Phil Downer, MD
- Hip Surgery
- Hip Replacement
- Hip Preservation
Phil Downer, MD
Dr. Downer is a board-certified orthopedic surgeon with a special interest in hip preservation surgery. Dr. Downer enjoys seeing patients of all ages, but his special interest in joint preservation has led him to treat many younger patients with hip problems, such as hip dysplasia or hip impingement.
One of only a few surgeons in the Pacific Northwest who performs hip arthroscopies for these issues, Dr. Downer has quickly become one of Seattle’s leading hip specialists.
In addition to joint preservation, Dr. Downer treats patients with more advanced complications. He performs over 350 hip replacements per year, primarily through the tissue sparing surgery anterior approach.
Dr. Downer completed his medical degree and residency at Memorial University Medical School in Canada. He went on to completed his orthopedics residency at McGill University in Montreal, Canada, and fellowship in hip surgery with Dr. Reinhold Ganz in Bern, Switzerland. Continuing education is important to Dr. Downer – in his spare time, he seeks out and visits other surgeons doing similar work all over the world.
Outside of medicine, Dr. Downer enjoys spending time with his wife and three children. He also likes to kite surf, wind surf and back country ski.
Hip impingement (femoral acetabular impingement) is a disorder of the hip that is becoming more recognized as a cause of hip pain in the active adult. It is also thought to be a previously unrecognized cause of arthritis in the young adult.
Causes of Hip Impingement
Hip impingement is caused by lack of room or clearance between the neck of the femur at the top of the thigh bone, and the rim of the socket (acetabulum). This lack of room may originate on the femoral neck, acetabulum, or both. The head of the femur may not be sufficiently offset from the neck of the femur to allow room when the hip is flexed. This can be caused by childhood disorders or from wear over time stimulating new bone to be laid down on the front of the femoral neck. The acetabulum may be the cause of the impingement by covering too much of the femoral head in the front of the hip joint. There may also be multiple causes in the same hip.
This lack of clearance causes the neck and rim of the socket to jam together as the hip is flexed (as in sitting or running). This contact between the femoral neck and socket leads to damage of the contacting structures. This damage may be a tear of the cartilage around the socket (acetabular labrum) to more advanced cartilage damage and degenerative arthritis of the hip.
Symptoms of Hip Impingement
Typically the person with hip impingement complains of pain in the groin region during hip flexion activities such as running or jumping. There may also be symptoms after prolonged sitting. During most of these activities, the hip is placed in a flexed position, although pain may also occur with standing and walking when irritation of the hip is more generalized.
HIP IMPINGEMENT TREATMENT
The pain of impingement may progress to the point where it interferes with activities of daily living. Treatment first consists of trying to control the pain with over the counter anti-inflammatory medications and Tylenol. If this does not control the pain sufficiently, surgical treatment may be warranted.
Hip arthroscopy involves correcting the cause of impingement and dealing the damage that has occurred the hip labrum as well as possible cartilage of the hip joint. Hip arthroscopy is the most common method of accessing the joint. The procedure allows the surgeon to visualize as well as treat the damaged area. Damage to the labrum is addressed with partial removal and possible repair.
The bony problems leading to this impingement are then addressed. This may involve removing a portion of the bone in the front of the hip socket. X-ray is used during the procedure to remove the correct amount as well as to visualize the motion of the hip during bone shaping. Bone at the junction of the head and neck of the thigh bone are then visualized, and the bone is shaped to create the proper offset necessary for smooth movement. Again, x-ray and hip motion are used to correctly remove bone in the critical area.
In cases of more severe malposition of the hip socket, a redirecting procedure, called a periacetabular osteotomy (PAO) may be required. This is in more severe cases of impingement where bone removal alone would not adequately address the problem.
About Hip Dysplasia and PAO
What is hip dysplasia?
Hip dysplasia is when the hip socket is too shallow providing inadequate support to the femoral head. This inadequate support leads to premature damage to the hip cartilage and arthritis.
What are the alternatives to surgery?
Activity modification, pain pills, gentle exercise.
What exactly is done in surgery?
The socket of the hip is repositioned to better cover the femoral head and support weight. This repositioning is done after freeing the socket from the rest of the pelvis. Once the position has been changed, the socket is held with screws to allow bone healing similar to fracture healing.
Will surgery fix my problem?
Surgery will improve the position of the hip and its biomechanics. The hip will not be perfect, but will be better able to support your weight for activities of daily living.
How long will I be in the hospital?
Typically 3-4 days. When you can do stairs and go to the bathroom, you can go home.
What special equipment will I need?
You should only need crutches. Occasionally a raised toilet seat helps, but not always necessary.
How long will I need to be off work after PAO?
Desk work can begin days after surgery. Manual labor is not possible for about 2 and ½ months.
When can I return to recreational activities?
Biking and swimming are good usually after about 2 weeks. Impact sports are not advisable until after 3 months.
When can I drive a car?
Once you are off narcotic pain pills, you can drive a car.
HIP DYSPLASIA TREATMENT
The goals of treatment for hip dysplasia are to decrease pain and prevent the early development of degenerative arthritis. Once pain becomes enough to interfere with normal activities, it may be advised to treat the dysplasia surgically.
Surgery is performed to redirect the socket and also rarely the upper femur. The socket is redirected using a periacetabular osteotomy (PAO) or Ganz Osteotomy. In severe cases, the upper femur is also addressed using a proximal femoral osteotomy. This redirection positions the joint such that body weight is spread over a larger area, therefore decreasing pain and slowing the progression of arthritis.
The PAO is performed with the patient laying flat on the operating table. A spinal or general anesthetic is used during the procedure. An incision is made over the front of the hip, exposing the inside of the pelvis and front of the hip joint. The bone around the socket is then cut. These cuts release the socket from the pelvis, enabling repositioning.
The socket is then repositioned to cover more of the femoral head and is fixed with screws. These screws hold the bone fragments while they heal. This bone healing begins immediately, but doesn‘t have significant strength until 2 to3 months after surgery, similar to fracture healing.
Usually patients stay in the hospital for 3 to 4 days. Therapy begins immediately to strengthen the muscles around the hip joint. Weight bearing is restricted to toe touch, as too much weight bearing too early can cause breakage of the screws and change in the socket position. At six weeks, weight bearing is increased gradually to full as pain permits. Once bone healing has occurred, activity can be resumed unrestricted.
The goals of this surgery are to decrease pain and slow or stop the progression of hip degeneration. This hip socket remains shallow, but is repositioned such that it better supports weight and decreases the damaging strain on the cartilage.
HIP LABRAL TEAR
The acetabular labrum is a structure attached to the outside rim of the hip socket. This labrum is made of fibrous cartilage, a flexible material present in multiple joints of the body. In the hip, the labrum is thought to act as a gasket, keeping fluid in the joint during the normal loading of the joint that occurs with movement. It also acts as a stabilizer of the joint keeping the head seated in the socket.
Causes of Labral Tears
Various conditions can lead to damage of this labrum. These include traumatic events, degenerative conditions over time, as well as situations where the shape of the hip bones is incorrect. Traumatic events leading to labral tears can occur with multiple activities including motor vehicle accidents as well as common trips and falls. Degenerative labral tears are a component of generalized hip degeneration where the cartilage throughout the hip joint becomes rough and torn.
Conditions where the shape of the hip bones is incorrect are currently falling under the term hip impingement. These conditions involve improper shape of the hip socket, junction of the thigh bone head and neck, and more commonly a combination of both. This improper shape causes the labrum to be pinched or rubbed during normal movement leading to tearing and degeneration.
Treatment of Labral Tears
Treatment of labral tears involves repairing tissue if possible and removing the tissue that is too severely torn. Attention is then directed at correcting any bony abnormalities that have caused the labral tear in the first place. This is usually possible with hip arthroscopy, but may require more invasive procedures to correctly address the underlying bony problem.
Hip arthritis occurs when the cartilage covering the bones of the hip joint breaks down. The cartilage of the joints is a very smooth material. This cartilage lowers the friction during joint motion, leading for smooth movement of the bones during activity.
Cartilage breakdown can occur because of mechanical problems of the hip and/or an inherent issue with the cartilage itself. There can be mild arthritis where a small area of cartilage is affected, or severe arthritis where the majority of the cartilage is damaged and the bones have no cushion between them leading to the so called “bone on bone“ situation.
Osteoarthritis is a form of arthritis in which mechanical issues lead to the eventual breakdown of the articular cartilage. These mechanical issues include hip dysplasia, hip impingement, as well as hip trauma.
In other forms of arthritis, inflammation is actually the reason the cartilage breaks down in the first place. Rheumatoid arthritis is the most commonly known, but there are many. Recent advancements in the medical treatment of inflammatory arthritis has decreased the role of surgery in the treatment of these conditions.
Symptoms of Hip Arthritis
A classic symptom of hip arthritis is joint pain. This may be a dull, aching pain in the groin, outer thigh, or buttocks. The pain is often worse in the morning, but after you get up and move around for awhile, it may lessen. Vigorous activity can also aggravate the pain and increase stiffness. Movement may be limited because of the pain as well as stiffness. Eventually even walking may become difficult.
Typically the extremes of motion are the most painful. With time all movement is painful. There can also be episodes where the joint feels as if it will give way due to the sudden onset of sharp pain. The joint may also become locked and difficult to change position as the condition advances.
There are a number of non surgical treatments for hip arthritis. These treatments are directed at controlling the inflammation caused by arthritis and minimizing the weakness and stiffness that is often present. Anti inflammatory medication is usually recommended. Cortisone injections in the joint can also give temporary relief. As with any medication, one needs to be aware of the risks. Physical therapy and exercise are also important to reduce stiffness and weakness.
When these non surgical treatment fail to provide adequate pain relief, joint replacement may be recommended. The type of surgery recommended depends on several factors including age, presence of obesity, the condition of the hip joint and surrounding bone, and the underlying cause of the arthritis.
Some recent advances in hip replacement enable placement of implants through a less invasive approach, as well as continued improvement in the longevity of these implants. We are also looking at novel implants for hip replacement, including hip resurfacing.
ANTERIOR HIP REPLACEMENT
Recent advances are enabling hip replacement to take place with much less disturbance of the muscle and soft tissues around the hip. Along with improvements in anaesthesia, and the implants and instruments used, this is leading to easier and more rapid recovery after hip replacement surgery.
The anterior approach to the hip is not new to orthopedic surgery. This approach has been performed for decades in orthopedics, but it has only recently been applied to hip replacement surgery in North America. This interest has occurred due to advancements in instruments and implants as well as the normal progression that occurs with surgery.
The anterior approach for hip replacement has been adopted by surgeons for a number of reasons. These reasons include:
- less chance of posterior dislocation due to decreased trauma to the capsule, ligaments and muscles at the back of the hip
- less pain after surgery due to decreased soft tissue disruption
- easier rehab after surgery
- improved precision of implant placement with the use of x-ray during the procedure
The anterior hip replacement procedure is usually performed with a spinal anaesthesia. Reasons for recommending a spinal anaesthetic include:
- relaxes the muscles about the hip
- reduce risk of blood clot
- reduced blood loss during surgery
- easier transition after surgery where patient remains more aware and in control
The procedure is usually performed with the patient lying flat on the operating table. A skin incision is made over the front/outside at the top of the thigh bone. The size of the incision is kept to a minimum, but made large enough to see what needs to be seen. Pain after surgery is less dependent on incision size, and more on the trauma to soft tissue structures under the skin.
After incising the skin, muscles are spread to gain access to the hip joint. No muscles are removed or detached, allowing faster recovery. The capsule is incised to expose the underlying bones of the hip. The bone is then prepared much the same as a traditional hip replacement. The implants are placed in the bone, using x-ray to decrease the variability in implant positioning. The soft tissues are closed and covered and patient brought to the recovery room.
After surgery, the patient is encouraged to walk and move. There are no restrictions on weight bearing or movement during the recovery time. Pain is the main dictator of activity. Patients are encouraged to place ice over the hip, and elevate the leg above the heart in a lying position to avoid swelling. Discharge home occurs once the patient can go the bathroom and do stairs. Usually the stay in hospital is 1 to 2 nights depending on other medical conditions.
Hip Arthritis and Hip Replacement Surgery
What is hip arthritis?
Hip arthritis is when the cartilage covering the bones of the joint is damaged and absent. It can vary from minimal damage to complete loss of the cartilage.
How does hip replacement work?
Hip replacement removes and replaces the ball and socket of the native joint. The artificial parts work the same as the native joint components. The capsule, ligaments, and surrounding muscles move the artificial parts the same as the native ones.
What is the difference between the anterior approach to the hip and the traditional approach?
The anterior approach to the hip enters the joint from the front. The more traditional approach in North America enters the hip through the back. Different muscles are altered for each approach, and the hip capsule and ligaments are weakened in the front versus the back.
How long will I need to stay in the hospital?
The typical stay is 1-2 days. Leaving the hospital is based on your pain and mobility. Once your pain is well controlled with oral pain pills, and you can climb stairs and use the bathroom, you are usually safe to go home.
Will I need physical therapy after my surgery?
The need for therapy varies from case to case, but it is not necessary for everyone. If a therapist can help you get moving faster and speed the recovery, one is prescribed.
When do I need to follow up with the doctor?
Typically the patient is seen 1 and ½ weeks, 1 and ½ months, and 3 months after surgery. Visits continue until pain and function have returned to normal.
How long will I be on pain medicines?
This can vary from days to weeks depending on disability before surgery and other medical issues.
When can I return to work?
Desk work is okay days after surgery. Manual labor is usually not safe for at least 1 and ½ months after surgery.
When can I drive a car?
Once you are off narcotic pain pills, you can drive.
What activities does a hip replacement prevent me from doing?
One can perform any activity after hip replacement. The issue is the activity’s impact on the longevity of the replacement. Higher impact activities will decrease the lifespan of the implants and therefore should be minimized.
About Hip Arthroscopy
What is a labral tear?
The labrum is a soft cartilage around the rim of the hip socket. This labrum can tear as a result of impingement conditions, described above, or with trauma.
What is hip arthroscopy?
Hip arthroscopy is a procedure where the hip joint is visualized using small instruments that require a very small incision to insert. The instruments enable visualization of the joint and certain interventions such as removal of pieces of tissue, repair of cartilage, and bone removal.
How does hip arthroscopy surgery fix my problem?
Hip arthroscopy addresses the different issues you may have. A torn labrum can be trimmed or repaired. Excessive bone can be shaped to avoid rubbing. Inflamed tissue lining the joint capsule (synovium) can be removed. Also rarely, tissue floating in the joint can be removed.
Will I need crutches?
If bone is removed from the femoral neck, the hip is protected with crutches for 4 weeks to reduce the risk of injury to the femoral neck. The bone takes longer to fully recover, but the risk of falling is fairly low at this time after surgery.
What is the recovery?
Recovery can vary, but typically if bone work is performed, the recovery is 2-3 months. One should remain active during this time, mainly taking part in low impact activities such as swimming and biking.
When can I return to recreational activities?
A gradual return can begin immediately after surgery beginning with swimming and biking. After 2-3 months, one can resume higher impact sports unless advised by the surgeon.
When can I drive?
You can drive once off narcotic pain pills.