Retired Chief Physician (DE) Dr. med. Wolfgang Zinser is a renowned specialist in orthopedics and traumatology who treats patients with orthopedic and trauma-related conditions and clinical presentations. His particular international expertise lies in the field of joint-preserving hip surgery, hip arthroscopy—including labral and cartilage reconstruction— pelvic corrections for hip dysplasia using minimally invasive PAO (periacetabular osteotomy), and corrective osteotomies of the femur (thigh bone).
With more than 2,000 cartilage cell transplantation procedures performed on the knee, hip, and ankle, he is one of the most experienced orthopedic surgeons in this field worldwide. His state-of-the-art practice, OrthoExpert, enables comprehensive diagnostics and treatment at the highest scientific level and in accordance with current guidelines. He performs surgeries at the state-of-the-art Privatklinik Graz Ragnitz (www.privatklinik-graz-ragnitz.at), where patients can enjoy excellent inpatient care. His goal is always to offer his patients the best possible holistic care so that they can quickly return to their normal activities.
Dr. Zinser specializes in preserving joints whenever possible. For two decades, he has been actively involved nationally and internationally as an educator, speaker, and advisor to patients and colleagues in the field of joint and cartilage regeneration. From April 2007 to January 2022, Dr. Zinser served as Chief Physician at St. Vinzenz Hospital in Dinslaken, where approximately 1,000 patients underwent joint-preserving surgeries each year.
Since July 1, 2022, Prim. Dr. Zinser has made Styria, Austria, his professional and personal home and has founded a center for joint-preserving orthopedics. He is also President of the QKG (Society for Cartilage Regeneration and Joint Preservation) (www.qkg-ev.de) and, thanks to his extensive experience and expertise in orthopedics and sports medicine, provides his patients with the best possible care. As a former member of the national track and field team (triple jump), he is particularly well-equipped to understand the concerns and challenges faced by injured athletes. His focus lies in the surgical specialties listed above. In addition, he offers numerous modern conservative therapies, including hyaluronic acid injections, PRP (platelet-rich plasma) injections, and cartilage-protective physical therapy.
As Medical Director of the Metagil Physical Therapy Clinic, he works closely with physical therapists and private practice colleagues, as well as the Austrian Ski Association (ÖSV), ensuring that his patients receive optimal care. Prim. Dr. Zinser works as a private practice physician and does not have a contract with health insurance companies, which offers the significant advantage that he can devote sufficient time to each individual patient. In Germany, approximately 10–15% of the population suffers from hip problems. The editorial team at Leading Medicine Guide wanted to learn more about hip pain and was able to ask Prim. Dr. Zinser several questions regarding hip complaints.
 Dr. med. Wolfgang Zinser.jpg "Primarius a. D. (DE) Dr. med. Wolfgang Zinser")
Hip problems can have a variety of causes and often impair the mobility and quality of life of those affected. Typical symptoms include pain in the hip area, which can worsen when walking, standing, or sitting. These symptoms can be caused by various factors, such as overuse, injuries, wear and tear, or inflammatory processes. It is important to take hip problems seriously and seek medical advice early on to determine the cause and initiate appropriate treatment. This may include conservative measures such as physical therapy, pain management, or injections. In some cases, surgery may be necessary if conservative therapies are not sufficiently effective or if there is severe structural damage.
Hip pain can have a variety of causes.
“When we talk about hip pain, we always mean groin pain—because that’s where the pain originating from the hip joint is felt. There are many causes unrelated to the joint itself. However, when it comes to the joint itself, there are three common causes: first, osteoarthritis; second, hip impingement; and third, hip dysplasia. In cases of osteoarthritis, approximately 50% have a cause that originates either in childhood or during puberty. And if these causes are identified early enough, osteoarthritis can be delayed or prevented. This is the goal of preventive therapy, as a 2016 study also demonstrated. For example, in Germany and many other European countries, infant ultrasound is performed as a standard procedure so that abnormal development of the hip socket (dysplasia) can be detected early. As treatment, babies are then “swaddled with their legs spread wide” or given abduction pants; in severe cases, more complex therapies are also used. As a result, the incidence of dysplasia—which would have required surgery later on—was reduced by one-fifth compared to the period before infant ultrasound screening was introduced. This is the major achievement of Univ. Prof. Prim. Dr. med. Reinhard Graf from Austria, who developed this ultrasound technique in the late 1980s and served as Medical Director of the Stolzalpe General and Orthopedic Regional Hospital in Austria from 1997 to 2011. “This is a very effective method for intervening in hip dysplasia at an early stage. This is because, in a baby, it is possible to effectively address the developmental disorder of the hip socket due to the still-soft cartilaginous ‘bones,’” explains Prim. Dr. Zinser at the beginning of our conversation.
With osteoarthritis, one must also distinguish between osteoarthritis resulting from normal age-related wear and tear—which accounts for less than 50% of patients—and osteoarthritis caused by a structural abnormality that leads to the condition. In the latter case, it is crucial to recognize and treat structural abnormalities—such as dysplasia, femoroacetabular impingement, or femoral neck malrotation—in a timely manner so that the onset of osteoarthritis can be prevented or delayed.
“Dysplasia is now less common in European countries, but there are more cases of impingement. This is due, among other things, to the fact that competitive sports during adolescence have become increasingly prevalent. This leads to the development of a pre-arthritic deformity that promotes the early onset of osteoarthritis. Sports that pose a particularly high risk include soccer, ice hockey, ballet, and martial arts—all of which involve many full-range-of-motion hip movements. In track and field, hurdle races and various jumping events carry a higher risk, whereas running events do not. This does not mean that adolescents are not allowed to participate in these sports. “But as long as adolescents are still going through puberty and have open growth plates, training should only take place under orthopedic supervision,” explains Prim. Dr. Zinser.
Hip impingement, also known as femoroacetabular impingement (FAI), refers to an abnormality in the structure of the hip joint that can lead to pain, restricted movement, and possibly the development of hip osteoarthritis. Hip impingement involves an abnormal shape of the hip bones or the hip joint, causing bones or soft tissues to interfere with one another or “get pinched” during movement of the hip joint. Symptoms of hip impingement may include pain in the groin, buttocks, or outer side of the hip, particularly during movement or when weight is placed on the hip joint. The pain may develop gradually and worsen with certain movements, such as squatting, bending, or rotating the hip joint. In most cases, hip impingement leads to limited range of motion in the hip joint.
Certain warning signs may indicate that hip pain is serious in nature and requires immediate medical evaluation.
For example, sudden and intense pain in the hip area may indicate an acute injury such as a fracture or labral tear—or, rarely, a dislocation—especially if it occurs after a fall or accident. This pain is often severe and immediate, and the affected person may have difficulty moving or putting weight on the leg. Swelling, redness, or warmth in the hip joint may be signs of inflammation or infection. These symptoms may be accompanied by a fever and a general feeling of illness. Limited mobility in the hip joint or the inability to bear weight on or move the leg are also alarming warning signs. They may indicate structural damage such as severe osteoarthritis, injuries to the ligaments or tendons, or other serious problems in the hip area. Early diagnosis and treatment can help prevent serious complications and achieve the best possible outcomes.
“First and foremost, it’s important to ask the patient detailed questions. How far can they walk without pain? Is there pain even at rest? How limited is their range of motion? Do they take pain medication regularly? If the patient then describes, for example, that they can no longer put on their socks or tie their shoes properly due to pain and have overall reduced mobility, this points to osteoarthritis. If, for example, pain at rest occurs only when sitting in a deep position, this tends to indicate impingement, whereas with dysplasia, mobility is still good, but symptoms occur during prolonged walking and standing—though usually not initially when sitting. “You then begin to form an idea of the cause and which specific tests to perform during the examination. This is followed by a specialized examination in combination with diagnostic imaging,” explains Prim. Dr. Zinser.
“For every young patient who asks about joint-preserving options and has hip pain, we take special X-rays, including a centered pelvic overview WITHOUT gonad protection, a Rippstein II view or axial view, and a faux-profile view, so that any deformities can be clearly visualized. These must then be measured to quantify their severity. There are angles that must be calculated from the X-ray and are described in the AWMF guidelines for coxarthrosis. Then an MRI is also needed, and here, too, there is a specialized hip MRI that uses specific sequences to examine the hip. There is a consensus among European radiology societies regarding which diagnostic methods must be available for hip diagnostics. And the results are not as straightforward as that. To the best of my knowledge, there are three radiology institutes in all of Styria that, thanks to my initiative, are capable of performing this complete set of specialized X-ray and MRI diagnostics. The imaging results are reviewed together with the patient’s medical history, and then the examination is conducted. There are specific tests for every possible cause: an impingement test, a dysplasia test, an instability test, and an osteoarthritis test. Together with the imaging and medical history, this leads to a diagnosis. Adjacent joints, such as the knee or spine, are also examined. This is because the problems may originate there as well, which could influence the diagnosis. In 10–20% of patients, it is initially unclear whether the pain originates in the hip, the spine, or elsewhere. In such cases, a so-called test injection is performed. Under sterile conditions, the hip is numbed with a local anesthetic under ultrasound guidance, and if the pain then subsides, we know for certain that the pain is coming from the hip joint,” explains Prim. Dr. Zinser in detail, adding the following recommendation:
“If a patient is young and repeatedly experiences groin pain—for example, after physical activity—this should definitely be evaluated by a specialist. Because these changes are a ticking time bomb. And if the changes are detected early—specifically, before any cartilage damage has occurred—it is very likely that a hip replacement can be avoided. In such cases, extremely successful treatments are possible, which we’ll discuss shortly, and thanks to which premature wear and tear can be prevented.”
Non-surgical treatment approaches, of course, always aim to relieve pain, reduce inflammation, improve mobility, and enhance patients’ quality of life.
“If the deformity and symptoms in the hip are mild, then a three-month course of conservative therapy involving physical therapy to correct muscular deficits can be pursued. It is then important for patients to remain under regular monitoring. This applies primarily to younger patients. For older patients who already have early-stage osteoarthritis and for whom joint-preserving surgical procedures would no longer be helpful, physical therapy with traction (pulling on the joint) combined with injections into the joint is recommended. In addition to cortisone injections during the acute phase, platelet-rich plasma (PRP) has proven effective here. This is concentrated plasma containing platelets from the patient’s own blood, which can also be used in combination with hyaluronic acid. After an initial course of three PRP/hyaluronic acid treatments at specific intervals, many of my patients come in every six months—and some as infrequently as once a year—for a maintenance injection. If the osteoarthritis does not progress too rapidly, it is certainly possible to gain 5–10 years—that is, to delay the implantation of an artificial hip joint—which is desirable but, of course, highly individual. Regular monitoring is also important here. In my practice, it’s often the case that the physical therapist notifies me when a patient’s hip condition worsens, since the therapist usually knows and has been treating the patient for several years. “And only when the patient’s suffering becomes truly unbearable is it time for a new hip joint,” explains Dr. Zinser, outlining one of the options for conservative therapy.
“Another non-surgical option, the effectiveness of which is not yet scientifically clear, is stem cell therapy. However, many people believe that this works wonderfully and simply—that you just inject stem cells and the entire cartilage is healed again. Of course, it’s not that simple. Stem cells—for example, those derived from adipose tissue—can positively influence the effects of osteoarthritis, namely inflammation and the impaired joint environment, which works particularly well for patients who have not yet completely lost their cartilage. Stem cells may be able to slow the progression of osteoarthritis and are particularly successful in patients with a grade 2–3 osteoarthritis diagnosis by stimulating the remaining cartilage cells. However, there are still too few studies on whether stem cell therapy is more effective than the platelet-rich plasma therapy mentioned earlier. “The cost, however, is 10 to 20 times higher,” says Prim. Dr. Zinser regarding stem cell therapy, and he offers an additional tip that’s easy to follow:
“In my experience, dietary supplements also play a role! Many patients suffer from vitamin D deficiency and have other deficiency symptoms due to an unbalanced diet. I like to prescribe Orthomol ChondroPlus (a combination of vitamins, minerals, trace elements, essential fatty acids, and other bioactive substances), which patients take over a period of three months because metabolism in cartilage proceeds very slowly. Exercise is another key factor—according to the World Health Organization, everyone should get at least 150 minutes of physical activity per week. Patients don’t necessarily have to move their painful hip; they can also perform movements with their arms. “It’s all about pure muscle movement and stimulation, since the muscles then send out signals that reduce pain and have anti-inflammatory effects.”
Hip surgery can prevent or delay wear and tear and osteoarthritis, especially when structural problems such as hip dysplasia, labral tears, or femoroacetabular impingement (FAI) are present.
Timely surgical intervention can correct anatomical abnormalities and restore normal hip joint function before osteoarthritis develops or worsens. The long-term outcomes of such early hip surgeries depend on various factors, including the exact cause of hip pain, individual predisposition (genetics), the patient’s overall health, and the type of procedure performed. In general, studies show that early hip surgery for structural problems such as hip dysplasia or FAI can help slow or prevent the progression of osteoarthritis and provide long-term pain relief and improved hip joint function.
“Basically, a distinction must be made between young and older patients. For older patients, the focus is on quality of life and, in most cases, joint replacement. Hip surgery involving the implantation of an artificial hip joint (endoprosthesis) is ultimately not “life-saving,” but it offers the chance to achieve a much better quality of life, which is then more important than the risk of the surgery. And there is approximately a 90% probability of being satisfied in the long term (on average 25 years) following hip surgery. The decision for or against surgery always rests with the patient. If sleep disturbances caused by pain continue to worsen, or if the use of pain medication increases (which is also dangerous in the long term), and mobility continues to deteriorate, then the patient should take advantage of the opportunity to have an artificial hip joint implanted. “In younger patients, if the pain does not subside after three months of conservative therapy and a deformity has been diagnosed, then according to the current state of scientific knowledge, joint-preserving surgery is recommended to prevent the progression of irreversible joint cartilage damage,” explains Prim. Dr. Zinser, distinguishing between the two main joint-preserving surgical procedures:
“First, there is hip arthroscopy, in which the deformity is smoothed out, the labrum is sutured, and, if necessary, small cartilage defects can be treated with regenerative therapy. In the second surgical method, which is performed in cases of dysplasia—that is, when the acetabulum is not properly formed—the pelvis must be repositioned to improve the coverage of the acetabulum. For younger patients, the goal is always to preserve the joint for as long as possible. For example, most patients return to their original level of athletic activity—and even exceed it—after the procedure, something many patients initially doubt but later come to realize is possible. In the case of so-called periacetabular pelvic osteotomy or periacetabular osteotomy (PAO) to correct the position of the hip socket, e.g., in cases of hip dysplasia, more than one-third of treated patients do not develop hip osteoarthritis even after 30 years, which clearly supports joint-preserving surgery, provided it is feasible for the individual patient. If these surgeries are not performed on these patients, or are performed too late, the symptoms will usually worsen rapidly and osteoarthritis will develop early.”
With total hip replacement (THR) as a treatment option for advanced osteoarthritis, the long-term outcomes are also generally positive. Modern implants and surgical techniques have significantly improved the durability and reliability of hip replacements, allowing many patients to continue enjoying good function and quality of life even after many years.
“As far as hip replacements are concerned, based on current knowledge, the average lifespan is approximately 25 years (perhaps even longer), provided everything goes well, the surgery was performed properly, and no infection develops. What we know for certain today is that, on average, a revision surgery is usually necessary after 25 years (for some, significantly sooner; for others, later!), and often sooner in younger patients. And once this replacement surgery has taken place, current evidence indicates that in over 10% of cases, another replacement surgery will be necessary after another ten years. However, after a replacement surgery, it is almost never possible to achieve the same level of functional outcome and freedom from symptoms as with the initial implantation of a new hip! Therefore, for younger patients, surgery should be performed with the goal of preserving the joint as much as possible. And this is where a major risk lies in some surgical decisions made regarding prostheses, since the good functionality of prostheses is observed in older patients, and, in my opinion, they are often implanted too readily in younger patients. Current data show that the number of revision surgeries in young people is rising disproportionately. There’s the young person who received their first prosthesis at age 20, who then faces their first revision surgery at 40 and again at 50, without any guarantee of continued freedom from symptoms—which increases the risk of disability during their working years (which generally lasts until age 65–67). Prosthetics have indeed improved today, but dangerous economic and health policy disincentives are currently being created for the implantation of artificial joints. In other words: Clinics that offer joint-preserving surgeries are currently being financially “penalized” within the healthcare systems of Germany and, above all, Austria, since these procedures are more costly and are therefore currently severely underreimbursed. Joint replacement, on the other hand, continues to be indirectly promoted by existing economic misincentives. Since joint-preserving surgery is much more complex and costly than joint replacement, many hospitals do not offer such procedures at all. Consequently, this means that too few doctors can be trained in these therapies, which makes the situation very concerning for the future. I am currently addressing this problem in Austria with a large expert group comprising members from all relevant orthopedic and trauma surgery professional associations, with the aim of persuading lawmakers to reconsider their approach and implement appropriate countermeasures. The initial discussions on this matter have been very positive, and the problem has been recognized. One reasonable demand from the expert group is that hospitals performing a high volume of joint replacement surgeries be legally required to also perform and provide training in joint-preserving therapies on a proportional basis. This must apply to both the hip and knee joints. Furthermore, joint-preserving procedures must be reimbursed in a way that ensures full cost coverage, just as is the case with prosthetics!” states Prim. Dr. Zinser critically.
A Call for the Future—More Education Is Needed!
“Together with colleagues from the expert panel, I have specific demands:
- As mentioned above, every hospital that performs a high number of joint replacement surgeries must be required to demonstrate expertise in joint-preserving therapies in accordance with the guidelines (AWMF guidelines) and to provide training in these therapies. This applies not only to the hip but also to knee replacement. This is because there are hospitals in Austria that have lost the skill to perform these surgical techniques—particularly with regard to PAO and hip arthroscopy—and patients may consequently receive suboptimal care in cases of uncertainty.
- Joint-preserving therapies require cost-covering reimbursement within the billing system (LKF system), which is currently being updated for 2025.
- Professional associations, with the support of health policymakers, must promote training in these therapies and provide better education on successful joint-preserving therapies—both for healthcare professionals, such as primary care physicians, and for the general public.
- Surgical capacity at state hospitals must be drastically increased, which can also be achieved through process improvements and flexible work schedules.
- Integrate specialists in joint-preserving therapies as trainers in public hospitals to accelerate training.
In Austria, some patients wait up to three years for their elective (i.e., non-acute, non-life-threatening) surgery. Many then pool their savings and turn to private clinics if they do not have supplemental insurance. In Austria, without private clinics, the shortage of care for elective orthopedic surgeries would be even greater. There is an urgent need for action. In Germany, as well as in Austria, calls for the centralization of certain treatments are growing louder. In principle, this is a good idea, but the necessary expertise must actually be available. For example, according to a study of 10,000 patients, one-quarter of knee replacements could currently be avoided through the timely use of cartilage cell transplantation. Furthermore, the important joint-preserving surgeries mentioned earlier can, in many cases, prevent enormous costs arising from frequent revision surgeries and the associated lost work time. This means that the centers being proposed must also be proficient in performing joint-preserving surgeries. “The current structural and financial incentives favoring joint replacement must urgently be shifted by law toward joint preservation. We owe this to our patients!” appeals Prim. Dr. Zinser, and with that, we conclude our conversation.
Thank you very much for this thoroughly critical look at hip replacement surgery!
