A child with a malformed hip does not become a different patient on their 18th birthday. Similarly, the disease does not recognize the border between pediatric and adult medicine.
The healthcare system often does recognize that border, however. Children’s hospitals traditionally stop treating patients near adulthood. Sports medicine practices may address a torn labrum without correcting the structural problem beneath it. Adult reconstruction surgeons may enter the picture only after the joint has deteriorated enough to require replacement. Between them sits a group of young patients whose conditions are too mature for conventional pediatric care and too early for an artificial joint.
Matthew Schmitz, MD, director of the Rady International Center for Pediatric and Young Adult Hip Disorders at Rady Children’s Hospital-San Diego, believes that gap is where the next generation of hip preservation programs must be built.
“Hip preservation doesn’t just stop when a child turns from 18 to 19 or 19 to 20,” Dr. Schmitz told Becker’s.
He spent 20 years in the Air Force, where he established the Defense Department’s first young adult hip preservation service. He is now helping Rady Children’s build a destination program for complex hip care extending into patients’ 20s and early 30s.
The work challenges several assumptions: that a children’s hospital should stop treating patients at adulthood, that hip disease belongs to one specialty and that a program can be built around one surgeon or one surgical technique. The operation may be the most visible part of hip preservation, but the program succeeds or fails long before the patient reaches the operating room.
The patients between specialties
Hip preservation treats structural problems before the joint has deteriorated enough to require replacement. The patients are often young and active. Some were born with hip dysplasia or another abnormality that did not become painful until later. Others are athletes whose symptoms initially resemble a routine sports injury.
They do not fit neatly into one service line. A pediatric orthopedic surgeon may understand developmental anatomy but primarily use open techniques. A sports medicine surgeon may be skilled in arthroscopy but less familiar with complex bone correction. An adult reconstruction surgeon may not see the patient until preserving the natural joint is no longer realistic. The strongest programs bring those perspectives together.
“We’ve learned a lot about hip pathology over the last two decades,” Dr. Schmitz said. “It brings together different backgrounds: pediatric orthopedics and sports medicine.”
That convergence has changed treatment. Some conditions can be addressed arthroscopically. Others require an open procedure such as a periacetabular osteotomy, or PAO, in which the surgeon reorients the hip socket to improve coverage of the femoral head. Some patients need both.
Dr. Schmitz said the best operation is not automatically the least invasive or the most technically complex; it is the one that matches the patient’s anatomy.
When the technique shapes the diagnosis
Orthopedic programs are often built around expertise. A hospital recruits an arthroscopist and develops an arthroscopy program. It recruits an open surgeon and becomes known for reconstruction.
Hip preservation exposes the weakness in that approach. If every patient enters a practice organized around one technique, the technique can begin to dictate the treatment. A sports surgeon may repair a labral tear without recognizing that dysplasia or another structural deformity caused it. An open surgeon may recommend a larger reconstruction when a more limited arthroscopic approach would be sufficient.
The program must choose among the tools rather than force the patient into whichever one it owns.
When Dr. Schmitz began building a hip preservation service in San Antonio, he came from a primarily open surgical background. He worked with sports medicine colleagues in a co-located clinic, sharing patients and sometimes operating together. At Rady Children’s, he performs both open and arthroscopic procedures. He estimates fewer than 20 surgeons combine both approaches themselves. More commonly, the patient requires two surgeons.
The field’s next expansion will depend on training physicians who are comfortable with both techniques, Dr. Schmitz said. That does not mean every surgeon must perform every operation. It means the team must understand when arthroscopy is enough, when open correction is necessary and when combining them offers the best chance of preserving the joint.
A children’s hospital has to outgrow its age limit
A hip preservation program cannot become a true destination if institutional policies exclude the patients most likely to need it. Many structural conditions begin in childhood but become symptomatic later. A patient may tolerate an abnormal hip through high school, then develop pain as activity intensifies in college or adulthood.
By the time the problem is recognized, the patient may no longer qualify for treatment at the children’s hospital with the most relevant expertise.
“You need to have buy-in from a facility, from a children’s hospital, to understand that this disease doesn’t just stop when someone reaches skeletal maturity or becomes an adult,” Dr. Schmitz said.
Rady Children’s has given Dr. Schmitz the resources to treat older adolescents and young adults, generally extending into patients younger than 35. The objective is to reach them while preserving the natural joint remains realistic.
As the model requires a pediatric organization to think beyond traditional age boundaries, it may involve insurance, anesthesia and facility policies that were not designed for patients in their 20s and early 30s. The hospital has to decide that preserving the joint matters more than preserving the administrative line, he said.
The business case is measured in decades
Hip preservation does not generate the predictable volume associated with total joint replacement. The patients are younger, the cases are less common and the procedures are specialized, and referral patterns can take years to build. That makes the service difficult to evaluate through a traditional volume-based business case.
Dr. Schmitz frames its value differently. “Ultimately, you’re looking at patient satisfaction and longevity,” he said. “The cases aren’t necessarily that high of a cost from a hospital standpoint, but they have huge impacts on patients and their ability to function.”
A successful procedure may allow a patient to remain active, avoid years of pain and delay or prevent joint replacement. Those benefits unfold over decades rather than one episode.
The program can also distinguish a hospital in a market where more common orthopedic procedures are widely available. Total hips and knees may produce greater volume, but complex preservation surgery can establish a regional or national reputation that draws patients, referring physicians and trainees.
Still, destination care does not emerge because a hospital announces a new program. It has to earn referrals from physicians who could send the patient elsewhere.
The referral network is the infrastructure
The most important investment may not be the operating room. It may be the surgeon’s cellphone number.
When Dr. Schmitz built the military’s young adult hip service, he contacted physicians caring for military populations across different locations. He offered to review imaging, discuss cases and see patients quickly. At Rady Children’s, he is using the same approach with community surgeons, academic centers and athletic trainers.
“Here’s my cellphone,” he tells them. “If you have questions, I’m happy to review patients’ information.”
That accessibility addresses the central referral problem in hip preservation: Many patients first see clinicians who do not specialize in complex hip disease. A community surgeon may not recognize dysplasia. A sports surgeon may perform arthroscopy but not offer open reconstruction. An academic center may identify the condition but lack the exact combination of expertise the patient needs.
A destination program has to become the place other physicians call before the patient undergoes an incomplete operation. That requires education.
Dr. Schmitz lectures to community surgeons and holds a monthly hip conference for residents and fellows. Rady Children’s also hosts programs for athletic trainers, who may be among the first to recognize that a young athlete’s hip pain is not resolving normally. He attends his daughters’ high school sporting events and speaks with trainers on the sidelines.
Those relationships may seem far removed from the economics of a tertiary referral program, but they are how the program is built.
The most valuable referral is the early one
Hip preservation loses options as the joint deteriorates. A patient referred before advanced arthritis develops may be eligible for reconstruction. A patient who spends years receiving treatment aimed only at symptoms may reach the specialist after preservation is no longer possible. That makes recognition a strategic priority.
“When I was a resident, a lot of this stuff, we didn’t know what it was yet,” he said. When he trained, Dr. Schmitz estimated that about 20 U.S. centers performed PAO surgery. Today, most major academic markets have someone offering it.
That expansion is evidence of progress. It also means programs can no longer distinguish themselves merely by offering the procedure. Reputation will increasingly depend on patient selection, combined expertise, outcomes and the experience of referring physicians.
Training cannot end at graduation
Dr. Schmitz uses the evolution of his own career to make a point to residents. Many of the operations that now make up most of his practice were not procedures he routinely encountered during training.
“When you finish training, you’re not a finished product,” he tells them. The lesson is especially important in hip preservation, where techniques continue to change and no single specialty owns the entire disease. A surgeon who stops learning risks treating new pathology through an outdated framework.
Dr. Schmitz’s military career reinforced that adaptability. He cared for children, service members, athletes and young adults and built a program before many hospitals had developed one. Now he is applying lessons from pediatric orthopedics, adult care, sports medicine and military medicine within one service. Hip preservation itself is becoming a hybrid field. Its leaders increasingly are, too.
Research has to follow the joint
Hip preservation is intended to alter the long-term course of a young person’s hip; immediate recovery is not enough to judge whether it worked. Dr. Schmitz participates in the Academic Network of Conservational Hip Outcomes Research, or ANCHOR, a multicenter consortium that studies hip pathology and follows patients over time. About 26 institutions participate, he said.
The collaboration allows surgeons to compare techniques, refine patient selection and study questions that no single center may have enough cases to answer. It also prevents the field from advancing on enthusiasm alone.
A minimally invasive procedure may look successful because the patient recovers quickly, even if the structural disease continues. A larger reconstruction may require more recovery but better protect the joint over decades. The central question is not only whether the athlete returns next season. It is whether the natural hip survives.
What makes a destination
Hospitals often use “destination program” as a marketing phrase. For Dr. Schmitz, it means patients and physicians are willing to travel because the center provides something difficult to find locally: integrated evaluation, advanced techniques and a treatment plan not limited by one specialty.
Rady Children’s has begun drawing patients from around the country. Dr. Schmitz jokes that patients already travel to Boston or St. Louis for hip surgery, so they might as well recover in San Diego.
Of course, though the city’s weather is an advantage, the strategy is to make the trip worthwhile. That means providing access at multiple clinic locations, responding quickly to referring physicians and building a team capable of open, arthroscopic and combined care.
A destination also cannot be difficult to enter. The best hip preservation centers will not be defined by how many scopes or osteotomies they perform. They will be defined by whether they can see the entire patient before the joint runs out of time.
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