Osteotomies Around the Hip for Osteoarthritis

Overview and Rationale

Key principle: Osteotomy should be considered in a young patient who maintains a good range of movement of the hip and whose imaging shows a joint devoid of significant degenerative change.

• Bailey and Love's Short Practice of Surgery, 28th Ed

Types of Osteotomy Around the Hip

1. Femoral Osteotomies

A. Intertrochanteric Varus Osteotomy

• Indication: Excessive valgus neck-shaft angle (coxa valga) with lateral uncovering of the femoral head
• The neck-shaft angle is reduced, bringing the femoral head into better contact with the acetabulum
• Redirects load-bearing to a healthier portion of articular cartilage
• Used in early/moderate OA in young adults, Perthes' disease, SCFE

B. Intertrochanteric Valgus Osteotomy

• Indication: Coxa vara, medial joint space narrowing with a steep Pauwels angle
• Redirects forces from the medial pole to the more lateral superior cartilage
• The "valgus-extension osteotomy" (Bombelli technique) was popular in the 1970s-1990s for medial pole OA - long-term results at 25 years have been reported

C. Valgus-Extension Osteotomy (Bombelli)

• Combines valgus angulation with extension
• Aims to move loading to the posterior-lateral articular cartilage
• Reported long-term results (J Bone Joint Surg Br, 2000) showed benefit in selected patients

D. Transtrochanteric Rotational Osteotomy (Sugioka)

• Rotates the femoral head anteriorly or posteriorly
• Used mainly in avascular necrosis (AVN) and in select OA cases
• Moves the necrotic/degenerate zone out of the weight-bearing area

2. Periacetabular Osteotomy (PAO) - Bernese PAO

• LCEA < 20° (true dysplasia)
• Tonnis OA grade 0 or 1 (minimal degenerative change)
• Good range of motion preserved
• Age < 35-40 years

3. Chiari Pelvic Osteotomy

• A salvage acetabular osteotomy - cuts the ilium horizontally above the hip joint
• Displaces the iliac wing medially, creating a bony "shelf" over the femoral head
• Used when cartilage is too damaged for redirectional PAO
• Reported for OA secondary to dysplasia (Lack et al.)
• Now less commonly performed due to widespread use of PAO and THR

4. Shelf Procedures (e.g., Spitzy, Staheli shelf)

• Augment lateral acetabular coverage by adding bone graft
• Primarily a pediatric/adolescent procedure but occasionally used in young adults
• Indirect joint preservation by reducing lateral subluxation forces

Indications Summary (Adult Hip OA)

• Bailey and Love's Short Practice of Surgery 28th Ed, Table 39.4

Patient Selection Criteria

1. Age: Young patient, ideally < 40 years (PAO results deteriorate beyond 40)
2. Joint space: Preserved (no severe OA - Tonnis grade 0-1)
3. Range of motion: Good, functional arc of movement
4. Cause: Correctable structural deformity (dysplasia, coxa vara/valga, AVN, Perthes', SCFE)
5. Imaging: 3D CT for preoperative planning is increasingly standard
6. Diagnostic injection: Confirms symptoms are truly intra-articular before proceeding

Preoperative Planning

• 3D CT scanning for deformity characterization
• 3D printing of models for surgical rehearsal
• Computer navigation and robotics - emerging adjuncts for accurate correction
• Diagnostic hip injection - confirms intra-articular source before osteotomy

Outcomes and Conversion to THR

• Intertrochanteric osteotomies do not impair long-term outcomes of subsequent cemented THR, an important reassurance for patients
• 25-year follow-up data exist for valgus osteotomy in arthritic hips (Clin Orthop 2004)
• PAO: intermediate-to-long-term results (Matheney et al., J Bone Joint Surg Am, 2009) show durable outcomes in well-selected patients
• Total Hip Replacement After PAO: Reviewed separately in Campbell's - technically more demanding but achievable (Campbell's Operative Orthopaedics 15th Ed, 2026)

Illustrative Radiographs

PAO for developmental dysplasia - note improvement in lateral centre-edge angle from 7° to 22°

AP radiographs 1 year vs 30 years after valgus intertrochanteric osteotomy - showing late OA progression and ischiofemoral impingement

Series showing joint-preserving osteotomies followed by eventual THR over 36 years

Key Takeaway

Conservative Management of Hip Osteoarthritis

"There is no specific pharmacological therapy for OA; however, non-operative treatment with non-steroidal anti-inflammatories, regular exercise, physiotherapy and modification of lifestyle with loss of weight does help."

• Bailey and Love's Short Practice of Surgery, 28th Ed

1. Patient Education (Universal - All Guidelines Agree)

• Nature of OA - a degenerative but manageable condition
• Goals of treatment: pain control + function preservation
• Self-management principles: pacing activities, ergonomic training, joint protection
• Discussion of all available treatment options
• Can be delivered individually, in multidisciplinary group programs, or online

2. Non-Pharmacological Interventions

A. Exercise (Strongly Recommended)

• Straight leg raises (SLR) for quadriceps/hip flexor strengthening
• Hip abductor strengthening (side-lying leg raises, clamshells) - targets the abductor weakness causing Trendelenburg gait
• Sagittal plane leg swings for ROM maintenance

Sagittal plane leg swing - improves hip mobility and coordinates periarticular muscles

B. Weight Loss

• Obesity is a major modifiable risk factor and significantly accelerates OA progression
• Even modest weight reduction (5-10% of body weight) meaningfully reduces joint load and pain
• Most effective when combined with structured exercise
• Reduces the force transmitted across the hip joint with each step

C. Walking Aids

• A walking stick (cane) held in the opposite hand (contralateral to the affected hip) is recommended
• Mechanism: reduces the workload of the ipsilateral hip abductors and unloads the affected hip joint
• Reduces the resultant force across the hip by approximately 30-40%
• Other aids: rollator frame for severe cases, crutches for acute flares

D. Physiotherapy

• Manual therapy: gentle mobilization of the hip capsule, soft tissue techniques
• Gait retraining - corrects antalgic gait patterns
• Hydrotherapy - warm water reduces muscle spasm and allows pain-free movement
• TENS (transcutaneous electrical nerve stimulation) - short-term analgesia

E. Activity Modification

• Avoid high-impact activities (running, jumping) that load the hip excessively
• Adapt activities of daily living: raised toilet seats, grab rails (aids independence)
• Ergonomic advice: avoid prolonged sitting with hip in extreme flexion/rotation

F. Footwear and Orthotics

• Cushioned footwear to reduce impact transmission
• Lateral wedge insoles have some evidence in lower limb OA

3. Pharmacological Treatment

Step 1 - Topical Agents (First-line, especially elderly/comorbid)

• Deliver anti-inflammatory effect locally with minimal systemic absorption
• Low risk of GI, renal, and cardiovascular side effects
• Effective for peripheral joints; some evidence supports use for hip
• Preferred in older patients and those with GI/cardiovascular risk
• Studies show similarly low adverse event rates even with long-term use (up to 12 months)

• Causes desensitization of skin nerve fibers
• Analgesic effect via modulation of neurotransmitter pathways (substance P depletion)
• Small but significant pain reduction in controlled studies
• Side effect: local burning/stinging - some patients discontinue

Step 2 - Oral Analgesics

Paracetamol (Acetaminophen)

• Historically recommended as first-line oral pharmacotherapy for mild-to-moderate OA pain
• Safe overall, but risk-benefit profile has been debated in recent years
• Current evidence suggests modest efficacy compared to placebo in OA
• Still used widely as baseline analgesia given favorable safety profile at standard doses (max 3-4 g/day)
• Avoid high doses in hepatic impairment or chronic alcohol use

NSAIDs (Oral)

• COX-1/COX-2 inhibitors and selective COX-2 inhibitors (celecoxib)
• Multiple systematic reviews confirm moderate short-term efficacy for hip/knee OA pain
• Key risks: GI bleeding, cardiovascular events (particularly selective COX-2 inhibitors), renal toxicity
• Risk mitigation:
  • Use the lowest effective dose for the shortest possible time
  • Co-prescribe a proton pump inhibitor (PPI) in high GI-risk patients
  • Avoid in heart failure, CKD, prior GI bleeding
  • COX-2 selective agents preferred in those with GI risk but no cardiovascular risk
• Educate patients on OTC NSAID availability and interaction with prescribed agents

Duloxetine (SNRI)

• An option for patients with central sensitization / chronic widespread pain component
• Increasingly used in OA where standard analgesics are insufficient or contraindicated

Opioids

• Weak opioids (tramadol, codeine) used when other analgesics fail
• Strong opioids: generally avoided for OA due to dependence risk, adverse effects, and modest functional benefit
• Reserved for severe pain in patients awaiting surgery or when surgery is not possible

Glucosamine / Chondroitin

• Nutraceuticals with anti-inflammatory and chondroprotective claims
• Evidence is mixed; some trials show modest symptom relief, others show no benefit over placebo
• OARSI considers them "inconclusive" for hip; AAOS does not recommend
• Generally safe; some patients report subjective benefit

Step 3 - Intra-Articular Injections

A. Corticosteroid Injection

• Short-to-medium term pain relief (weeks to 2-3 months)
• Most effective for hip OA with an inflammatory component (effusion, warmth)
• Must be performed under image guidance (ultrasound or fluoroscopy) for the hip due to its deep location - confirmed by contrast arthrogram before injection
• Evidence: systematic review confirms efficacy for hip OA under ultrasound guidance
• Repeated injections: caution if >3-4/year due to risk of cartilage damage and soft tissue complications
• Risk of sepsis: rare but serious (estimated ~1 in 77,000 injections)

B. Hyaluronic Acid (Viscosupplementation)

• Restores viscoelastic properties of synovial fluid
• More commonly used in knee OA with moderate evidence
• Evidence for hip OA is weaker but some guidelines support use
• Effect is delayed (2-4 weeks onset) but potentially longer-lasting than corticosteroids (up to 6 months)
• OARSI: conditionally appropriate for hip; AAOS: insufficient evidence to recommend

C. Platelet-Rich Plasma (PRP)

• Emerging treatment; growing evidence base
• Not yet universally recommended by major guidelines
• May provide symptom relief through growth factor-mediated cartilage protection

4. Assistive Devices and Aids

5. Multidisciplinary and Psychological Approaches

• Cognitive behavioral therapy (CBT): addresses pain catastrophizing and improves coping
• Occupational therapy: home modification, adaptive equipment
• Dietitian referral: structured weight management program
• Pain clinic referral: for chronic, refractory pain with central sensitization

6. Indications to Move to Surgery

• Relentless pain - especially night pain unresponsive to analgesia
• Failure of conservative management after an adequate trial
• Significant limitation of activities of daily living (ADLs) and lifestyle
• Radiological evidence of severe OA with functional decline

Summary Algorithm

Diagnosis confirmed → Patient Education + Exercise Programme + Weight Loss
        ↓
Add: Walking aid + Physiotherapy + Activity modification
        ↓
Add: Topical NSAID → Oral Paracetamol → Oral NSAID (with PPI if needed)
        ↓
Consider: Intra-articular corticosteroid injection (image-guided)
        ↓
Consider: Hyaluronic acid / PRP injection
        ↓
Failure → Surgical referral (osteotomy if young + correctable deformity; THR if advanced OA)