Early Hip Disorders: Advances in Detection and Minimally Invasive Treatment

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It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation. Volume 5. Article Contents. The management of the painful borderline dysplastic hip Michael C Wyatt. Correspondence to: M. E-mail: michaelcharleswyatt icloud.

Oxford Academic. Google Scholar. Martin Beck. Cite Citation. Permissions Icon Permissions. Abstract Improved imaging and the evolution of surgical techniques have permitted a rapid growth in hip preservation surgery over the last few decades. Open in new tab Download slide.

Impingement adversely affects year survivorship after periacetabular osteotomy for DDH. Search ADS. Arthroscopy of the hip for patients with mild to moderate developmental dysplasia of the hip and femoroacetabular impingement. Outcomes after arthroscopic treatment of femoroacetabular impingement for patients with borderline hip dysplasia. Early functional outcomes of periacetabular osteotomy after failed hip arthroscopic surgery for symptomatic acetabular dysplasia.

Microinstability of the hip—it does exist: etiology, diagnosis and treatment. Studies on dysplastic acetabula and congenital subluxation of the hip joint: with special reference to the complication of osteoarthritis. The role of arthroscopy in the dysplastic hip—a systematic review of the intra-articular findings, and the outcomes utilizing hip arthroscopic surgery.

Measurement of center-edge angle in developmental dysplasia of the hip: a comparison of two methods in patients under 20 years of age. Arthroscopic capsular plication and labral preservation in borderline hip dysplasia. Surgical treatment of femoroacetabular impingement: what are the limits of hip arthroscopy? Recognition of minor adult hip dysplasia: which anatomical indices are important?

The natural history of congenital dislocation of the hip: a critical review. Subclinical deformities of the hip are significant predictors of radiographic osteoarthritis and joint replacement in women. A 20 year longitudinal cohort study. The Warwick agreement on femoroacetabular impingement syndrome FAI syndrome : an international consensus statement. Google Preview. Femoroacetabular impingement: radiographic diagnosis—what the radiologist should know. Classic measures of hip dysplasia do not correlate with three-dimensional computer tomographic measures and indices.

Femoral antetorsion: comparing asymptomatic volunteers and patients with femoroacetabular impingement. Magnetic resonance arthrography of labral disorders in hips with dysplasia and impingement. The femoro-epiphyseal acetabular roof FEAR index: a new measurement associated with instability in borderline hip dysplasia? Mechanism of longitudinal bone growth and its regulation by growth plate chondrocytes. Influences of mechanical stress on prenatal and postnatal skeletal development.

Theoretical study of the decrease in the femoral neck anteversion during growth. Nonoperative treatment for femoroacetabular impingement: a systematic review of the literature. The dysplastic and unstable hip: a responsible balance of arthroscopic and open approaches.

Anterior Hip Pain

Acute iatrogenic dislocation following hip impingement arthroscopic surgery. Catastrophic failure of hip arthroscopy due to iatrogenic instability: can partial division of the ligamentum teres and iliofemoral ligament cause subluxation? Periacetabular osteotomy after failed hip arthroscopy for labral tears in patients with acetabular dysplasia. Biomechanics of the hip capsule and capsule management strategies in hip arthroscopy. Arthroscopy for labral tears in patients with developmental dysplasia of the hip: a cautionary note.

Arthroscopic disease classification and interventions as an adjunct in the treatment of acetabular dysplasia. Minimally invasive periacetabular osteotomy using a modified Smith-Petersen approach. Activity level and severity of dysplasia predict age at bernese periacetabular osteotomy for symptomatic hip dysplasia. Published by Oxford University Press.

For commercial re-use, please contact journals. Issue Section:. Download all figures. View Metrics. Email alerts New issue alert. Advance article alerts. Article activity alert. Receive exclusive offers and updates from Oxford Academic. More on this topic Trajectory of clinical outcomes following hip arthroscopy in female subgroup populations. Primary labral reconstruction in patients with femoroacetabular impingement, irreparable labral tears and severe acetabular chondral defects decreases the risk of conversion to total hip arthroplasty: a pair-matched study.

A history of spine surgery predicts a poor outcome after hip arthroscopy. Reliability and normative values of common adult radiographic parameters for hip preservation in the developing pelvis. Related articles in PubMed First application of 7-T ultra-high field diffusion tensor imaging to detect altered microstructure of thalamic-somatosensory anatomy in trigeminal neuralgia. Letter to the Editor. Predictor for pain-free survival after microsurgery for trigeminal neuralgia: case closed?

Long-term outcomes of lumbar microdiscectomy in the pediatric population: a large single-institution case series. The caput is not deeply and tightly held by the acetabulum. Instead of being a snug fit, it is a loose fit, or a partial fit. Secondly, the caput or acetabulum are not smooth and round, but are misshapen, causing abnormal wear and tear or friction within the joint as it moves. First, the joint itself is continually repairing itself and laying down new cartilage. However, cartilage repair is a relatively slow process, the tissue being avascular , so the joint may suffer degradation due to the abnormal wear and tear, or may not support the body weight as intended.

The joint becomes inflamed and a cycle of cartilage damage, inflammation and pain commences. This is a self-fueling process, in that the more the joint becomes damaged, the less able it is to resist further damage. The inflammation causes further damage. The bones of the joint may also develop osteoarthritis , visible on a radiograph as small outcrops of bone, which further degrade the joint. The underlying deformity of the joint may get worse over time, or may remain static. A dog may have good radiographs and yet be in pain, or may have very poor radiographs and have no apparent pain issues.

The hip condition is only one factor to determine the extent to which dysplasia is causing pain or affecting the quality of life. In mild to moderate dysplasia it is often the secondary effects of abnormal wear and tear or arthritis, rather than dysplasia itself, which is the direct causes of visible problems. Hip dysplasia may be caused by a femur that does not fit correctly into the pelvic socket, or poorly developed muscles in the pelvic area. Large and giant breeds are most susceptible to hip dysplasia possibly due to the body mass index BMI of the individual animal , [4] though many other breeds can suffer from it.

The Orthopedic Foundation for Animals maintains a list of top breeds affected. To reduce pain, the animal will typically reduce its movement of that hip. This may be visible as "bunny hopping", where both legs move together, or less dynamic movement running, jumping , or stiffness. Since the hip cannot move fully, the body compensates by adapting its use of the spine , often causing spinal, stifle a dog's knee joint , or soft tissue problems to arise.

The causes of hip dysplasia are considered heritable, but new research conclusively suggests that environment also plays a role. Neutering a dog, especially before the dog has reached an age of full developmental maturity, has been proven to almost double the chance he or she will develop hip dysplasia versus intact dogs or dogs that were neutered after reaching adulthood [7] Other environmental influences include overweight condition, injury at a young age, overexertion on the hip joint at a young age, ligament tear at a young age, repetitive motion on forming joint i.

As current studies progress, greater information may help provide procedures to effectively reduce the occurrence of this condition. The problem almost always appears by the time the dog is 18 months old. The defect can be anywhere from mild to severely crippling, and can eventually cause severe osteoarthritis.

Usually, only mild to moderate lameness is noted which may suddenly worsen. Dogs with a cranial anterior cruciate ligament tear typically hold the affected leg up which is unusual with hip dysplasia. Patients with back spinal problems often scuff their toenails when walking, have an uncoordinated gait, and are weak in the rear limbs. They may be very painful if they have a disc rupture sciatica or show no spinal pain in certain degenerative spinal cord conditions German Shepherd myelopathy.

Petplan Australia reported that signs of arthritis in dogs and cats include stiffness, difficulty moving, lethargy, irritability, and cat or dog may lick, chew or bite at sore joints. Dogs might exhibit signs of stiffness or soreness after rising from rest, reluctance to exercise, bunny-hopping or other abnormal gait legs move more together when running rather than swinging alternately , lameness, pain, reluctance to stand on rear legs, jump up, or climb stairs, subluxation or dislocation of the hip joint, or wasting away of the muscle mass in the hip area.

Radiographs X-rays often confirm the presence of hip dysplasia, but radiographic features may not be present until two years of age in some dogs. Moreover, many affected dogs do not show clinical signs, but some dogs manifest the problem before seven months of age, while others do not show it until well into adulthood. In part this is because the underlying hip problem may be mild or severe, may be worsening or stable, and the body may be more or less able to keep the joint in repair well enough to cope.

Also, different animals have different pain tolerances and different weights, and use their bodies differently, so a light dog who only walks, will have a different joint use than a more heavy or very active dog. Some dogs will have a problem early on, others may never have a real problem at all. A dysplastic animal has probably lived with the condition since it was only a few months old, and has therefore grown up used to the chronic pain and has learned to live or function with it.

Dogs suffering such pain do not usually exhibit acute signs of pain. Sometimes, they will suddenly and abnormally sit down when walking, or refuse to walk or climb objects which they usually would, but this can equally be a symptom of many other things, including a thorn in the paw, or a temporary muscle pain. So pain recognition is less common a means of detection than the visible gait and other abnormalities described above. The classic diagnostic technique is with appropriate X-rays and hip scoring tests.

These should be done at an appropriate age, and perhaps repeated at adulthood - if done too young they will not show anything. Since the condition is to a large degree inherited, the hip scores of parents should be professionally checked before buying a pup, and the hip scores of dogs should be checked before relying upon them for breeding.

Despite the fact that the condition is inherited, it can occasionally arise even to animals with impeccably hip scored parents. In diagnosing suspected dysplasia, the x-ray to evaluate the internal state of the joints is usually combined with a study of the animal and how it moves, to confirm whether its quality of life is being affected.

Evidence of lameness or abnormal hip or spine use, difficulty or reduced movement when running or navigating steps, are all evidence of a problem. Both aspects have to be taken into account since there can be serious pain with little X-ray evidence. It is also common to X-ray the spine and legs, as well as the hips, where dysplasia is suspected, since soft tissues can be affected by the extra strain of a dysplastic hip, or there may be other undetected factors such as neurological issues e.

Some of these tests require manipulation of the hip joint into standard positions, in order to reveal their condition on an X-ray. The following conditions can give symptoms very similar to hip dysplasia, and should be ruled out during diagnosis:. A dog may misuse its rear legs, or adapt its gait, to compensate for pain in the forelimbs , notably osteoarthritis , osteochondritis OCD or shoulder or elbow dysplasia , as well as pain in the hocks and stifles or spinal issues. Patients are living longer because of advancements in medical treatments.

However, this also places these patients at an increased risk of developing metastatic bone disease [ 2 ]. The exact incidence of metastatic disease to the bone is unknown, but it is estimated that , people die with bony metastases each year in the USA [ 3 ]. Metastatic disease can affect various locations in the human body with the skeleton being the third most common behind metastatic disease to the lungs and liver [ 3 , 4 ].

Metastatic bone disease, although not the primary site of cancer, can be the source of significant morbidity. Pain secondary to metastatic bone disease can cause loss of function and decreased quality of life. Treatments for metastatic bone disease are usually not curative but rather are primarily palliative.

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Hip Dysplasia - Physiopedia

The specific goals of treatment are to relieve pain, gain local tumor control, and maintain or regain functional status. With increased life expectancy after diagnosis and treatment, achieving the treatment goals and maintaining durability of the reconstruction become even more important. Like so many other areas of medicine, the treatment of metastatic bone disease has continued to advance.

Formal surgical treatments and minimally invasive procedures have evolved with the development of new technology. In addition to advances in treatment, there have also been new techniques in diagnosis and tools to help the physician more accurately predict which cases of metastatic bone disease require operative management and which can be treated with other treatments or even observed.

Minimally invasive procedures are now becoming more common and showing promising results for the safe and effective treatment of metastatic bone disease. The purpose of this article is to review the latest developments in surgical and minimally invasive treatment of metastatic bone disease.

The focus is on involvement in the long bones and acetabulum, as treatment of metastatic spinal disease, which has also undergone significant advances, is beyond the scope of this article. The presence of a pathologic fracture in a weight-bearing long bone has long been an accepted indication for surgical management. The goals of treatment are to alleviate pain and restore function by allowing immediate weight bearing in the lower extremity and functional use of the upper extremity. Likewise, prophylactic treatment by internal fixation of impending pathologic fractures has also been an accepted indication for surgical management in patients with metastatic bone disease, myeloma, and lymphoma.

Ward et al. Advantages included decreased blood loss, shorter hospital stays, greater likelihood of discharge to home, and increased chance of resuming support-free ambulation. Mirels [ 8 ], in his now classic article, proposed a scoring system to quantify the risk of sustaining a pathologic fracture through a known metastatic bone lesion.

Mirels' Metastatic Disease in Long Bones.

Minimally Invasive Hip Replacement Surgery- Hip Arthritis - Dr. Michael Anderson

A proposed scoring system for diagnosing impending pathologic fractures. El-Husseiny et al. Over recent years, physicians and surgeons have begun using CT-based structural rigidity analysis CTRA to predict fracture risk [ 14 , 15 ]. This method is based on laboratory evaluations showing that the force required to fracture a bone with a simulated lytic lesion is related to the amount of reduction in structural rigidity of the weakest cross section through the bone [ 14 , 15 ].

This model as well as fracture definition has been applied to a series of pediatric patients who presented with a fracture through a benign skeletal lesion compared to similar patients who had a benign skeletal lesion that had been thought to be at increased risk for fracture, had not fractured at the time of the study, underwent no surgical treatment, and had been followed for a minimum of 2 years [ 14 ]. The same group then prospectively looked at 41 pediatric patients with benign skeletal lesions using the CTRA to predict fracture risk [ 15 ].

While the use of CT-based examination in pediatric patients may be controversial because of the additional radiation exposure needed, the success of the technique has provided a basis for investigating its use in adult patients with metastatic disease, where the additional radiation exposure is of little consequence in these terminal patients. In this femoral lesion with lytic characteristics, selected sagittal and axial CT slices are shown illustrating the region of maximal involvement by the lesion in question.

The graph at the top was obtained from the CTRA report, showing the reductions in torsional, bending, and axial rigidity at the site of the defect.


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Based upon Mirels' classification, this patient was given 3 points each for size and nature, 2 points for location, and 2 points for pain, for a total of 10 points, qualifying as an impending pathologic fracture. Preliminary multi-institutional results show that CTRA is more specific than Mirels for fracture prediction. Standard treatment for impending or actual femoral neck fracture. This patient presented with right groin pain and a solitary lesion of the right femoral neck. Anteroposterior a and frog lateral b plain radiographs show the destructive femoral neck lesion.

The CT scan c shows cortical disruption in the superior femoral neck without more distal lesions. Biopsy showed metastatic carcinoma, and the patient underwent long-stem cemented hemi-arthroplasty d. She had excellent pain relief and was able to fully weight bear immediately after the operation. Since the CT scan of the entire femur did not show any evidence of other lesions, this patient may have been fine with a shorter stem, which would have decreased the risk of the pulmonary embolic phenomenon associated with longer cemented stems.


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  6. Failed internal fixation necessitating conversion to megaprosthesis. Because of the previous irradiation and low likelihood for healing, the patient was treated with resection to below the fracture level and reconstruction with a long stem cemented megaprosthetic hip hemiarthroplasty b. Pain relief was complete, and the patient was able to fully weight bear immediately after the procedure. The role of locked plates in pathologic fracture and impending fracture fixation has yet to be defined [ 24 ]. While the poor results with plating in this context in the past were associated with earlier types of plate fixation, many of those are no longer in use.

    Unfortunately, there is there is a paucity of published data on biomechanical and clinical outcomes with the use of locking plates in the musculoskeletal oncology literature, and further clinical trials need to be published before we can truly see what the advantages and disadvantages of locking plates have in treating metastatic bone disease over conventional plates and possibly even intramedullary nails. Over the past decade and a half, locked plating has become a popular mode of fixation in the osteosynthesis of traumatic fractures [ 25 , 26 ]. Osteoporosis in the setting of trauma has become a common indication for the use of locked plating constructs [ 26 , 27 ].

    In traditional non-locked compression screws, the plate is secured to the bone as the screw is tightened. The friction created between the plate and bone by the screws establishes secure fixation.

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    In locking screw-plate systems, the construct acts as a single beam in the bone, and the plate does not require compression and friction to achieve mechanical stability. Locking technology can potentially be advantageous when working with compromised bone as is the case with pathologic fractures or impending fractures, where bone quality may be less than ideal extending proximal and distal to the fracture or lesion.

    It is highly likely that with the increased availability and popularity of locked plating in the trauma community, surgeons treating pathologic fractures have implemented locking plates into their practice as well. However, reported results lag behind the clinical usage. The anatomic sites where locking plates would appear to have the most theoretical benefit are the distal femoral and proximal tibial peri-articular regions, but these are relatively uncommon sites of metastatic disease.

    Pathologic fractures and impending fractures of the humerus have been treated in a variety of ways, with much ongoing debate among surgeons. Although indications for operative intervention are generally accepted, the controversy lies in the specific methods of internal fixation. Treatments with intramedullary nails, plates, and arthroplasty have each been advocated in the literature [ 28 , 29 , 30 , 31 ].

    Intramedullary nails are commonly used and offer several advantages over plate fixation. They can protect a longer segment of the bone although not distal to the superior aspect of the olecranon fossa compared to plates, the dissection needed is less than that for plate fixation, and rigid fixation can be achieved by combination with both interlocking screws and methylmethacrylate although interlocking screw fixation alone is not generally considered truly rigid fixation.

    Plate fixation offers the advantage of avoiding damage or pain to the rotator cuff, better fixation in very proximal or distal fractures where adequate control of the fracture might not be possible with an intramedullary device, and more rigid fixation than can be achieved with intramedullary stabilization without bone cement. Arthroplasty is most useful when rigid fixation cannot be achieved with internal fixation or when the articular surfaces have been destroyed past the point of achieving adequate internal fixation.

    It offers the advantage of not relying on stability of internal fixation devices, provides immediate pain relief and restoration of function of the more distal upper extremity although shoulder function is poor , and is generally very durable. The latest literature for each of these treatment options will be reviewed in the following paragraphs.

    Cemented humeral fixation. In this patient with a pathologic fracture of the midshaft of the humerus, the patient carried no pre-existing diagnosis of cancer. Anteroposterior view of the right humerus shows a segmental defect at the level of the fracture a. Hence, a biopsy and operative treatment of the humeral lesion were planned. Since the lesional site needed to be approached directly for the biopsy, after the frozen section confirmed the diagnosis of metastatic carcinoma, the lesion was thoroughly curetted, and an antegrade intramedullary humeral nail was cemented into the humerus using the technique described by Laitinen et al.

    Other options for this lesion would have been a percutaneous needle biopsy followed by intramedullary humeral stabilization without cement, plating with cementing of the defect, and use of an intercalary segmental prosthetic defect device. This patient had complete early pain relief and restoration of shoulder and elbow function. Intercalary humeral spacers. Prosthetic reconstruction for humeral segmental defects has evolved to a lap joint construct with or without accompanying plate fixation, depending upon the manufacturer. In this case, an early generation intercalary humeral spacer was cemented proximally and distally.

    Note the healing bone surrounding the body portion of the implant but some evidence of radiolucency developing at the prosthetic-cement interface around the proximal stem. The distal humerus is the least likely area of the humerus to be involved by metastatic disease. Since intramedullary stabilization is not possible in this anatomic location, the options include plating when adequate distal bone is available or prosthetic distal humeral reconstruction when bone is lacking. Funovics et al. The series included 53 elbows of which 38 were for tumor resection and 15 were for failed treatment of elbow joint degeneration.

    Elbow function and clinical outcomes assessed with the Inglis-Pellicci scoring system were also better with the tumor group 85 compared to the revision group The authors concluded that the modular prosthesis provides a stable reconstruction of the elbow with satisfactory function and disease control in patients with a tumor involving the distal humerus. Metastatic processes commonly involve the bony pelvis.


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    When this occurs in the periacetabular region, it can create substantial morbidity for patients with metastatic bone disease. Due to the short life expectancy after arthroplasty for patients with disseminated malignancy, 8. Harrington developed specialized operative techniques to allow for adequate support and fixation of the acetabular component of a total hip prosthesis [ 3 , 38 ].

    These techniques were divided into subgroups based on the specific biomechanical deficiencies in the periacetabular bone. The goal of each was to support a total hip prosthesis in its normal anatomical position and to allow transmission of weight-bearing forces into bone. Marco et al. Fifty-four of the hips were reconstructed with a protrusio cup and one patient was treated with a hemi-pelvis endoprosthesis. Large defects were reinforced with a cement and pin or screw fixation the modified Harrington technique. Nine of the 18 patients who could not walk preoperatively regained the ability to ambulate after surgery.

    Fourteen of the 17 patients who were community ambulators retained that ability after surgery. Pelvic irradiation has been long recognized as an independent adverse factor in the outcome of total hip arthroplasty, even in patients without active pelvic metastatic disease [ 40 ]. Because of these difficulties, tantalum acetabular components and augments have begun to be used for total hip arthroplasty in this setting [ 41 , 42 ].

    Porous tantalum acetabular implants have potential benefits for acetabular component fixation in challenging situations such as a history of or need for pelvic irradiation. The material has a high coefficient of friction, potential for ingrowth, and encouraging results when used for primary and revision total hip arthroplasty in traditional arthroplasty patient populations. Rose et al. Harris hip scores improved from an average of 46 points to 88 points postoperatively.

    More recently, in , Khan et al. In this series a large uncemented porous tantalum acetabular shell sometimes with tantalum augments was fixed to the remaining bone after local tumor curettage. The Harris hip scores improved from a mean of 32 preoperatively to a mean of 74 postoperatively.

    There were no cases of progressive radiolucent lines or component migration. Tantalum cup reconstruction.

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