Degenerative Hip Joint Pain – The Non-Arthroplasty Surgical Options

Degenerative Hip Joint Pain (DHJP) is a major cause of functional limitation in both young active and old sedentary patients. Total hip arthroplasty (THA) is one of the most successful surgical procedures performed in orthopaedics. Sir John Charnley introduced the concept of low friction arthroplasty for end stage hip arthritis. The rewarding result of this procedure makes THA the gold standard for the treatment of end stage degenerative hip disease. In a recent retrospective study to establish the implant survivorship after THA in young patient at 25 years follow up, up to 89% (80%-98%) survivorship was reported among patients who were diagnosed with developmental dysplasia, 85% (77%-93%) in patients diagnosed with rheumatoid arthritis and 74% (61%-87%) in patients group with idiopathic degenerative arthritis of the hip[1]. Despite improved surgical technique, implant biomaterial and prosthesis design, complications such as recurrent dislocation, osteolysis and loosening still exist. Failure of THA may present with particular problems when revision arthroplasty is needed in young patient, which makes hip joint preservation techniques still actual in this population (hip arthroscopy, surgical dislocation with osteochondroplasty, periacetabular osteotomy, proximal femur osteotomy), and put back on track older surgical procedures such as hip fusion or resection arthroplasty for certain rare indications.


Introduction
Degenerative Hip Joint Pain (DHJP) is a major cause of functional limitation in both young active and old sedentary patients. Total hip arthroplasty (THA) is one of the most successful surgical procedures performed in orthopaedics. Sir John Charnley introduced the concept of low friction arthroplasty for end stage hip arthritis. The rewarding result of this procedure makes THA the gold standard for the treatment of end stage degenerative hip disease. In a recent retrospective study to establish the implant survivorship after THA in young patient at 25 years follow up, up to 89% (80%-98%) survivorship was reported among patients who were diagnosed with developmental dysplasia, 85% (77%-93%) in patients diagnosed with rheumatoid arthritis and 74% (61%-87%) in patients group with idiopathic degenerative arthritis of the hip [1]. Despite improved surgical technique, implant biomaterial and prosthesis design, complications such as recurrent dislocation, osteolysis and loosening still exist. Failure of THA may present with particular problems when revision arthroplasty is needed in young patient, which makes hip joint preservation techniques still actual in this population (hip arthroscopy, surgical dislocation with osteochondroplasty, periacetabular osteotomy, proximal femur osteotomy), and put back on track older surgical procedures such as hip fusion or resection arthroplasty for certain rare indications.

Evaluation of painful hip joint
Evaluation of painful hip joint starts with history and physical examination followed by imaging study and laboratory investigation, as needed. Patient with DHJP presents with acute or insidious onset pain, usually with a recurring pattern. It is critical to differentiate sources of hip pain originating from intra-articular pathology from those secondary to extra articular pathology. Intra-articular pathology usually causes deep-seated pain, localized in the anterior groin or inguinal region, although pain of intra-articular origin may be felt at any area around the hip joint. Individuals with symptoms secondary to Femoroacetabular impingements (FAI) might indicate the location of pain by gripping the lateral hip, just above the greater trochanter, between the abducted thumb and index finger. This is known as C-sign [2]. Other symptoms of intra-articular pathology include catching, popping and locking, although those symptoms may represent a misinterpretation of extra-articular conditions such as snapping of the psoas tendon or of the tensor fascia lata.

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The pain is usually aggravated by weight bearing, going upstairs, and prolonged seating with hip flexion and adduction as in limited seat space, such as a car seat. Extra-articular pathology will cause pain mostly in the pubic area, lateral trochanter region, buttock region, or posterior thigh. Referred pain from spine or vascular claudication should be ruled out. Pelvic pathology and anterior abdominal wall hernia might cause pain in the groin region. Physical examination starts with inspection of the patient gait while getting into the office. A limp, Trendelenburg lurch and poor trunk balance should be looked for [3]. Inspection may disclose pelvis malposition, joint contractures or limb inequality. The foot progression angle should be observed. The patient should sit for history taking. After history, the patient should lay supine on the examination table. Ligament laxity can be tested. Log roll the limb to elicit any pain secondary to intra-articular pathology by rotating the femoral head in the acetabulum. Bony prominences, muscles and tendons around the hip joint, along with, the sciatic nerve and bursa overlying the greater trochanter are then palpated. Anterior abdominal wall examination and groin hernia test should be done. The spine, sacroiliac joint and the knee should also be examined. A complete neurovascular assessment of the limb involved should then be performed. Ranges of motion should be done both actively and passively ( Table 1).

Hip arthroscopy
The first recorded attempt of arthroscopic visualization of the hip joint is attributed to Michael Burman in 1930. The limited indications of hip arthroscopy at that time and the anatomic constraints of the hip joint with suboptimal equipment design have limited the use of hip arthroscopy for long time. However with improved hip arthroscopy tools, the indications for hip arthroscopy continue to evolve. Currently, many clinical issues related to the hip joint and the surrounding tissue can be treated with hip arthroscopy. Degenerative hip conditions that can be treated with hip arthroscopy are listed in Table 2.

Labral lesions
The etiology of labral tear is traumatic, degenerative, idiopathic or congenital. Labral pathology can also be classified based on location (anterior, superolateral, posterior). Anterior labral tears are the most common form in the western population, accounting for 90% of cases. Degenerative labral tears are more and more frequently felt to result from FAI and usually starts in the avascular (water-shield) white zone of the labral structure. In this zone, there is low chance of successful healing of the labral tear with conservative treatment. Labral tears may cause pain and microinstability of the hip joint. They also may increase friction within the joint and the strain within the articular cartilage; thereby possibly untreated lesion will result in accelerated degeneration of the joint. In FAI, persisting conflict between femoral neck and acetabulum will lead to chondral delamination and thinning, further the labral tear, paralabral cyst and ultimately, degenerative osteoarthritis of the involved joint. With hip arthroscopy, the labrum can be debrided, resected, repaired or reconstructed.

Femoroacetabular impingement (FAI)
This is a descriptive diagnosis characterized by combined clinical features and pathomorphological findings that can result in degenerative changes. The patient's pathomorphology is characterized by either cam lesion, pincer lesion or a combination of both. Mechanical abutment of cam lesion commonly causes pathological changes starting with focal, deep chondral delamination in the anterolateral (superolateral) region of the acetabulum. Separation of the labrum-chondral junction will allow the synovial fluid to extravasate to the subchondral bone or para-labral region creating intra osseous or paralabral cyst ( Figure 3). Leverage of head-cam lesion against the acetabulum with extreme range of motion can result in contre-coup lesion in posterinferior acetabulum [7]. Leading to global degenerative changes.   The pincer lesion will cause a crush-type injury of the labrum and progressive degenerative changes with minimal damage to the articular cartilage of the acetabulum. Indication of hip arthroscopy in this setting is symptomatic FAI with concomitant labral and or cartilage lesion. The labrum is addressed as mentioned in the previous section, while the cartilage damage is addressed by debridement or micro fracture of the underlying subchondral bone. The osseous abnormalities are treated with an osteochondroplasty and acetabuloplasty as needed.

Degenerative arthritis
Arthroscopic intervention in early hip joint degeneration may relieve pain and others associated symptoms (i.e. catching, locking and range of motion limitation). However, as seen with knee arthroscopy, it provides little benefit on the long term and thus represents a limited indication for hip arthroscopy. Hip arthroscopy in this clinical scenario will provide limited role through removal of loose bodies, debridement of degenerative chondral or labral tears and subtotal synovectomy. Capsular release and osteophyte excision might improve the hip range of motion. Before attempting hip arthroscopy for advance degenerative changes, patient needs to know the limitation of such procedure. The patient are less likely to benefit from hip arthroscopy when joint space is less than 50% of normal, with pain at rest, functionally depleting limitation of hip range of motion or pre-operative Harris Hip Score (HHS) of less than 60.

Surgical technique
Under general, spinal or combined anesthesia, the patient is positioned supine or in lateral decubitus according to the surgeon's preference. This section will only address the hip arthroscopy while the patient on supine position. A well-padded perineal post will be used to protect the pubis and provide counter traction force during distraction of the hip joint. The foot should also be well-padded befor connecting the foot attachments. Distraction of the hip joint is gently performed with the hip slightly flexed in neutral abduction and rotation until approximately 8 mm of joint space is achieved. Multiple portals can be used to visualize both central (articular surfaces) and peripheral (extra articular) compartments of the hip joint. Common portals used are anterior, anterolateral and posterolateral in relation to the Greater Trochanter (GT). Fluoroscopic views should be used during portal preparation to ensure enough joint distraction and to avoid labral penetration. The 70-degree lens is used most of the time. Labral tear, cartilage damage or over coverage can be treated as described above. Inspection of the peripheral compartment and excision of the cam lesion can be done without traction with the use of fluoroscopy x-ray to guide precise cam lesion excision. Dynamic assessment is helpful to assess the relief of FAI.

Postoperative rehabilitation
After arthroscopic osteochondroplasty and labral debridement, full weight bearing will be permitted, unless micro fractures were performed, in which case toe touch weight bearing is recommended for 6-8 weeks. Aggressive active-passive range of motion and proprioception exercise will be started early post operative. High impact sport is not allowed for 2 months post femoral neck osteoplasty.

Complications
Complications occur in 0.5% to 5% of patients and are most often related to the required distraction of the hip joint [8]. Sciatic, femoral or pudendal nerve palsy can result from prolonged traction time. Nerve injury tends to be transient neuropraxia, which completely resolve spontaneously in few weeks. A well-padded post should prevent perineal tear and pudendal nerve injury. Bleeding and lateral femoral cutaneous nerve injury can occur during portal placement. Postoperative persistent secondary to trochanteric bursitis, intraarticular capsular adhesion (especially between the capsule and repaired labrum, or between the capsule and anterior neck) may occur. Femoral neck fracture, avascular necrosis of the femoral head, and under or over resections of cam lesion can be a mode of failure. Instrumental breakage rarely happen, but sometimes requires open arthrotomy to remove the broken fragment. Incidence of deep venous thrombosis ranges from 0 to 3.7% in various retrospective clinical reports [9].

Combined limited open arthrotomy and hip arthroscopy
Combined limited open arthrotomy and hip arthroscopy can be utilized to treat symptomatic anterolateral FAI: the hip arthroscopy will focus on any labral pathology and allow microfracturing for acetabular chondral damage. The limited arthrotomy approach will allow easy access to the pathologic part of the femoral head neck junction.

Surgical technique
Patient is positioned supine, exactly the same as described in previous section. After arthroscopic treatment of labral and chondral lesions, the traction is released. Anterior or anterolateral approach can be performed. We prefer a modified Watson-Jones approach, which allow better visualization of the anterolateral and posterolateral aspect of head neck junction. The 8-10 cm incision starts 2-3 cm distal and 2-3 cm lateral to the Anterior Superior Iliac Spine (ASIS) directed distally and laterally toward the anterior tip of GT. Subcutaneous dissection is carried down to the fascia lata. The interval between Tensor Fascia Lata (TFL) and Gluteus Medius (GM) muscles can be identified just anterior to the GT after incising the fascia. The GM is retracted posteriorly while the TFL is retracted anteromedialy. The rectus femoris tendon is identified and the hip joint capsule exposed. A T-shaped capsulotomy is 11 performed with care to prevent injury of the labrum. Spiked tip retractors can be placed intracapsular anterior and posterior around the rim of the acetabulum which will allow safe dynamic assessment of the hip joint. We use a high-speed burr to resect the cam lesion on the anterolateral femoral neck then ensure effective resection by using intraoperative fluoroscopy and dynamic assessment of the hip joint. Removing all bone debris and minimizing muscle damage can play significant role in reducing the incidence of Heterotopic Ossification (HO). Capsular and fascia lata closure are performed at the end of the procedure.

Postoperative care
Weight bearing as tolerated is permitted early post operatively. Contact sport is not allowed for at least 2-3 months. Active and passive range of motion along with unrestricted strengthening is allowed. However, when rectus femoris tendon is violated, then restrictions will be applied on active straight leg raise (SLR) for 6 weeks. Subcutaneous low molecular weight heparin is given for 10 days.

Indications
Surgical dislocation of the hip joint for the treatment of FAI is safe when performed with appropriate understanding of the vascular anatomy of the proximal femur. Surgical dislocation of the hip is considered the gold standard procedure for the treatment of FAI, despite the advance of hip arthroscopy technique and the encouraging results of the limited open surgical procedure. Surgical dislocation of the hip is especially indicated with global or posterior impingement requiring acetabular rim trimming, with severe deformity of the 12 proximal femur or when chondral lesions of the femoral head have to be addressed. Patient with no more than mild arthrosis (Tonnis <=2) and age less than 50 years are considered the best candidates for such surgical intervention.

Contraindications
Advance arthrosis, is a contraindication for this procedure.

Surgical technique
The not to injure the labrum. The proximal arm of the capsulotomy runs parallel to the acetabulum posteriorly toward the piriformis tendon, the closest the capsulotomy to the acetabular edge the less likely to risk injuring the lateral epiphyseal branches. The distal arm of the Z-shaped capsulotomy should not extend beyond the lesser trochanter. Distraction force with the use of bone hook with the hip in flexion and external rotation can help dislocating the femoral head. The ligamentum teres can prevent complete dislocation and a curved blunt tip long scissor should be used to cut the ligament if circumferential exposure of the femoral head is required. A straight spiked Hohmann retractor is placed anteriorly around the acetabular rim and a curved Hohmann is placed inferiorly under the transverse ligament to push the femoral head posteriorly. The leg is placed in a sterile bag anteriorly across the table. This will provide 360-degree acetabular exposure for cartilage defects treatment, acetabular rim trimming and labral re-fixation ( Figure 6). To treat pathology on the femoral side, the retractors are removed and the head and neck are delivered back into the surgical wound for evaluation and treatment of any head cartilage defect and head-neck junction pathology (Figure 7). When satisfactory treatment is completed, the femoral head is reduced and the capsule is closed with loose interrupted suture to prevent stretch of retinacular vessels. The greater trochanter fragment should be reduced and fixed with three 3.5mm screws. The fascia lata and overlying skin are closed in layers ( Figure 8).

Postoperative care
Patient will be on DVT prophylaxis for 35 days and HO prophylaxis for 2 weeks (Celebrx 200mg twice a day). The patient will be allowed toe touch weight bearing for 6 weeks. Passive range of motion is allowed in all directions, however active abduction and deep flexion beyond 90 degree are not allowed for at least 6 weeks.

Complications
Complications of the surgical dislocation approach for patients who had had the procedure for multiple differential diagnoses (including Femoroacetabular impingement, Legg-Calve-Perthes disease in a skeletally mature hip, trauma, and deformity following a slipped capital femoral epiphysis) were reported by different North American centers that participate in the ANCHOR (Academic Network for Conservational Hip Outcomes Research) group [16]. We listed all possible complications might be anticipated with this procedure, however ANCHOR have reported no cases of osteonecrosis, femoral neck fracture, or any complication leading to long-term morbidity, with the exception of the one sciatic nerve injury, which partially resolved. 1. DVT (0.5%) 2. Infection. 3. Neurovascular injury (permanent and complete major nerve palsy was not reported, however partial sciatic nerve palsy occur in one patient eventually recovered partially). 4. Heterotopic ossification (Brooke I & II 5.3%) [17]. 5. Trochanteric fragment displacement and delay union (0.5% require no intervention), or nonunion (rate of 1.8 % that required refixation). 6. Femoral neck fracture 7. AVN 8. Hardware complications: breakage, irritation of surrounding soft tissue (trochanteric bursitis, psoas tendon when prominent medially). 9. Under-correction, or over correction of cam and pincer lesion. 10. Capsular adhesion.

Results
Retrospective reports demonstrate significant improvement in both radiographic and clinical functional scores. Murphy et al reported on the surgical dislocation approach for FAI treatment in 23 patients with a mean follow up of 62 months. Preoperative hip scores of Merle d'Aubigné scale were average 13.2 (range, [11][12][13][14][15]. THA was performed for 7 patients. Of the surviving 15 hips, the hip scores improved significantly to 16.9 ± 1.35 (range [13][14][15][16][17][18]. No case of AVN was reported [18]. patients required hardware removal [20]. Espinosa et al found less arthrosis at final follow up in 52 patients (60 hips) when labrum was refixed instead of removed after rim trimming for pincer type impingement. The recovery time and the final clinical and radiographic features favored labral re-fixation [21]. Beck et al reported the mid-term results of surgical dislocation of 19 hips and concluded that this procedure was not suitable for patient with advanced degenerative changes [22]. The same conclusion also reported by Murphy et al [18].

Periacetabular osteotomy
Developmental dysplasia of the hip can result in structural instability that exacerbates shearing forces across a limited acetabular cartilage surface area. Ultimately, the abnormal force distribution can result in rim failure and progressive degenerative hip disease [23]. The aim of periacetabular osteotomy is to change the acetabular cavity orientation, thus optimizing the joint mechanics through restoration of joint stability and transformation of shearing forces on an oblique acetabular roof to compressive forces on a reoriented horizontal acetabular roof. It was found on long term radiographic follow up that patients with a Center Edge Angle (CEA) less than 16 degrees, acetabular index greater than 15 degrees and femoral head uncoverage more than 30% have higher incidence of osteoarthritis by age 60 [24]. Various pelvic osteotomies were proposed to treat symptomatic hip dysplasia. Most of the techniques apply to the infant or adolescents. Salter innominate osteotomy has limited degree of correction in adult hip dysplasia and it dose not solve hip-center lateralization because the acetabular fragment rotation is hinged on a fixed point (symphisis pubis). Double and triple osteotomy provides more freedom for rotation of the osteotomized fragment but since the acetabular fragment is still attached to the sacropelvic ligament, only limited correction angle is possible. This angle of correction can be improved through placing the osteotomy closer to the acetabulum. One disadvantage of this type of osteotomy is the size of acetabular fragment that can cause pelvic narrowing and might interfere with future child bearing in female patient. Spherical periacetabular osteotomy is a highly demanding surgical procedure; it can improve acetabular coverage but can't improve hip-center lateralization because the medial acetabular wall is intact. The osteotomy passes close to the acetabulum capsular attachment, which is considered to be an important source of blood supply to the acetabular bone. Performing a capsulotomy to evaluate intra-articular structure at the remaining time of the osteotomy will jeopardize the acetabular blood supply [25]. Reinhold Ganz initially described Bernese Periacetabular Osteotomy (PAO) [26]. It became widely recognized as an effective osteotomy for the treatment of acetabular dysplasia. Through improved geometric cut around the acetabulum, the polygonal shape acetabular fragment can be reoriented to achieve almost unlimited femoral head coverage and acetabular version as well as allowing control of medialization of the hip-center when needed. The vascular anatomy around the acetabulum is preserved, which allow safe capsulotomy for simultaneous evaluation and treatment of intra-articular pathology.

Indications
The clinical uses of Bernese PAO in adult patient are indicated in the presence of the following situations: Acetabular retroversion can be identified on a standard AP pelvis view (symmetrical obturator foramen and coccyx centered 2-3 cm above the symphisis pubis). The patient radiographic finding will be consistent with acetabulum retroversion if the hip center of rotation is lateral to posterior acetabular rim and the patient have both cross-over sign and ischeal spine sings [27,28].

Surgical technique
Under general anesthesia, the patient is positioned supine and the limb on the dysplastic acetabulum side is prepped and draped free in sterile fashion. Antibiotics are given before incising the skin. A cell saver is used during this procedure. A curvilinear incision is starting from the gluteal tubercle on the iliac crest and curved lateral to the ASIS distally for approximately 20 cm. Abdominal external oblique muscle is Fig. 11. Curvilinear incision for the anterior approach to perform PAO.

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Recent Advances in Hip and Knee Arthroplasty 18 elevated off the internal iliac crest and the interval between TFL and the Sartorius is defined. The ASIS is osteotomized and retracted medially to expose the rectus femoris, which is released from the AIIS. The sartorius and rectus femoris are retracted medially and the TFL is retracted laterally. The ilocapsularis muscle is elevated off the anterior capsule. A spiked Hohmann retractor can be slid over the superior pubic ramus 1.5 cm medial to iliopectineal eminence and serves to retract the medial soft tissue including the psoas and the neurovascular bundle. The medial capsular tissue is freed of soft tissue attachment using long blunt and curved scissors. This provides a window to reach the ischeal tubercle and infracotyloid region, which is also freed of soft tissue attachments. Four bone cuts are performed to create a polygonal acetabular fragment: 1. Partial ischeal cut using curved Ganz osteotome (avoid sciatic nerve injury by abducting the hip joint) 2. Superior pubic ramus cut using straight osteotome starting medial to iliopectineal eminence (avoid penetrating the joint by aiming 45 degrees medial, away from the acetabulum). 3. Iliac bone cut starting just distal to ASIS toward greater sciatic notch using oscillating saw. 4. The posterior column cut is one centimeter thick and done using both straight and curved osteotome starting off the third cut end with an angle of approximately120 degrees to join the first ischeal cut.
The acetabular fragment should be now free for re-orientation. We use two Schantz screws inserted in the acetabular fragment away from the zone of fixation to accomplish efficient orientation in both abduction and anteversion. Fluoroscopy is used to assess acetabulum version and orientation. The fragment can be allowed to rotate freely around the hip center of rotation. When the desired orientation is achieved, preliminary fixation is obtained with multiple Steinmann pins. True AP pelvic X-ray is done prior final fixation. Multiple screws are used to fix the acetabular fragment. The hip is then taken through full range of motion and if 90-degrees of flexion cannot be achieved, retroversion is corrected or a capsulotomy can be safely done to resolve any intra-articular pathology responsible for impingement. Fig. 13. Postoperative x-ray of the right hip for the same patient presented previously ( figure  11) demonstrates combined PAO and proximal femoral osteotomy.
The rectus tendon is reattached to the AIIS using nonabsorbable suture transfixed through drill hole in the iliac bone. The ASIS is fixed with a screw or nonabsorbable suture drilled through the osteotomiesed fragment. A drain is left in place while closure is performed [31].

Postoperative care
Patients will be on DVT prophylaxis for 35 days. Non-weight bearing is indicated for 6 weeks, and then progressive weight bearing is started when radiographic evidence of healing of the osteotomy. Straight leg raising exercise is delayed for 6 weeks, and the hip joint can be taken through passive range of motion early postoperative.

Complications
Minor and major complications can occur when doing Bernese PAO. The complexity of the procedure combined with the surgeon learning curve can affect the overall outcome. It was observer that the major complication rate ranged from 6% to 37% [32]. There was a 20 statistically significant decrease in major complications from 17% to 2.9% when comparing the first 35 cases with the second 35 cases of periacetabular osteotomy performed by one surgeon [33].

Surgical technique
The pre-requisite for a successfully executed ITO is proper pre-operative planning, adequate range of motion and appropriate choice of the fixation device. A direct lateral approach to the femur is used. The planned osteotomy is performed under fluoroscopic assistance and defined with Steinman pins. A blade plate is used for fixation and the corresponding chisel is inserted in the desired position. The osteotomy is performed with an oscillating saw and can be fixed under compression with a blade plate or condylar plate.

Postoperative care
DVT prophylaxis is given for 2 weeks, and weight-bearing protection should de respected for 2 months. Passive and active ranges of motion are permitted.

Postoperative complications
In addition to common surgical complications, AVN and delayed union or non-union of the osteotomy can occur. Over correction or under correction can be a source of patient dissatisfaction. Hardware failure or soft tissue irritation might require removal after fracture healing.

Results
Multiple clinical studies on the use of proximal femoral osteotomy are reported in the literatures. Haverkamp et al reported the results of 276 patients that had ITO for various indications. The best clinical results at 10 years were achieved when the osteotomy was performed in young patient with posttraumatic deformity (90% success rate at 10 years). Arthritic changes in association with an idiopathic etiology had the worst results with only 50% success rate at final follow up [37].

Salvage procedure for degenerative hip joint pain
Salvage surgery, including the Chiari osteotomy and shelf procedures; do not provide coverage of the femoral head by a surface of hyaline cartilage. The hip capsule is interposed between newly formed acetabular roof and femoral head.

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Chiari Pelvic Osteotomy: Chiari medial displacement pelvic osteotomy may be used to treat degenerative hip pain in young patient with incongruent hip joint. The osteotomy is performed at 15 degrees superior inclination within the supracetabular iliac bone and the hip joint is displaced medially to improve superior coverage of the femoral head. Excessively low or too high osteotomy cut can give suboptimal clinical result. Sufficient acetabular fragment medial displacement is critical to provide enough femoral head coverage. The superior capsule is used as the articular surface under the displaced ilium. The posterinferior aspect of the hip is spared from disease, as seen on the false-profile roentgenogram. and a reconstructive osteotomy can be performed. Furthermore anterior coverage of the head is difficult to obtain with a medial displacement osteotomy. This procedure relies on fibrocartlage metaplasia of the capsule, results in lower functional outcome compared to other periacetabular osteotomies or THA. One advantage of this type of osteotomy is improving future acetabular component bone fixation [38].  Shelf Procedure: Placing a bone graft in the superolateral region of the acetabulum as a shelf can provide containment and coverage of the femoral head, thus preventing lateral or upward migration of the femoral head. The shelf procedure provides greater lateral coverage but the original steep inclination of the acetabulum persists. The technique can be used as a supplemental procedure with other type of osteotomy and can be performed with a limited incision technique [39].

Hip fusion (arthrodesis)
Young patients with advanced unilateral degenerative hip changes, secondary to trauma or septic conditions are good candidate for hip fusion. Hip arthrodesis provides better clinical results in young (less than 35) active patient with normal contralateral hip, no pathology in the ipsilateral knee or lower spine and when the hip fusion technique preserves the abductor muscles integrity. Although a valuable option, it has many drawbacks including loss of motion, shortening of the extremity, increased expenditure of energy during walking, and increased stress on the low back and the ipsilateral knee [40]. Several techniques have been described. The femoral head and the acetabulum are denuded of cartilage and the hip is positioned in approximately 30 degrees of flexion, 0 to 5 degrees of adduction and 10 degrees of external rotation. The fixation can be intra articular (screws through the femoral head to the iliac bone), or extra articular (side plate, cobra plate, anterior plate). A trochanteric osteotomy is advisable to preserve the abductor function for future conversion of hip fusion to THA when side plate or cobra plate is used.
The reported clinical results of THA after hip fusion demonstrate a wide spectrum of clinical outcome. Hamadouche et al studies 45 THA performed after hip fusion at a mean follow up of 8.5 years. He reported 91% survival with walking improvement up to 2-3 years after surgery, however, 50% of patients required a cane for walking [41]. Joshi et al found that 79% of the patients had minimal pain with a 96% 10 years survival. The complications reported for the 208 fused hips converted to THA were 8 sciatic nerve and 7 femoral nerve palsies, 28 cases of HO, 5 dislocations and 3 infections [42].

Resection arthroplasty
Gathome Girdlestone described the surgical technique of resection arthroplasty of the hip joint to palliate hip condition secondary to chronic infection (i.e. tuberculosis hip infection). This procedure has been widely used to relive pain or to improve the hip range of motion in conditions such as advanced hip degeneration and chronic hip joint infection. Improvement in the treatment of infection, fracture fixation technique and the introduction of prosthetic hip replacement has significantly limited the role of hip resection arthroplasty. The current indications for resection arthroplasty are nonambulatory patient with significant cognitive or neuromuscular condition or patient with chronic prosthesis infection and significant comorbidity that cannot go through complex surgical procedure. After the Girdlestone procedure, patients have significant functional limitations secondary to weak abductor and limb length inequality [43].

Summary
Non-arthroplasty surgical options for treating painful degenerative hip joint conditions are well established surgical procedures. Patient selection and proper preoperative evaluation is critical for successful long-term result. Understanding the indications and the contraindications as well as the limitations and the expected outcome of each procedure is critical during pre operative counseling of the patient about nonarthroplasty surgical option.