Well, here is little me blogging away
about my hip problems, but there seems to be a bigger picture to these hip conditions. In terms
of chronic back pain, the evidenced based messages being promoted in
recent medical history are spoken into a context of fear and sometimes
faulty beliefs about pain and tissue damage which can be exaccerbated by
nocebic language if we're not careful. I am nowhere near what I would consider an expert
in any of this, but I just thought I'd share my thoughts on what I understand of the current context of young adult hips.
There has been a huge increase in the concept of Femoro-acetabular Impingement (FAI) in the past 10-20 years, due to the invention of new technologies allowing for more and more hip arthroscopies to take place and discoveries about the 'lumps and bumps' as potential underlying causes of hip pain in many patients. In fact, the number of hip arthroscopies just on the NHS between 2002 and 2013 has increased by 727% (Palmer et al, 2016). This concept and the associated surgeries have exploded very quickly, and there is still a lot of uncertainty about what is the best long term management for this condition. The Warwick agreement states FAI is only confirmed with imaging (Griffin et al, 2016). Immediately rushing to MRI scans and jumping into hip arthroscopies has not always yielded good long term results, though and it is now starting to be questioned whether conservative management - for some patients at least – is a better idea. And if management of the condition is conservative, it has been postulated as to whether or when imaging should be used (O'Sullivan et al, 2017). However, I believe this may depend on the particular Impingement pathology in each individual and how exactly it causes damage to the labrum over time, and also on how it is affecting the patient themselves and their quality of life (like I said though, I'm not an expert).
Hip dysplasia, as I understand it, is not a 'new' phenomenon. It is well known amongst health professionals that it is a relatively common condition in babies, and there is the seemingly never-ending debate on what screening should be used for new-borns, and what is the best pathway for treatment if dislocated or dysplastic hips are found. But there is little knowledge or evidence-base around the effects of this condition in adults and what good management should be. Because, you know, babies become adults (who knew?). It is also now beginning to be understood that hip dysplasia can be present in adults even without an infant diagnosis, and often with very similar clinical signs and symptoms to FAI (Gala et al, 2016; Pun, 2016).
Yes, you heard me right: adult hip
dysplasia and FAI can present in a very similar way, so until you have a definitive diagnosis, you don’t
know what underlying morphology could be contributing to a patient’s hip or groin
pain, or labral symptoms (Groh et
al, 2009).
Unlike FAI, however, there seems to be a lot more certainty that those with hip dysplasia will go on to develop early osteoarthritis (Wyles et al, 2017). Like I said, hip dysplasia is not rare, in fact it is said to be the leading cause of early onset hip OA (International Hip Dysplasia Institute, 2016). Some quote its incidence as between 0.5 and 4% of the population, others say something between 3 and 5% (Engesaeter et al, 2011; Pun, 2016). How many of these present in a sporting context or the general population I don't know. It is on a spectrum, and it is unclear the incidence of symptomatic dysplasia in young adults.
Unlike FAI, however, there seems to be a lot more certainty that those with hip dysplasia will go on to develop early osteoarthritis (Wyles et al, 2017). Like I said, hip dysplasia is not rare, in fact it is said to be the leading cause of early onset hip OA (International Hip Dysplasia Institute, 2016). Some quote its incidence as between 0.5 and 4% of the population, others say something between 3 and 5% (Engesaeter et al, 2011; Pun, 2016). How many of these present in a sporting context or the general population I don't know. It is on a spectrum, and it is unclear the incidence of symptomatic dysplasia in young adults.
We know that PAO surgery
(Peri-acetabular Osteotomy or Pelvic Osteotomy) is an option for adults with
hip dysplasia (Coobs et al, 2015). This has a long recovery period and is a hugely technically demanding
procedure, more so than other types of surgeries, but there is actually some
evidence around the positive long term outcomes for PAOs (Steppacher et al, 2008; Lerch et al, 2017), I believe better evidence
than there is for long term hip arthroscopy outcomes (Bedi et al, 2013), and a better option than a THR at a young age (Mariconda et al, 2011). PAO is
extensive surgery. The variables play an
important role in this, but when the psychological factors are taken into
account, a patient who is adequately informed, under an experienced surgeon and
MDT team and early on enough in the trajectory of the condition can return to a
functional and higher quality of life than before the surgery (Clohisy et al, 2017; West et al, 2011). Some, but not
everyone, can even get back to sporting activities.
The reproducibility of PAO surgery is still in it’s infancy though and there appears to be some teething problems. Some undergo PAO in one or both hips without being fully psychologically prepared, or with comorbidities that hinder a good recovery or under surgeons without a higher level of experience, or too late on into the trajectory of the condition. As a result of these things the surgery and recovery has a potential to be unsuccessful or at least be a rather traumatic experience for the patient. I get the impression surgeons who see a high volume of hip dysplasia patients take all the aforementioned aspects into consideration and as a result seem to generally see better outcomes in the long run (Novais et al, 2017).
The reproducibility of PAO surgery is still in it’s infancy though and there appears to be some teething problems. Some undergo PAO in one or both hips without being fully psychologically prepared, or with comorbidities that hinder a good recovery or under surgeons without a higher level of experience, or too late on into the trajectory of the condition. As a result of these things the surgery and recovery has a potential to be unsuccessful or at least be a rather traumatic experience for the patient. I get the impression surgeons who see a high volume of hip dysplasia patients take all the aforementioned aspects into consideration and as a result seem to generally see better outcomes in the long run (Novais et al, 2017).
However, the lack of awareness that
this is an adult hip condition too, along with a lack of consensus on where on
the spectrum each individual case would fall (Malviya et al, 2016; Witt et al, 2017)
is leading to significant delays in appropriate diagnosis (Nunley et al, 2011), resulting in many reaching
a diagnosis or receiving intervention too late when their hips have already
begun to deteriorate at a young age.
There is a chasm in the evidence base around what clinical signs to look
out for and what the best physiotherapy management should be. There is no evidence at all in regards to
long term conservative management, and I’m not sure how or if this would change
the natural history of a dysplastic hip.
The referral pathway towards
diagnostic imaging may vary depending on the country or clinic, but in
the UK NHS, most patients will not present in clinic with their x-rays or MRI
scans. In fact, in some cases of hip dysplasia it has been known to take many years for
individuals with symptoms to be referred for any imaging at all, in some cases pain is even classed as psychosomatic and routes to diagnosis can often be quite circuitous. The average time between symptom onset and diagnosis is stated as 5 years (Nunley et al, 2011). This may be partly due to symptoms in some being mild and subtle to begin with, and progressing very slowly over a number of years until mobility is more of a problem. Research seminars I have been privy to and shared experiences from peers with hip dysplasia seem to testify to the above.
Some, when they are referred, find
that their x-ray is reported as 'normal,' perhaps because it has only been
cleared for arthritis or a fracture. (There
is more detail on how dysplasia is diagnosed in a previous post here). Some are diagnosed with labral tears and
undergo arthroscopic surgery, but without dealing with the underlying
morphology this surgery is very often unsuccessful (Bedi et al, 2013; Witt et al, 2017).
Some patients who do reach diagnosis
aren't keen on having their pelvis broken and screwed back together again in a
PAO (understandably) and resolve to manage their pain in day to day life.
Their quality of life may not be equal to somebody without hip dysplasia, but
they can get by. Unfortunately if it is not made clear to them that
intervention needs to be preventative, then they may end up with a nasty shock some years later when their symptoms and quality of life worsen a bit more
and they discover osteoarthritis in the joint. At that point THR is then
the only other option for them, and for patients in their 20s or 30s this is
particularly distressing. "Why did nobody tell me the treatment
needs to be preventative?!"
Is a troubling thing to hear from peers of mine in this
predicament.
The surgeon is then in a position of
needing to perform a hip replacement on a dysplastic hip, and I believe this can
be quite difficult to do. Custom parts can sometimes be used in the
prosthesis but usually as there isn't enough bone in the acetabulum to work
with there is less chance of seeing a good outcome from this. Again, surgeon experience with dysplastic
hips appears to play a role here.
Due to there being very few specialists treating adult hip dysplasia, an individual’s route to diagnosis, surgery options and outcome seems to depend very much on where they live in the country. But under those with more expertise diagnosis and outcomes are better, and this is reflected in the literature (Malviya et al, 2016; Novais et al, 2017).
Due to there being very few specialists treating adult hip dysplasia, an individual’s route to diagnosis, surgery options and outcome seems to depend very much on where they live in the country. But under those with more expertise diagnosis and outcomes are better, and this is reflected in the literature (Malviya et al, 2016; Novais et al, 2017).
There is no set of guidelines or
recognised pathway for an adult presenting with hip dysplasia, or anyone with
young adult hip problems for that matter.
So what we have is something resembling chaos, and on paper the statistics
can look bland, but we need to remember the quality of life and psychological
wellbeing of the individuals who are on the other side of those facts and
figures.
Added to this we have Perthes and SUFE (Slipped Upper Femoral Epiphysis). These are two other hip conditions which can be treated in childhood and I believe can present in adulthood (although I don't know as much about these conditions). There is less known about the long term outcomes of these conditions which, although less common, can also lead to ‘Young Adult Hip Disease’ resulting in early osteoarthritis and hip replacements in the young adult population.
Added to this we have Perthes and SUFE (Slipped Upper Femoral Epiphysis). These are two other hip conditions which can be treated in childhood and I believe can present in adulthood (although I don't know as much about these conditions). There is less known about the long term outcomes of these conditions which, although less common, can also lead to ‘Young Adult Hip Disease’ resulting in early osteoarthritis and hip replacements in the young adult population.
What I’m trying to say is: there is
an element of excitement around the FAI concept, a ‘silent epidemic’ which in
some cases may have been over medicalised.
But on the other hand, we have hip dysplasia (and Perthes and SUFE!),
which have been very under-recognised
in adults, to the detriment of those suffering unnecessarily for so many years. This is very different to the context of back pain. With adult hip dysplasia, in general, we do
know what the best surgical management is, but I wonder just how much this condition can be
overlooked, particularly as it can present in almost exactly the same way as
FAI. I do think a simple x-ray is
necessary for somebody presenting with hip or groin pain when specific physiotherapy
intervention or a graded return to activities has been unsuccessful. Without being sure of what the exact
underlying morphology is maybe it's better to be wary of avoiding imaging altogether? Unless the x-ray machine breaks and falls on
top of a patient, I'm doubtful of whether this could cause any serious physical or
psychological harm.
But, like I said, I am only a student, with little experience yet, so these are just my thoughts!
But, like I said, I am only a student, with little experience yet, so these are just my thoughts!
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