you

know how things have progressed again from the registry you

can see that hip resurfacing had a bit of a fad

sort of in the early 2000s then some metal on

metal you know badness happened and now it's like much lower okay so it's you

know around that three percent mark and you can see that there is definitely

a higher overall revision rate when you look at all types of resurfacing versus

a conventional total hip replacement we're still pretty good.

I mean, we're talking at 14% or so over 20 years versus about 11% for a total hip replacement.

So I guess some advances that have happened recently, and I mentioned these

specifically because I'm actually pretty excited about them because I think

they do solve a problem that exists in orthopedics.

And anyone who knows me, okay, you speak to me long enough, I'm very skeptical

about the use of technology in orthopedics, okay?

I actually am very skeptical about robots and computers and how much they actually

add to what we're doing, okay?

It doesn't really, really improve patient outcomes all that much.

It's probably an incremental advance, okay?

I actually think this is more a better advance, okay? These are things that

I'm pretty excited about.

So instead of metal on metal, we've got ceramic. This has literally just been

come out in the last few years.

They needed to get, obviously, the research and the data to support its use,

so we've got I think about 5 years of results now,

excellent results, so very very promising for that sort of more longer term outcomes,

so you can see why, because it just, you know, you don't have that metal on

metal bearing anymore, it's a ceramic bearing and we know that ceramic bearings

don't cause any of that nasty consequence,

okay?

And then the other thing with hip resurfacing is this sort of patient-specific approach.

So essentially the summary of this is that doing a hip resurfacing is much less

forgiving technically.

It's very difficult to get it exactly right.

With a total hip replacement, you've got a lot of leeway. I mean,

we like to be very, very accurate, but you can get it off by like 10, 20 degrees.

And I've seen x-rays where like they look completely wildly off

and the patient still does really really well when things

are put in you know a little bit off right

but hip resurfacing you can't get this very wrong

and the main reason is because you've got this shell and that

shell needs to go on in a very specific way and if

it isn't then you're going to start to get this thing called notching or

you're going to get overloading of one part of the resurfacing and that's

been associated with early failure of this prosthesis so

much less forgiving so the way i think

that this has improved things is it does things specifically for

the patient and you get these scans and you know

it's used in other types of orthopedic surgery as well but with

a resurfacing it allows it to be very very precise so you get this sort of jig

that attaches to their bone and then it allows you to put the wire in exactly

where that patient needs it and then to resurface the bone exactly where that

patient needs it so those two things in combination the ceramic and,

and this patient-specific stuff, I think, is a big advance, especially when

it comes to a younger patient, active, bad arthritis.

I think this is a game-changer in my view.

So, summary, arthritis does affect the young disproportionately when it happens.

In the younger patient, always think of alternate causes.

15% of hip replacement surgery is in the younger patient and hip resurfacing

may be a good option for them.