This article was written as a blog post for the IHDI and was published on 7/11/19. To see this blog post as well as others from the IHDI, please visit: https://hipdysplasia.org/news/
Treatment Options for Adolescents/Adults Diagnosed with Hip Dysplasia
Treatment for hip dysplasia can be broken down into two main categories: non-operative/conservative or operative/surgical.
Most doctors and surgeons will recommend that patients start with conservative management. This may be as simple as modifying your activities, taking over-the-counter pain medication, or doing physical therapy to strengthen your core and hips and re-train your movement patterns. Some people argue that hip dysplasia is a structural issue and that conservative management cannot “fix” the structural issue. This is true. But hip dysplasia pain is also poorly understood, and a course of conservative management can help determine what pain is related to the actual structure (primary) and what is secondary. Sometimes activity modification, reducing pain and inflammation, and strength, posture, and movement training is enough to relieve symptoms and allow people with healthy joint tissue to continue to lead active lives with only occasional monitoring of their hips. For others, the risk of arthritic progression is high, or conservative management is not effective and quality of life remains decreased. In these cases, surgery may be a good option.
There are several surgical treatments for adolescent and adult hip dysplasia, including operations to change the alignment of the hip bones (osteotomies); minimally-invasive operations to reshape the bones or address the soft tissue structures inside or around the joint like the labrum, cartilage, or joint capsule (arthroscopies or “hip scopes”); and total hip replacement (arthroplasty).
Osteotomy Procedures: Pelvis
Osteotomy procedures are considered to be a type of “joint preservation surgery” since the goal is to improve the function of the person’s natural hip. Osteotomies involve cutting bones and moving them to improve alignment. Since hip dysplasia is characterized by a shallow hip socket (acetabulum) that doesn’t fully cover the top of the thigh bone (head of the femur), the most commonly performed osteotomy surgery for hip dysplasia is a pelvic osteotomy called the periacetabular osteotomy or “PAO.” PAO surgery involves performing a series of bone cuts (osteotomies) around (peri) the hip socket (acetabulum). The acetabulum can then be moved to improve coverage of the head of the femur to improve weight bearing stresses and decrease pain. Screws are used to keep the bones stable until they heal in their new position.
Osteotomy Procedures: Femur
Some people with hip dysplasia also have abnormally-shaped thigh bones (“femurs”). In these cases, the femur may be described as being anteverted (top of the femur is turned forward more than the bottom), retroverted (top of the femur is turned back more than the bottom), valgus (increased angle between the long bone and the top of the femur), or varus (decreased angle between the long bone and the top of the femur). If your doctor feels that the shape of your femur is contributing to your symptoms, he may decide to do a “femoral osteotomy” (surgery that involves cutting the femur and repositioning it to improve the alignment). Depending on the patient, this may be performed as a stand-alone procedure or it may be before, during, or after a pelvic osteotomy. A long rod that is inserted into the femur and secured by screws or a metal plate with screws are used to keep the bones stable until they heal in their new position.
Hip Arthroscopy (“scopes”)
Some patients with hip dysplasia benefit from a less invasive surgery called hip arthroscopy (often referred to as a “scope”). During arthroscopy, the surgeon makes several small incisions and can insert a special camera into the joint. Special instruments can be inserted and used to address “intraarticular” issues (problems inside the joint such as repairing the labrum or cartilage) and “extra-articular” issues (problems outside the joint such as shaving down bone of the thigh bone or pelvis to improve alignment).
When the surgeon feels that intraarticular or extra-articular issues are causing pain and may continue to be problems even after osteotomy procedures, he may recommend doing hip arthroscopy either before, during, or after an osteotomy. If the damage in the joint is mild and the surgeon feels that improving the alignment of the joint with an osteotomy surgery will take the load off of the inside structures of the joint and improve overall alignment and joint function, he may decide to do the osteotomy alone.
Arthroscopy, alone, is often not appropriate for people with hip dysplasia. This is because it cannot address the underlying issue, which is a shallow hip socket that doesn’t fully cover the head of the femur. However, in some cases of very mild or borderline hip dysplasia, or when symptoms are felt to be more due to impingement and not instability from dysplasia, a surgeon may decide to only do hip arthroscopy. Some patients choose this option knowing that they may still have to have an osteotomy at a later point, but they may want to try a less invasive surgery first. In select patients, arthroscopy, alone, may be enough to improve symptoms and function and prevent the need for an additional hip surgery. This is still an area of debate in the hip preservation world.
When hip arthroscopy is an option in a patient with dysplasia, patients should have a detailed conversation with their surgeon to understand why this might be an appropriate surgery and what the goals and expectations of it should be.
Hip Arthroplasty (“hip replacement”)
Patients who are older and/or who already have significant cartilage damage or arthritis in their hip joint may not be candidates for osteotomy or arthroscopy surgeries. Patients who are having pain and decreased function may decide to have arthroplasty surgery (a total hip replacement or “THA”). THA involves replacing the socket and the head of the femur with an implant made out of a variety of materials such as plastic, metal, and ceramic. In some patients, resurfacing may be an option. Historically THA has not been recommended for younger or more active patients since the parts can wear down and need to be replaced multiple times in a lifetime. Research and technology in this field is improving though. Implants are starting to last for longer periods of time and changes in surgical techniques may allow some patients to continue to be active for many years after surgery.
Author: Nancy Muir, PT, DPT, PCS