Dr. Woyski’s article, Surgical Treatment of Labral Tears: Debridement, Repair, Reconstruction, was featured in last week’s blog post about debridement, repair and reconstruction of the labrum. I was able to connect with him and ask him some questions as well. I know many of you hip patients are wanting to be informed and educated about your hips. This week begins that focus with Dr. Woyski!
Why did you choose hip preservation as your specialty?
I was exposed to hip arthroscopy as a resident and was very interested in the areas of growth such as capsular management and labral reconstruction. Also, I knew very little about dysplasia and treatments for adults with dysplasia and was interested in learning more about non-arthritic hip pain.
What is the most exciting innovation or focus that you see in the area of hip preservation?
There has been more focus on the borderline dysplastic patient. There have been good results with arthroscopic labral repair, some are also performing capsular plication. But long-term studies are needed to see if it’s a lasting procedure. Additional studies are looking at PAO for these patients and following longer term outcome. Again, patient selection is key. In my opinion a hypermobile patient that is borderline is better served with a PAO. Femoral osteotomies are also becoming an area of study again - when and how to do them.
What is your philosophy of repair, debridement, reconstruction of the labrum?
I think the labrum serves an important role in hip stabilization. Now this isn’t the same for every hip. Some patients have stiff soft tissues and a very well covered femoral head. In that case the labrum may not be as vital for stabilization, but nonetheless should be repaired if possible. In the hypermobile patient with borderline dysplasia it’s absolutely essential. Reconstruction and/or augmentation is a newer technique that allows the surgeon to replicate the labrum with allograft or autograft tissue to restore the suction seal in a labral deficient hip. Debridement is reserved for a select group of patients though historically patients with debridement can have long lasting relief. In all categories patient selection is most important. No matter what you do, if the patient has more than borderline dysplasia or have arthritis they are not well served with hip arthroscopy as an isolated procedure.
As a fellow from Duke University, what further research would you like to be involved with to contribute to the global hip preservation field?
I’m in private practice currently so research is difficult to do in that setting. And while I like reading studies, I’ve never been the “research guy”. Questions I’d like to see answered though are: What are the midterm outcomes of capsular reconstruction? Does hip arthroscopy actually decrease risk of having THA in the future? What patients are at risk for hip arthroscopy failure? Does arthroscopy in conjunction with PAO improve outcomes or survivorship of PAO? What role does proximal femoral osteotomy serve in the armamentarium of the hip surgeon?
What do you see as the reason for the increase in hip arthroscopy?
Increased awareness of FAI and demand for those procedures.
How do you see hip preservation being practiced in the U.S. as compared to other countries?
I have not had the opportunity to travel outside the US to observe. But we are lucky in the US to have a vast network of experienced hip preservation surgeons and now have developed centers in large hospitals such as Boston Children’s, Duke, HSS, Mayo, etc. so we are in good hands. Outside the US though there are great minds working on these difficult questions which is why every year they have ISHA which is an international symposium on both arthroscopic and open hip preservation.
What type of surgeon training should patients look for when choosing a surgeon? Why?
I’m obviously biased but I think a surgeon that has done fellowship training in hip preservation procedures is key. A designated 6 month or 1-year [hip preservation] fellowship is preferable. In a sports medicine fellowship, you may get exposed to 30-60 arthroscopic procedures, if that. And rarely any open procedures such as PAO or femoral osteotomies. In a pediatric fellowship similar can be said about pelvic osteotomies and the patient population may be very skewed towards pediatric patients and not young adults. I performed over 150 arthroscopies and 50 PAOs during fellowship as well as 100 hip replacements and engaged in discussions about difficult cases with surgeons experienced in all aspects of hip pathology including replacements. So to me it’s apples and oranges [regarding] the training I received in hip preservation versus another surgeon that observed 30 hip scopes or went to a weekend course.
What do you feel are the most important questions to be answered for a patient prior to their decision to have hip surgery?
What are their goals! Is it to return to sport? Decrease pain and increase function? A ballet dancer is a good example. Certain hip pathologies can be advantageous to various positions in dance such as first position. Pelvic and femoral osteotomies may help preserve the function and longevity of their hip but [will] not allow them to dance at a professional level. So they may want to only treat their hip symptoms and forego a preservation procedure and elect for replacement in the future.
What do you see as challenges for patients when deciding to have a hip preserving surgery?
The recovery from the surgeries can be very long. A hip replacement is relatively easy to recover from compared to a labral repair. Additionally, a PAO (periacetabular osteotomy) is also very difficult and is a young person’s game. A 15 year old can recover so much faster than a 35-40 year old. Even endoscopic hamstring and gluteus medius repairs are arduous recoveries.
When picking a PT for post-op rehab, what types of questions should a patient ask a prospective PT?
I’m not a PT but I think similar. Have you treated patients with hip pain before? Are you interested in hip pathology? Have you treated patients post hip arthroscopy or PAO?