June

As part of Hip Dysplasia month this June, here are some key messages for health professionals.

Much appreciation to Hip Pain Cardiff and various other helpful physios for contributing to these last year (you know who you are)! 

Adults and Adolescents can have Hip Dysplasia too

Hip Dysplasia can develop from adolescence or from a residual infant diagnosis, even if earlier treatment has been successful (Lee et al, 2013; Okano et al, 2015; Pun, 2016).  Dysplasia needs to be in your differential diagnosis when seeing a young adult patient with recurring hip or groin pain.

What to look out for

Signs and symptoms can include:

• Recurring hip, groin or lateral hip pain
• Exacerbated by activity/sport and relieved with rest.
• C-sign pain
• Labral symptoms, such as clicking, locking, catching & giving way of the hip
• Positive Impingement test
• Knee pain
• Low back pain
• Pelvic pain
                 (Nunley et al, 2011; RCS, 2017; Reiman et al, 2015)

Symptoms can appear subtle & manageable at first, & very slowly worsen over a number of years (Gambling et al, 2018).  Others find that pain and function suddenly deteriorates over just a few months as the joint begins to 'decompensate' for the abnormal biomechanics

Ask about family history of hip problems

Remember to ask if a patient has any infant or family history of hip problems in a subjective assessment.  There is a genetic link with hip dysplasia, for example, they might have a female relative who has had hip problems or an early hip replacement (Carroll et al, 2016; Basit et al, 2017; Lee et al, 2013; Pun, 2016).

Careful not to confuse with Femoroacetabular Impingement (FAI)

Hip Dysplasia in adults can present very similar to FAI.  Make sure you back up any suspected diagnosis of either of these with accurately interpreted x-rays (Kappe et al, 2012; Nepple et al, 2015).

Can cause early Osteoarthritis (OA)

Hip Dysplasia has strong links to early-onset hip OA (Jacobsen et al, 2005; Kaya et al, 2016; Reijman et al, 2005; Wyles et al, 2017), so it's important to be working from an accurate diagnosis when seeing a patient with hip or groin pain.  Remember that the approach needs to be preventative rather than waiting for things to get worse (RCS, 2017).

Pelvic Osteotomy surgery can delay Total Hip Replacement (THR)

Pelvic Osteotomy (also called Periacetabular Osteotomy or PAO) is a surgery that reshapes the acetabulum to better cover the femoral head, aiming to delay the onset of OA and therefore delay THR (Mei-Dan et al, 2017; Pascual-Garrido et al, 2017).  This is more likely to be successful before OA is present and before pain and function have significantly reduced (Coobs et al, 2015).  Timely diagnosis & referral is essential if you suspect Hip Dysplasia.  If symptoms are no better after roughly 3 months, or the patient can't return to sport or activities, a referral for x-ray is recommended (Groh et al, 2009; RCS, 2017).

There is evidence showing good survival rate in PAOs at 20 and 30 years and improved quality of life for patients (Boje et al, 2018; Lerch et al, 2017; Steppacher et al, 2008).  Variables need to be considered and surgeon experience is important (Kralj-Iglic, 2017; Mei-Dan, 2013; Novais et al, 2016).

X-rays need careful reporting

Some x-rays showing Hip Dysplasia have been known to be reported as 'clear.'  If your patient is not improving with physiotherapy, consider wording a referral request specifically to look for Acetabular Dysplasia and take note of the centre-edge angle and the acetabular angle (Dick et al, 2018; IHDI, 2018; Laborie et al, 2013).

Consensus on Diagnosis

Hip Dysplasia is a 3-dimensional spectrum of conditions of the acetabulum.  There seems to be a lack of consensus amongst clinicians on the criteria used to diagnose hip dysplasia, in particular, when it would be classified as ‘mild’ or more severe.  However, there is more consensus amongst clinicians who treat high volumes of young adult hip patients (Larson et al, 2012; Malviya et al, 2016; Musielak et al, 2015; Wilkin et al, 2017; Witt et al, 2017; Xu et al, 2018; Yeung et al, 2016).

Where to find a specialist

It is recommended that young adult hip patients are referred to high volume specialist hip centres if an orthopaedic opinion is required (RCS, 2017).  Due to there being very few of these specialists across the country, this may mean a patient travelling to another part of the country to receive an accurate diagnosis and treatment plan.  Consider this when referring a patient on; it may not be the first consultant they see who ends up diagnosing them or treating them.  Travelling to another part of the country may not be feasible for every patient but it's important to weight up their options with them and what the potential long term consequences of those options are.

References

Basit, L., Albalawi, A. M., Alharby, E. & Khoshhai, K. L. (2017) Exome sequencing identified rare variants in genes HSPG2 and ATP2B4 in a family segregating developmental dysplasia of the hip. BMC Medical Genetics, 18 (34). 18-34.

Boje, J., Caspersen, C. K., Jakobsen, S. S., Soballe, K. & Mechlenburg, I. (2018) Are changes in pain associated with changes in quality of life and hip function 2 years after periacetabular osteotomy? A follow-up study of 321 patients. Journal of Hip Preservation Surgery, 0 (0). 1-8

Carroll, K. L., Schiffern, A. N., Murray, K. A., Stevenson, D. A., Viskochil, D. H., Toydemir, R., MacWilliams, B. A. & Roach, J. W. (2016) The Occurrence of Occult Acetabular Dysplasia in Relatives of Individuals with Developmental Dysplasia of the Hip. Journal of Pediatric Orthopaedics, 36 (1). 96 – 100.

Coobs, B. R., Xiong, A. & Clohisy, J. C. (2015) Contemporary Concepts in the Young Adult Hip Patient: Periacetabular Osteotomy for Hip Dysplasia, The Journal of Arthroplasty, 30

Dick, A.  G., Houghton, J. M. & Bankes, M. J. (2018) An approach to hip pain in a young adult. British Medical Journal, 361. Doi: 10.1136/bmj.k1086

Gambling, T. S. & Long, A. (2018) Psycho-social impact of developmental dysplasia of the hip and of differential access to early diagnosis and treatment: A narrative study of young adults. Sage Open Medicine, 7. 1–13.

Groh, M. M. & Herrera, J. (2009), A comprehensive review of hip labral tears. Current Reviews in Musculoskeletal Medicine. 2 (2).   doi: 10.1007/s12178-009-9052-9

International Hip Dysplasia Instituted (IHDI) (2018) Adult Hip Dysplasia: Adult Diagnosis. Retrieved from: https://hipdysplasia.org/adult-hip-dysplasia/adult-diagnosis/

Jacobsen, S., Sonne-Holme, S., Søballe, K., Gebuhr, P. & Lund, B. (2005) Hip dysplasia and Osteoarthrosis: A survey of 4,151 subjects from the Osteoarthrosis Substudy of  the Copenhagen City Heart Study. Acta Orthopaedica, 76 (2). 149-158.

Kappe, T., Kocak, T., Reichel, H. & Fraitzl, C. R. (2012) Can femoroacetabular impingement and hip dysplasia be distinguished by clinical presentation and patient history? Knee Surgery Sports Traumatology Arthroscopy, 20. 387–392.

Kaya, M., Suzuki, T., Emori, M. & Yamashita, T. (2016) Hip Morphology influences the pattern of articular cartilage damage. Knee Surgery, Sports Traumatology, Arthroscopy 24. 2016-2023

Kralj-Iglic, V. (2017) CORR Insights: Does Surgeon Experience Impact the Risk of Complications After Bernese Periacetabular Osteotomy? Clinical Orthopaedics and Related Research, 475. 1118-1119

Laborie, L. B., Engesaeter, I. O., Lehmann, T. G., Sera, F., Dezateux, C., Engesaeter, L. B. & Rosendahl, K. (2013) Radiographic measurements of Hip Dysplasia at skeletal maturity - new reference intervals based on 2, 038 19 year old Norwegians. Skeletal Radiology, 42 (7). 925 - 935.

Larson, A. N., Rabenhorst, B., De La Rocha, A. & Sucato, D. J. (2012) Limited Intraobserver and Interobserver Reliability for the Common Measures of Hip Joint Congruency Used in Dysplasia. Clinical Orthopaedics and Related Research, 470. 1414–1420

Lee, C. B., Mata-Fink, A., Millis, M. B. & Kim, Y. J. (2013) Demographic Differences in Adolescent-diagnosed and Adult-diagnosed Acetabular Dysplasia Compared with Infantile Developmental Dysplasia of the Hip. Journal of Pediatric Orthopaedics, 33 (2). 107–111

Lerch, T. D., Steppacher, S. D., Liechti, E. F., Tannast, M. & Siebenrock, A. (2017) One-third of Hips After Periacetabular Osteotomy Survive 30 Years With Good Clinical Results, No Progression of Arthritis, or Conversion to THA. Clinical Orthopaedics & Related Research, 475. 1154-1168.

Malviya, A., Raza, A. & Witt, J. D. (2016) Reliability in the diagnosis of femoroacetabular impingement and dysplasia among hip surgeons: role of surgeon volume and experience. Hip International, 26 (3)

Mei-Dan, O. (2013) Hip Preservation: Reality Check on Training. Orthopedics, 36 (4). 244-245

Mei-Dan, O., Jewell, D., Garabekyan, T., Brockwell, J., Young, D. A., McBryde, C. W. & O'Hara, J. N. (2017) The Birmingham Interlocking Pelvic Osteotomy for Acetabular Dysplasia: 13-to-21-Year Survival Outcomes. The Bone & Joint Journal, 99-B (6). 724 - 731. 

Musielak, B., Idzior, M. & Jozwiak, M.  (2015) Evolution of the term and definition of dysplasia of the hip - a review of the literature. Archives of Medical Science, 11 (5). 1052-1057.

Nepple, J. J. & Clohisy, J. C. (2015) The Dysplastic and Unstable Hip: A Responsible Balance of Arthroscopic and Open Approaches. Sports Medicine and Arthroscopy Review, 23 (4). 180-186.

Novais, E. N., Carry, P. M., Kestel, L. A., Ketterman, B., Brusalis, C. M. & Sankar, W. N. (2016) Does Surgeon Experience Impact the Risk of Complications After Bernese Periacetabular Osteotomy? Clinical Orthopaedics & Related Research. 475 (4). 1110 – 1117. Doi: 10.1007/s11999-016-5010-1

Nunley, R. M., Prather, H., Hunt, D., Schoenecker, P. L. & Clohisy, J. C. (2011) Clinical Presentation of Symptomatic Acetabular Dysplasia in Skeletally Mature Patients. The Journal of Bone & Joint Surgery. 93-A (2) 

Okano, K., Yamaguchi, K., Ninomiya, Y., Matsubayashi, S., Aoyagi, K., Osaki, M., Enomoto, H. & Takahashi, K. (2015) Relationship Between Developmental Dislocation of the Hip in Infant and Acetabular Dysplasia at Skeletal Maturity. Medicine, 94 (1). 1-5

Pascual-Garrido, C., Harris, M. D. & Clohisy, J. C. (2017) Innovations in Joint Preservation Procedures for the Dysplastic Hip “The Periacetabular Osteotomy.” The Journal of Arthroplasty, 32. 532-537.

Pun, S. (2016) Hip Dysplasia in the young adult caused by residual childhood and adolescent-onset dysplasia. Current Reviews in Musculoskeletal Medicine, 9 (4).

Reijman, M., Hazes, J. M. W., Pols, H. A. P., Koes, B. W. & Bierma-Zeinstra, S. M. A. (2005) Acetabular Dysplasia Predicts Incident Osteoarthritis of the Hip: The Rotterdam Study. Arthritis & Rheumatism, 52 (3). 787 - 793.

Reiman, M. P., Mather, R. C. & Cook, C. E. (2015) Physical examination tests for hip dysfunction and injury.  British Journal of Sports Medicine, 49. 357-361.

Royal College of Surgeons (RCS) (2017) Commissioning guide: pain arising from the hip in adults. London: British Hip Society, British Orthopaedic Association and Royal College of Surgeons of England

Steppacher, S. D., Tannast, M., Ganz, R. & Sienbenrock, K. A. (2008) Mean 20-year Followup of Bernese Periacetabular Osteotomy. Clinical Orthopaedics and Related Research, 466. 1633 – 1644.

Wilkin, G. P., Ibrahim, M. M., Smit, K. M. & Beaule, P. E. (2017) A Contemporary Definition of Hip Dysplasia and Structural Instability: Toward a Comprehensive Classification for Acetabular Dysplasia. The Journal of Arthroplasty, 32. S20-S27

Witt, J. D. & Haddad, F. S. (2017) Acetabular Dysplasia: Multiple Pathologies and Myriad Solutions. The Bone and Joint Journal, 99-B (6). 705-707.

Wyles, C. C., Heidenreich, M. J., Jeng, J., Larson, D. R., Trousdale, R. T. & Sierra, R. J. (2017) The John Charnley Award: Redefining the Natural History of Osteoarthritis in Patients with Hip Dysplasia & Impingement. Clinical Orthopaedics & Related Research, 475. 336 – 350

Xu, M., Wang, Y., Zhong, L., Song, Y., Xiao, J., Sun, Y., Li, W., Zhu, Z., Zhao, X. & Wang, J. (2018) Three-dimensional morphology of lunate surface in hip dysplasia: Theoretical implications for periacetabular osteotomy. Journal of Orthopaedic Science, 23. 81 – 87

Yeung, M., Kowakzuk, M., Simunovic, N. & Ayeni, O. R. (2016) Hip arthroscopy in the setting of hip dysplasia. Bone and Joint Research, 5 (6). 225-231.

Images obtained from:

'Pixabay'  https://www.pixabay.com