Select Cases
Treatment of Hip Dysplasia in a Young Patient
Background: An 18-year-old male patient was referred to our offices from out of state with activity-related pain in his left hip. He was an avid athlete, full-time student, and had only started having symptoms over the past few months. As a child he was very active in multiple sports, particularly basketball and soccer early on and then baseball later on, as well as golf for the last two years. His hypermobility status had never been brought up and he was unaware that he might have this condition.
Initial Visit: The patient indicated that almost all of the symptoms were on the left side, starting with clicking and pain. He had obtained a 3T MRI which showed a tear of the right labrum and also one on the left. With regard to hypermobility, he could touch his thumb easily to his forearm on both hands, but all other Beighton indicators were negative for a score of 2 out of 9. With his Hakim-Grahame at 1 out of 5, this would ordinarily not qualify him as hypermobile. However, after speaking with his mother, it was reported that her daughter, the patient's sister, is extremely hyperflexible as is one of her nieces. With the significant family history and abnormally flexible thumbs, he would be appropriately classified as hypermobile.
Physical Exam: Patient presented with a BMI of 22.7. Gait was limp-free. He had a click going from extension to flexion on the left side, which was an unusual pattern. There was also a click when just simply rotating from internal to external position. There was limited internal rotation and flexion consistent with cam impingement. The ranges of motion and relevant hip tests are indicated in the table below:
Radiographs:
AP Pelvis (standing)
Left Lateral
Left False Profile
Mild bilateral dysplasia with retroversion is seen on the standing films. The left lateral film shows positive bulging of the anterior femoral neck (cam impingement). The standard AP radiograph of the left hip shows generalized hypoplasia without evidence of retroversion.
Diagnoses:
1. Dysplasia, bilateral hips (Left more symptomatic than Right)
2. Pain left hip, moderately severe
3. Systemic hypermobility, mild and familial
4. Labral tear, left hip
5. Activity induced neck hypertrophy, left
Plan: Patient is an appropriate candidate for multidirectional periacetabular osteotomy for posterolateral coverage enhancement and a femoral neck ostectomy for recreation of physiologic offset of the anterior femoral neck.
Post-Surgical Follow Ups: On the day of surgery, he was able to walk and wanted to walk even more than he was allowed by physical therapy. The next morning, he was completely pain-free. He looked and felt great. By 1 week, at his first follow-up visit, passive range of motion was well tolerated with flexion to 70 degrees after which there was discomfort. However, after multiple attempts the joint freed up nicely and could flex to 90 degrees. He tolerated internal and external rotation very well. He had a dramatic improvement in internal rotation, having gained about 20 degrees of internal rotation after the femoral ostectomy.
Radiographs: 3-month follow-up (Left side)
AP Pelvis (standing)
Left Lateral
Left False Profile
By 3 months, all of the pain from before the operation was relieved. There was no more clicking. X-rays showed very good coverage enhancement and dramatic improvement in femoral offset of the anterior neck. The patient was extremely pleased with his symptom-free status. There was slight weakness compared with his right side. All provocative tests were negative. His range of motion was very good, and gait was limp-free.
Plan: Proceed with the right-side periacetabular osteotomy, without arthroscopy as there appears to be no residual symptoms associated with the labral tear, and perform an ostectomy of the femoral neck to correct the cam lesion deformity. Hardware removal will be deferred until right-side hardware removal takes place aproximately 6 months after the right side surgery.
Post-Surgical Follow Ups: By 5-days-out from his second surgery, the patient was walking really well. His internal rotation on the right side went from -15 to +15. He said he had virtually no pain. He was only taking Tylenol and Celebrex and felt that the recovery was much better the second time around. He avoided all narcotics and that had made a huge difference.
Radiographs: 3-month follow-up (Right side)
AP Pelvis (standing)
Right Lateral
Right False Profile
X-rays showed very good healing and excellent position of the osteotomy. The large cam defect was trimmed back to normal. The patient was delighted with the enhanced coverage and overall appearance of the hip joint. He was walking full weightbearing with no limp and no support.
Plan: Recommended anticipation of the bilateral hardware removal at 6 months from the second surgery date.
Comparison: Pre-Op and Post-Op
Right Pre- vs Post-Op
