Patient Stories 
Many young people who suffer from hip pain stop physical activities altogether. The Hip Preservation Institute finds solutions to help patients rediscover pain-free movement.
Seventeen-year-old Rayana Shoberg is not the type of person to wait around for something she wants. When she decided to start working and earning her own money, she didn’t just get an after-school or summer job, she graduated high school two years early after acquiring her diploma through an online program, and then started a career in health care.
As impatient and ambitious as she is, when she was 13, lingering pain in her hips slowed her down. So, Rayana sought medical help. “Doctors and nurses told me that I just had growing pains,” she said. “I had doctor appointments where they would do MRIs and X-rays. I went through years and multiple different kinds of physical therapy, but nothing improved.”
A lifelong dancer and active athlete in cross country, basketball and softball, Rayana felt she had no choice but to give up dancing. By the time she was 16, Rayana was still in pain and growing frustrated. She hadn’t given up hope, though, and with the help of her parents, kept pushing for answers. “That’s when Dr. Milligan came in, and he realized that I have hip dysplasia in both hips and there was a chance of it becoming arthritis later in my life.”
After some initial treatment and physical therapy to judge the responsiveness of Rayana’s hips to nonsurgical solutions, Kenneth Milligan, M.D., Orthopedic Surgeon at the Hip Preservation Institute, suggested that Rayana undergo a periacetabular osteotomy (PAO) surgery.
The PAO procedure is a highly specialized hip surgery that is typically only available to patients in large metropolitan areas such as Denver and Minneapolis — and sometimes not even then. Its rarity is due to the training and expertise required to perform the procedure. It is also a relatively recent innovation — there just aren’t that many surgeons trained to perform PAOs yet.
In a PAO, the surgeon makes a small incision over the hip and uses live X-ray to help make several cuts in the pelvis allowing the hip socket to be rotated in a better position. This results in better stability of the hip and less pain.
The Shoulders of Giants
At his own practice, Pediatric Orthopedic Surgeon Eric Krohn, D.O., frequently encounters patients with hip dysplasia, many of them much younger than Rayana. Because of Dr. Milligan’s training in PAO procedures and his sole focus on hips, and Dr. Krohn’s experience diagnosing and monitoring hip deformities in young patients, the two began discussing how to help patients with hip pain who may encounter the same kind of frustrations as Rayana. The lack of accuracy in diagnoses, as Dr. Krohn pointed out, is not the fault of primary care providers or other physicians.
“They literally just don’t know what to look for because it’s not even on their radar,” he said.
“As recently as 10 years ago, specialists were still improving and refining the PAO technique,” Dr. Milligan said. “I had the benefit of watching them go through that learning curve. As a result, I’m able to avoid a lot of the mistakes of the early surgeons just because I got to train with the original pioneers of this surgery.”
“You can see so far because you stand on the shoulders of giants,” added Dr. Krohn.
The solution for Drs. Milligan and Krohn was to join their talents with Orthopedic and Sports Medicine Physicians, a General Surgeon and Physical Therapists at Monument Health Orthopedic & Specialty Hospital in forming the Hip Preservation Institute (HPI), which launched this past May. The goal is to diagnose and treat hip problems early enough to prevent long-term complications like arthritis and delay total hip replacement surgery until old age. This way, patients can expect to live a full, active life without worry about discomfort, pain or further damage.
Catching hip dysplasia in young patients affords HPI the privilege of offering the full complement of treatments from the beginning. If physical therapy and rehabilitation exercises prove ineffective, surgical options are considered. One of those solutions is the PAO procedure.
Early intervention is so important because in order for the PAO surgery to be most effective, it needs to be performed on patients who are physically mature enough to be nearly finished growing. However, they also must have sustained as little cartilage damage as possible. Damage tends to compound as hips age. It is also irreversible.
Drs. Milligan and Krohn prefer not to focus on a specific ideal age for a patient to undergo a PAO. However, they say it’s generally in the 12- to 35-year-old range and varies on a case by case basis. “Really the idea of this surgery is to get people back to sports, to activities. We do the surgery on professional athletes, so we try to minimize any extra soft tissue disruption or muscle disruption and allow for the fastest recovery possible,” said Dr. Milligan.
The worst-case scenario for the HPI is that a young patient experiences hip pain which goes untreated for too long. “We’re really focusing on trying to educate the public that if your kid has hip pain, and you go and you see your pediatrician or an orthopedist and they say it’s just growing pains, you should get a second opinion,” said Dr. Milligan. “Come have us take a look at it, because this is a fairly new field and that provider may not have had this particular training. Plus, in our specialty, we also follow special imaging protocols and have technology that allow us to make these diagnoses.”
A Birthday Procedure
Rayana’s PAO surgery was scheduled for late 2024 and just happened to be the day after she turned 17. “I’m not going to be able to go out and do what I enjoy anymore if I don’t get the surgery done,” she remembered thinking. “I’ve seen my grandma go through hip replacements later in life on both of her hips. She is 70 years old and can barely walk. Hopefully doing this surgery now would solve some of those future issues for me.”
The PAO took six hours to complete, and five months to heal. It was a trying time for Rayana; she made it through with help from her family and her boyfriend, and a physical therapy routine designed to get her hip back to full weight bearing as soon as possible.
In a follow-up appointment, Dr. Milligan determined that Rayana’s gait had improved. She decided to return to work. “I had put in an application for Nurse Aide at Rapid City Hospital in August of 2024 but couldn’t interview because of my upcoming surgery,” Rayana said. “They asked me to contact them when I was ready to return to work, which is what I did. There was an open Junior Clinical Assistant position at the Heart and Vascular Institute. I started March 10th.”
Rayana is now employed at the very organization that provided her hip treatment. “I want to be able to accomplish my dreams at a young age. You don’t find very many 20-year-olds that are nurses,” she said.
Her new job also provided a road test of sorts for the results of the PAO. “Before the surgery, if I worked a full day I’d be almost limping because I was hurting so bad. After the surgery, I could work an eight-hour day just fine. Later this summer, I will start my medical assistant program, then eventually go to nursing school. I’m really glad that I did the surgery.”
Whether or not Rayana goes back to have a PAO on the left side depends on her recovery, though she said it’s pretty likely that she will, despite her reluctance to spend another five months healing.
“A lot of people tell me that they’re having hip problems, too. And my advice is: if you feel it, get it checked out now. A $200 bill is better than having a $90,000 hip replacement surgery later in life,” she said.
Rayana is done waiting around. She’s ready to move on. And, thanks to HPI, she can do so pain free.
Learn more about the Hip Institute and meet the team of Physicians and Caregivers by going to: www.monument.health/hippreservation