Borderline Hip Dysplasia Research Articles

Arthroscopic Shoelace Capsular Closure Technique in the Hip Using Ultratape

Hip arthroscopy is promising tool for assessing and treating intra-articular pathologies including labral tears, cartilage injuries, and ligamentum teres tears of the hip. Interportal capsulotomy allows for better visualization and accessibility of the arthroscope and working instruments. The hip capsule has been defined as a crucial stabilizer of the hip joint. Thus, capsular closure is recognized as an important procedure to prevent postoperative instability after hip arthroscopic surgery. Despite the routine capsular closure during hip arthroscopy, there is a small subset of patients who complain of hip pain and dysfunction after surgery most likely because of disruption of hip closure site after routine complete capsular closure with strong suture for treating hip instability.This technical note describes the arthroscopic shoelace capsular suture technique using Ultratape for treating femoroacetabular impingement with capsular laxity and borderline hip dysplasia.

CORR Insights®: The Femoro-Epiphyseal Acetabular Roof (FEAR) Index: A New Measurement Associated With Instability in Borderline Hip Dysplasia?

CORR Insights®: The Femoro-Epiphyseal Acetabular Roof (FEAR) Index: A New Measurement Associated With Instability in Borderline Hip Dysplasia?

The Effectiveness of Arthroscopy in Borderline Hip Dysplasia

Purpose: The outcome of hip arthroscopy as a treatment of patients with hip dysplasia is variable. In patients with severe hip dysplasia, arthroscopy has the potential to exacerbate instability and unfavorable outcome. To the best of out knowledge, there has not been a report regarding arthroscopic treatment in patients with borderline hip dysplasia in Korea. We favorable outcome with using arthroscopy to treat symptomatic borderline hip dysplasia. Materials and Methods: Between August 2010 and February 2015, 143 patients undergoing hip arthroscopy for intra-articular hip disorder were retrospectively enrolled. From this cohort, a borderline dysplasia group compromising 29 patient with lateral center edge angle (LCEA)＞18° and ＜25° and a minimum of 1 years follow-up, was identified. Patient-reported outcome scores, including modified Harris hip score, the hip outcome score-activity of daily living, the sport-specific subscale, visual analogue scale (VAS) and satisfaction survey were obtained preoperatively and at postoperative 3 months, 6 months, 1 year, 2 years, and 3 years. Revision surgery and complications were recorded for each group. Results: The mean age was 35.7 years (range, 16–63 years) years respectively. There were 16 females (55.2%) and 13 males (44.8%). The mean LCEA was 22.0° (range, 18°-25°) and the mean Tonnis angle was 6.1° (range, 0°-18°). The mean follow-up was 20.2 months (range, 12-39 months), and at the 1 year follow-up, there was significant improvement (p＜0.001) in all patient reported outcome scores and VAS. Satisfaction survey showed an average score of 7.7. Conclusion: In patients with borderline hip dysplasia, if there is an occurrence of symptomatic labral tear, arthroscopic labral refixation has a good short-term result. Therefore, if patients have no response to conservative treatment or have severe pain, arthroscopic labral refixation is a useful treatment options to relieve symptom.

Hip arthroscopy in the setting of hip dysplasia: A systematic review.

ObjectiveHip arthroscopy in the setting of hip dysplasia is controversial in the orthopaedic community, as the outcome literature has been variable and inconclusive. We hypothesise that outcomes of hip arthroscopy may be diminished in the setting of hip dysplasia, but outcomes may be acceptable in milder or borderline cases of hip dysplasia.MethodsA systematic search was performed in duplicate for studies investigating the outcome of hip arthroscopy in the setting of hip dysplasia up to July 2015. Study parameters including sample size, definition of dysplasia, outcomes measures, and re-operation rates were obtained. Furthermore, the levels of evidence of studies were collected and quality assessment was performed.ResultsThe systematic review identified 18 studies investigating hip arthroscopy in the setting of hip dysplasia, with 889 included patients. Criteria used by the studies to diagnose hip dysplasia and borderline hip dysplasia included centre edge angle in 72% of studies but the range of angles were quite variable. Although 89% of studies reported improved post-operative outcome scores in the setting of hip dysplasia, revision rates were considerable (14.1%), with 9.6% requiring conversion to total hip arthroplasty.ConclusionThe available orthopaedic literature suggests that although improved outcomes are seen in hip arthroscopy in the setting of hip dysplasia, there is a high rate of re-operation and conversion to total hip arthroplasty. Furthermore, the criteria used to define hip dysplasia vary considerably among published studies.Cite this article: M. Yeung, M. Kowalczuk, N. Simunovic, O. R. Ayeni. Hip arthroscopy in the setting of hip dysplasia: A systematic review. Bone Joint Res 2016;5:225–231. DOI: 10.1302/2046-3758.56.2000533.

Outcomes After Arthroscopic Treatment of Femoroacetabular Impingement for Patients With Borderline Hip Dysplasia

Background: The outcomes of hip arthroscopy in the treatment of dysplasia are variable. Historically, arthroscopic treatment of severe dysplasia (lateral center-edge angle [LCEA] <18°) resulted in poor outcomes and iatrogenic instability. However, in milder forms of dysplasia, favorable outcomes have been reported. Purpose: To compare outcomes after hip arthroscopy for femoroacetabular impingement (FAI) in borderline dysplastic (BD) patients compared with a control group of nondysplastic patients. Study Design: Cohort study; Level of evidence, 3 Methods: Between March 2009 and July 2012, a BD group (LCEA, 18°-25°) of 46 patients (55 hips) was identified. An age- and sex-matched control group of 131 patients (152 hips) was also identified (LCEA, 25°-40°). Patient-reported outcome scores, including the modified Harris Hip Score (mHHS), the Hip Outcome Score–Activities of Daily Living (HOS-ADL) and Sport-Specific Subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-33), were collected preoperatively and at 1 and 2 years postoperatively. Results: The mean LCEA was 22.4° ± 2.0° (range, 18.4°-24.9°) in the BD group and 31.0° ± 3.1° (range, 25.4°-38.7°) in the control group (P < .001). The mean preoperative alpha angle was 66.3° ± 9.9° in the BD group and 61.7° ± 13.0° in the control group (P = .151). Cam decompression was performed in 98.2% and 99.3% of cases in the BD and control groups, respectively; labral repair was performed in 69.1% and 75.3% of the BD and control groups, respectively, with 100% of patients having a complete capsular closure performed in both groups. At a mean follow-up of 31.3 ± 7.6 months (range, 23.1-67.3 months) in unrevised patients and 21.6 ± 13.3 months (range, 4.7-40.6 months) in revised patients, there was significant improvement (P < .001) in all patient-reported outcome scores in both groups. Multiple regression analysis did not identify any significant differences between groups. Importantly, female sex did not appear to be a predictor for inferior outcomes. Two patients (4.3%) in the BD group and 6 patients (4.6%) in the control group required revision arthroscopy during the study period. Conclusion: Favorable outcomes can be expected after the treatment of impingement in patients with borderline dysplasia when labral refixation and capsular closure are performed, with comparable outcomes to nondysplastic patients. Further follow-up in larger cohorts is necessary to prove the durability and safety of hip arthroscopy in this challenging group and to further explore potential sex-related differences in outcome.

Biomechanics of the Hip Capsule and Capsule Management Strategies in Hip Arthroscopy.

Recent advances in our understanding of the function of the hip capsule have clarified its importance to normal hip function and kinematics. The iliofemoral ligament is the primary stabilizing structure for controlling anterior translation and external rotation of the hip, and is violated by the arthroscopic interportal capsulotomy. Microinstability of the hip occurring after surgical trauma remains a poorly defined clinical entity. In certain at-risk populations, capsular repair should be considered as part of an arthroscopic hip procedure to achieve optimal outcomes and avoid iatrogenic instability (dislocation or microinstability). Despite a lack of conclusive evidence-based indications, we recommend capsular repair in the settings of borderline hip dysplasia (or dysplastic variants such as increased femoral anteversion), hip hypermobility, connective tissue disorders, and traumatic or atraumatic instability. With careful attention to arthroscopic capsular management, adequate exposure can be achieved and reproducibly allow for an effective capsular repair when indicated.

A retrospective study on findings of canine hip dysplasia screening in Kenya.

Aim:The current study was undertaken to evaluate the findings of canine hip dysplasia screening in Kenya.Materials and Methods:Records for 591 dogs were included in this study. The data was obtained from the national screening office, Kenya Veterinary Board, for the period between the years 1998 and 2014. Monthly screening records were assessed and information relating to year of evaluation, breed, sex, age, and hip score captured. Descriptive statistics of hip scores was computed based on year, sex, age, and breed.Results:A total of 591 records from the year 1998 to 2014 were retrieved at the National Screening Centre, the Kenya Veterinary Board. Each record was examined and data pertaining to year of screening, the breed, sex, age of the dogs, and the total hip score were recorded. The highest number of dogs screened for hip dysplasia (HD) was in the year 2009 and the lowest in the year 1998. More females than males were screened for HD and the mean age of all the dogs was 22.9±12.7 months. The most common breeds of dogs screened during the study period were German Shepherd (67.0%), Rottweiler (15.6%), and Labrador Retriever (12.2%). The mean hip score for the 591 dogs was 15.1±10.9 and the median 12.0. The mean hip scores per breed were; German Shepherd (16.3±12.1); Golden Retriever (16.0); Hungarian Vizla (15.0); Labrador Retriever (3.0±6.7); Great Dane (13.3±3.2); Rottweiler (12.2±8.2); Doberman (10.3±4.2); Rhodesian Ridgeback (9.6±3.8); and Boxer (9.3±0.6). Based on the hip score, moderate to severe HD was diagnosed in 16.6% of the dogs, mild HD in 32.7%, Borderline HD in 37.7%, fair HD in 6.9%, and good HD in 6.1%.Conclusion:Canine HD is a common occurrence in Kenya with most dogs suffering mild to border line HD. In addition, German Shepherd and Golden Retriever appear to be the most affected breeds. It is therefore recommended that stringent measures be imposed to dog breeding programs to avoid transmission of this undesirable trait and consequently improve the welfare and the quality of dog breeds in Kenya.

Morphological and Functional Hip Long-Term Results after Exstrophy Repair.

Introduction Abnormalities of the bony pelvis in exstrophy-epispadias complex (EEC) and their possible relation to hip disease are well described. However, there is a lack of information about long-term orthopedic consequences and hip function in patients with EEC. Therefore, we investigated clinical and radiological results in an EEC patient cohort after long-term follow-up. Patients and Methods We conducted a cross-sectional study using standardized radiography, clinical investigation, and the Harris hip score. Seventeen postpuberty consecutive unselected EEC patients (3 female, 14 male; mean age 18.2 years) that presented to our clinic due to urological procedures or routine check-up from 2010 to 2011 were included. All had undergone symphysis approximation with a traction bandage without osteotomy in early childhood. Radiological analysis was conducted offline by two independent investigators. Results Radiological analysis showed a mean pubic diastasis of 5.1 cm (range 2.8-8.5 cm). Borderline hip dysplasia was present in four patients, one of them having had co-occurring developmental hip dysplasia in previous history. No severe dysplasia, subluxation, or luxation of the hip was found; however, one patient showed early hip arthrosis. Clinical examination revealed no relevant restriction of range of motion, although rotation and abduction were slightly altered in five patients. None of the EEC patients complained about pain or restriction in sports or daily activities. Harris hip score was perfect for all but one study participants. Conclusion Despite EEC-specific hip morphology, long-term hip function is not impaired in patients after symphyseal approximation without osteotomy in the newborn period. The symphysis diastasis after this procedure is comparable to available postosteotomy data. The large majority of EEC patients did not show dysplastic or degenerative hip disease. Functional hip score results confirmed reasonable age-related hip function in nearly all examined patients. However, postnatal ultrasound hip screening is recommended to prevent and adequately treat potential co-occurring developmental hip dysplasia.

An increased iliocapsularis-to-rectus-femoris ratio is suggestive for instability in borderline hips.

The iliocapsularis muscle is an anterior hip structure that appears to function as a stabilizer in normal hips. Previous studies have shown that the iliocapsularis is hypertrophied in developmental dysplasia of the hip (DDH). An easy MR-based measurement of the ratio of the size of the iliocapsularis to that of adjacent anatomical structures such as the rectus femoris muscle might be helpful in everyday clinical use. We asked (1) whether the iliocapsularis-to-rectus-femoris ratio for cross-sectional area, thickness, width, and circumference is increased in DDH when compared with hips with acetabular overcoverage or normal hips; and (2) what is the diagnostic performance of these ratios to distinguish dysplastic from pincer hips? We retrospectively compared the anatomy of the iliocapsularis muscle between two study groups with symptomatic hips with different acetabular coverage and a control group with asymptomatic hips. The study groups were selected from a series of patients seen at the outpatient clinic for DDH or femoroacetabular impingement. The allocation to a study group was based on conventional radiographs: the dysplasia group was defined by a lateral center-edge (LCE) angle of < 25° with a minimal acetabular index of 14° and consisted of 45 patients (45 hips); the pincer group was defined by an LCE angle exceeding 39° and consisted of 37 patients (40 hips). The control group consisted of 30 asymptomatic hips (26 patients) with MRIs performed for nonorthopaedic reasons. The anatomy of the iliocapsularis and rectus femoris muscle was evaluated using MR arthrography of the hip and the following parameters: cross-sectional area, thickness, width, and circumference. The iliocapsularis-to-rectus-femoris ratio of these four anatomical parameters was then compared between the two study groups and the control group. The diagnostic performance of these ratios to distinguish dysplasia from protrusio was evaluated by calculating receiver operating characteristic (ROC) curves and the positive predictive value (PPV) for a ratio > 1. Presence and absence of DDH (ground truth) were determined on plain radiographs using the previously mentioned radiographic parameters. Evaluation of radiographs and MRIs was performed in a blinded fashion. The PPV was chosen because it indicates how likely a hip is dysplastic if the iliocapsularis-to-rectus-femoris ratio was > 1. The iliocapsularis-to-rectus-femoris ratio for cross-sectional area, thickness, width, and circumference was increased in hips with radiographic evidence of DDH (ratios ranging from 1.31 to 1.35) compared with pincer (ratios ranging from 0.71 to 0.90; p < 0.001) and compared with the control group, the ratio of cross-sectional area, thickness, width, and circumference was increased (ratios ranging from 1.10 to 1.15; p ranging from 0.002 to 0.039). The area under the ROC curve ranged from 0.781 to 0.852. For a one-to-one iliocapsularis-to-rectus-femoris ratio, the PPV was 89% (95% confidence interval [CI], 73%-96%) for cross-sectional area, 77% (95% CI, 61%-88%) for thickness, 83% (95% CI, 67%-92%) for width, and 82% (95% CI, 67%-91%) for circumference. The iliocapsularis-to-rectus-femoris ratio seems to be a valuable secondary sign of DDH. This parameter can be used as an adjunct for clinical decision-making in hips with borderline hip dysplasia and a concomitant cam-type deformity to identify the predominant pathology. Future studies will need to prove this finding can help clinicians determine whether the borderline dysplasia accounts for the hip symptoms with which the patient presents. Level III, prognostic study.

Arthroscopic Capsular Plication and Labral Preservation in Borderline Hip Dysplasia

Background: The role of hip arthroscopy in the treatment of patients with dysplasia is unclear because of the spectrum of dysplasia that exists. Patients with borderline dysplasia are generally not candidates for periacetabular osteotomy because of the invasive nature of the procedure. However, arthroscopy in dysplasia has had mixed results and has the potential to exacerbate instability. Hypothesis: Patients with borderline dysplasia will demonstrate postoperative improvement, high satisfaction rates, and low reoperation rates after a surgical approach that includes arthroscopic labral repair augmented by capsular plication with inferior shift. Study Design: Case series; Level of evidence, 4. Methods: Between April 2008 and November 2010, patients less than 40 years old who underwent hip arthroscopy for symptomatic intra-articular hip disorders, with a lateral center-edge (CE) angle ≥18° and ≤25°, were included in this study. Patients with Tönnis grade 2 or greater, severe hip dysplasia (CE ≤17°), and Legg-Calve-Perthes disease were excluded. Patient-reported outcome scores, including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score–Sport-Specific Subscale (HOS-SSS), Hip Outcome Score–Activity of Daily Living (HOS-ADL), and visual analog scale (VAS) for pain were obtained in all patients preoperatively and at 1, 2, and 3 years postoperatively. Revision surgery and complications were recorded for each group. Results: A total of 26 patients met the criteria to be included in the study. Of these, 22 (85%) patients were available for follow-up. The mean (± standard deviation) length of follow-up for this cohort was 27.5 ± 5.5 months (range, 17-39 months) and the average age was 20 years (range, 14-39 years). The mean lateral CE angle was 22.2° (range, 18°-25°) and the mean Tönnis angle was 5.8° (range, 0°-17°). There was significant improvement in all patient-reported outcome scores (mHHS, NAHS, HOS-SSS, and HOS-ADL) (P < .0001). There was a significant improvement in VAS scores from 5.8 to 2.9 (P < .0001). Overall patient satisfaction was 8.4 out of 10. Seventeen patients had good/excellent results (77%). Two patients required revision arthroscopy. Conclusion: Patients with borderline dysplasia have often fallen into a gray area between arthroscopy and periacetabular osteotomy, and viable treatment options have remained scarce. The current study demonstrates favorable results at 2-year follow-up for an arthroscopic approach that includes labral repair augmented by capsular plication with inferior shift.

Is There a Role for Acetabular Dysplasia Correction in an Asymptomatic Patient?

Childhood hip dysplasia is best treated in infancy or early childhood with hopes that the acetabulum will be completely normalized by nonoperative treatment methods, which may include Pavlik and brace treatment as well as formal closed reduction and hip spica casting. In many cases, this ideal result cannot be achieved and the child is left with residual dysplasia, which is often not symptomatic. Other patients may present late with hip dysplasia that is not identified in early childhood. Some develop hip pain with no prior known hip problem. Other children have asymptomatic dysplasia that is picked up on an incidental radiograph. The orthopaedic literature is clear regarding the need for corrective hip osteotomies in symptomatic children. Surgery to correct asymptomatic hip dysplasia remains controversial. Children who have no symptoms yet have abnormal radiographs present a puzzling circumstance. In these cases, surgeons need to use quoted radiographic normal values for acetabular coverage of the femoral head as well as long-term natural history studies to decide whether to proceed with a corrective acetabular osteotomy. Long-term follow-up studies confirm that even patients with borderline dysplasia are likely to have significant hip symptoms and arthritis by middle age. Many children and adolescents with asymptomatic residual hip dysplasia should have corrective acetabular procedures performed. Surgery is more easily performed with more predictable results when the child is younger than 8 years. It is impossible to state with certainty which children with residual radiographic hip dysplasia, but without symptoms, should have a corrective acetabular osteotomy. Review of the literature confirms that many patients have been undertreated in the past, with a high percentage of children with borderline hip dysplasia developing premature arthritis in early to mid-adult life. Current data suggest that surgery should be performed in borderline cases. Skill of the surgeon in performing acetabular osteotomies and/or ease of referral to a treatment center may temper the timing of such decisions.

Paper 29: Recognizing Borderline Hip Dysplasia on Pelvic Radiographs of Young Adults

Paper 29: Recognizing Borderline Hip Dysplasia on Pelvic Radiographs of Young Adults

The Iliocapsularis Muscle: An Important Stabilizer in the Dysplastic Hip

The iliocapsularis muscle is a little known muscle overlying the anterior hip capsule postulated to function as a stabilizer of dysplastic hips. Theoretically, this muscle would be hypertrophied in dysplastic hips and, conversely, atrophied in stable and well-constrained hips. However, these observations have not been confirmed and the true function of this muscle remains unknown. We quantified the anatomic dimensions and degree of fatty infiltration of the iliocapsularis muscle and compared the results for 45 hips with deficient acetabular coverage (Group I) with 40 hips with excessive acetabular coverage (Group II). We used MR arthrography to evaluate anatomic dimensions (thickness, width, circumference, cross-sectional area [CSA], and partial volume) and the amount of fatty infiltration. We observed increased thickness, width, circumference, CSA, and partial volume of the iliocapsularis muscle in Group I when compared with Group II. Additionally, hips in Group I had a lower prevalence of fatty infiltration compared with those in Group II. The iliocapsularis muscle typically was hypertrophied, and there was less fatty infiltration in dysplastic hips compared with hips with excessive acetabular coverage. These observations suggest the iliocapsularis muscle is important for stabilizing the femoral head in a deficient acetabulum. This muscle serves as an anatomic landmark when performing a periacetabular osteotomy. Additionally, preoperative evaluation of morphologic features of the muscle can be used as an adjunct for decision making when treating patients with borderline hip dysplasia or femoroacetabular impingement.

Influence of borderline hip dysplasia on joint kinematics of clinically sound Belgian Shepherd dogs

To detect changes in joint kinematics of clinically sound dogs with or without radiographically detectable borderline hip dysplasia (HD). 20 Belgian Shepherd Dogs (Malinois; mean +/- SD age, 2.75 +/- 1.32 years) with no clinical signs of HD. Kinematic gait analysis was performed in Malinois walking on a treadmill. On the basis of results of radiographic examination for HD and in accordance with guidelines established by the Fédération Cynologique Internationale, dogs were assigned to group 1 (no radiographic signs of HD; 8 dogs) or group 2 (borderline HD; 12 dogs). Ground reaction forces and weight distribution among limbs and differences between groups were evaluated. Maximal sagittal angle during the stance and swing phases, the time at which they were detected, and angle velocities were calculated for joints of the hind limbs. Ground reaction forces revealed no differences between groups. Dogs in group 1 had significant changes (earlier time for maximal flexion of the hip joint and less flexion and less range of motion of the stifle joint), compared with results for dogs in group 2. Maximal angle velocity of the stifle and tarsal joints was significantly lower during the swing phase in group 1 than in group 2. This study revealed that dogs with borderline HD had altered joint kinematics. Our data provide basic kinematic values for clinically sound and affected dogs and can be used to investigate the long-term effects for subclinical radiographic changes of the hip joints of dogs.