Hip Dysplasia in the Skeletally Mature Patient

28 Bulletin of the Hospital for Joint Diseases 2014;72(1):28-42

Hip Dysplasia in the Skeletally Mature Patient

Rachel Y. Goldstein, M.D., M.P.H., Ian David Kaye, M.D., James Slover, M.D., and
David Feldman, M.D.

Abstract from increased and abnormal forces across the joint with
resultant shear forces causing pathologic changes. Changes
Abnormal hip development causes one-quarter to one-half of classically appear at the anterolateral region of the acetabu-
all hip disease. Dysplastic hips typically share characteristic lum, the posterior region of the femoral head, or the femoral
anatomic abnormalities. The dysplastic acetabulum is typi- head and neck junction.2
cally shallow, lateralized, and anteverted with insufficient Eventually, the mechanical hip dysfunction from dys-
coverage anteriorly, superiorly, and laterally. The dysplastic plasia leads to early hip degeneration and osteoarthritis.6 It
proximal femur has a small femoral head with excessive has been suggested that there is a direct correlation between
femoral neck anteversion and a short neck with an increased the onset of radiographically determined degenerative joint
neck shaft angle. These characteristic changes result in in- disease and the amount of acetabular dysplasia present.2,7
traarticular pathology leading to hip arthritis. A variety of Neonatal hip instability has been associated with a 2.6 times
treatment options exist based on the degree of dysplasia and increased risk for total hip replacement in young adulthood
the amount of concomitant hip arthritis. Treatment options in comparison to stable hips.8 And, one quarter of hip re-
include hip arthroscopy, acetabular or femoral osteotomies, placements performed in patients aged 40 years or younger
hip arthrodesis, and total hip arthroplasty. are due to underlying hip dysplasia.9
Hip dysplasia may be a primary process caused by con-
According to the Center for Disease Control, 25% genital or developmental abnormalities. It has been well
of Americans will experience symptomatic hip established that there is some genetic component to hip
arthritis during their lifetimes, and it has been es- dysplasia.10-16 A positive family history for developmental
timated that 20% to 50% of disease burden is secondary to hip dysplasia may be found in 12% to 33% of patients who
acetabular dysplasia. have DDH.13,15,17-20 One study reported a tenfold increase in
Hip dysplasia refers to an abnormality in development, the incidence of DDH among the parents of index patients
such as in size, shape, or organization, of the femoral head, and a sevenfold increase among siblings compared with the
acetabulum, or both.1 These changes may lead to increased incidence in the general population.19 Another study found
contact pressures on the joint and ultimately to hip arthro- that over 50% of patients requiring periacetabular osteotomy
sis.2-6 However, before the development of frank degenera- for hip dysplasia had a family history of hip dysplasia,
tive changes, many patients become symptomatic secondary and over 40% were first degree relatives.21 In addition, a
to abnormal hip biomechanics, hip instability, impingement, number of secondary causes of dysplasia exist, including
or labral and chondral pathologies.2-5 These processes arise neuromuscular diseases, slipped capital femoral epiphysis,
Perthes disease, trauma, or epiphyseal dysplasias.
Rachel Y. Goldstein, M.D., M.P.H., is a Juvenile Hip Preservation
Fellow at Boston Children’s Hospital, Boston, Massachusetts. Ian Normal Hip Development
David Kaye, M.D., James Slover, M.D., and David Feldman, M.D.,
are in the Department of Orthopaedic Surgery, NYU Langone The formation of the hip joint begins at the seventh week
Medical Center, Hospital for Joint Diseases, New York, New York. of gestation. The acetabulum and the femoral head develop
Correspondence: Rachel Y. Goldstein, M.D., M.P.H., Boston Chil- from the same group of mesenchymal stem cells.22-24 At the
dren’s Hospital, 300 Longwood Avenue, Hunnewell 221, Boston, seventh week of gestation, a cleft develops in the precarti-
Massachusetts 02115; [email protected].

Goldstein RY, Kay ID, Slover J, Feldman D. Hip dysplasia in the skeletally mature patient. Bull Hosp Jt Dis. 2014;72(1):28-42.

Bulletin of the Hospital for Joint Diseases 2014;72(1):28-42 29

laginous cells. This cleft defines the acetabulum from the ized, and anteverted.2,37-42 The coverage is typically deficient
femoral head. By the 11th week of gestation, the hip joint is anteriorly, laterally, and superiorly. In some cases, the entire
fully formed, but acetabular development continues through- pelvis may be underdeveloped. The dysplastic femur has a
out intrauterine life, particularly by means of growth and small femoral head with excessive femoral neck anteversion
development of the labrum.23-25 and a short neck with an increased neck shaft angle.2,43-45 The
In the normal hip at birth, the femoral head is deeply greater trochanter is often displaced posteriorly and the lesser
seated in the acetabulum and held within the confines of the trochanter assumes a relatively more anterior position. The
acetabulum by the surface tension of the synovial fluid. It femoral canal is usually narrow and has been described as
is extremely difficult to dislocate a normal infant hip, even a “pipe stem” femur (Fig. 1).
after incising the hip joint capsule.26,27 Hips in newborns As these bony changes develop, the soft tissues also
with developmental dysplasia are not just normal hips with become abnormal. The abductor muscles become oriented
capsular laxity; they are structurally abnormal. more transversely and therefore function less efficiently. The
In the infant, the entire proximal end of the femur, includ- psoas tendon hypertrophies and the hip capsule thickens.
ing the greater trochanter, the intertrochanteric zone, and the In addition, the hamstrings, adductors, and rectus femoris
proximal femur, is composed of cartilage. Between the fourth muscles all shorten.
and seventh months of life, the proximal femoral ossification These pathologic changes result in abnormalities within
center appears. The bony centrum and its anlage continue to the hip joint. As the hip joint becomes less stable, the
enlarge until adulthood. The proximal femur and the trochan- acetabular labrum initially hypertrophies in an attempt to
ter enlarge by appositional cartilage cell proliferation.28 maintain the femoral head within the acetabulum.3 Similarly,
The growth areas in the proximal femur are the physeal the ligamentum teres hypertrophies. If chronic shear stress
plate, the growth plate of the greater trochanter, and the persists, the labral soft tissue compensation will likely fail,
femoral neck isthmus.28 A balance among the growth rates and the labrum can be torn away from the acetabular rim,
of these centers accounts for the normal configuration of
the proximal femur, the relationship between the proximal Figure 1 The classic dysplastic acetabulum is typically shallow,
femur and the greater trochanter, and the overall width of the lateralized, and anteverted with deficient coverage anteriorly, later-
femoral neck. Growth of the proximal femur is affected by ally, and superiorly. The dysplastic femur has a small femoral head
the pull of muscles inserting on the proximal femur, forces with excessive femoral neck anteversion and a short neck with an
being transmitted across the hip joint with weightbearing, increased neck shaft angle.
normal joint nutrition, normal joint circulation, and normal
muscle tone.28-31
Normal development and subsequent functioning of the
hip joint requires a balanced growth of the acetabular and
triradiate cartilages as well as a concentrically reduced femo-
ral head. Experimental animal studies and clinical findings
in humans with unreduced hip dislocations suggest that the
main stimulus for the concave shape of the acetabulum is
the presence of a spherical femoral head.32,33 Harrison and
coworkers determined that the acetabulum failed to deepen
in area and depth after femoral head excision in rats.33 He
also demonstrated atrophy and degeneration of the acetabu-
lar cartilage.32
The acetabulum is deepened by the natural pressure from
the developing femoral head on the acetabulum.32-35 The
depth of the acetabulum is further enhanced at puberty by
the development of three secondary ossification centers.27,33,36
The os acetabulum develops in the thick cartilage that sepa-
rates the acetabular cavity from the pubis. The os acetabulum
is the epiphysis of the pubis and forms the anterior wall of
the acetabulum. The epiphysis of the ilium, the acetabular
epiphysis, forms a major portion of the superior edge of the
acetabulum. A third small epiphysis also forms in the ischial
region and contributes to its normal growth.

Anatomy

Dysplastic hips often share anatomic abnormalities. The
classic dysplastic acetabulum is typically shallow, lateral-

30 Bulletin of the Hospital for Joint Diseases 2014;72(1):28-42

AB

Figure 2 Arthroscopic images from a patient with hip dysplasia demonstrating the classic hypertrophied labrum (A) and labral tear at
the acetabular rim (B).

resulting in increased contact forces on the cartilage surfaces found to have intraarticular pathology sufficient to require
(Fig. 2).3,5,46-50 surgical treatment.57
Ultimately, these pathologic processes lead to decreased While there is considerable evidence that radiographic
contact area between the femoral head and the acetabulum acetabular dysplasia leads to secondary degenerative joint
and lateralization of the center of rotation of the hip. This disease,15,58 there are no predictive radiographic parameters.
results in an increased body-weight arm and resultant higher Cooperman and associates (1983) studied 32 dysplastic hips
forces transmitted through a smaller surface area, culminat- with lateral center edge angles of less than 20° for more
ing in degenerative hip changes. than 20 years in order to determine the natural history of
acetabular dysplasia. The investigators found that all patients
Natural History eventually developed radiographic evidence of degenerative
joint disease. Moreover, they determined that none of the
Studies have demonstrated that acetabular dysplasia leads conventional radiographic parameters used to describe hip
to degenerative changes over time, likely secondary to me- dysplasia were able to predict the rate of the degenerative
chanical factors and related to increased contact stresses.51-55 joint disease.54
Reduced acetabular size and obliquity create shearing
forces on the articular cartilage. These forces lead to chronic Patient Presentation
overload of the anterior and anterolateral acetabular rim.
Eventually, the articular cartilage of the anterior acetabulum Patients who present with hip pain require a thorough
and the femoral head fail. Previous reports demonstrate that history and physical examination to elucidate the source
radiographic degenerative joint disease correlates with the of their symptoms. Patient factors, including age, overall
magnitude and length of the excessive pressure.54,56 health, activity level, occupation, and illicit habits, should
In 2011, Ross and colleagues published their results of be identified. In addition, a hip specific history should be
arthroscopy in 73 dysplastic hips undergoing periacetabular taken, including family history of hip problems, any known
osteotomies. A labral tear or chondral degeneration was previous hip disease, and any history of prior hip surgery.
found in 86% of hips, and 63% of hips demonstrated a hyper- Previous hip disease or related treatments, such as child-
trophied labrum. Only 7% of hips were without intraarticular hood and adolescent hip problems, previous hip surgery,
pathology. Labral disease was most common in the anterior hip trauma, and osteonecrosis, may indicate a secondary
(81%) and superolateral (67%) labrochondral junctions. dysplasia.
Over two-thirds of patients were found to have acetabular Pain characteristics need to be thoroughly evaluated.
chondromalacia. Acetabular chondral lesions were primar- Patients with hip dysplasia may initially present with mild
ily located at the anterior (76%) and superolateral (84%) peritrochanteric pain reflecting abductor fatigue, an almost
labrochondral junctions. Femoral head chondromalacia was universal finding in pre-arthrotic hip dysplasia in the mature
seen in only 11% of hips. Sixty-three percent of patients were adult.59 Commonly, patients with dysplasia will have groin

Bulletin of the Hospital for Joint Diseases 2014;72(1):28-42 31

pain in the affected hip that is worsened with activity.59 positive in patients with labral lesions as well. It is performed
Similarly, the pattern of symptoms may help elucidate the by having the patient lie supine on the table. The affected
nature of the dysplasia. Pain worse with weightbearing and extremity is extended and rapidly externally rotated. The test
activity may indicate underlying joint pathology. Pain with is considered positive if it elicits apprehension or anterior
flexion positions or prolonged periods of sitting may com- hip pain.
monly be associated with femoroacetabular impingement Finally, patients should be assessed for hip abductor
(FAI). The sensation of locking or catching in the affected weakness. The Trendelenburg sign is elicited if the patient
joint may indicate intraarticular mechanical problems, such leans away from the affected extremity during single legged
as a labral tear, chondral flap, or loose body. stance on the affected extremity. Nunley reported that 38%
Nunley and colleagues examined 57 patients with known of patients in his study had a positive Trendelenburg sign.60
hip dysplasia. Ninety-seven percent of their patients reported Alternatively, abductor strength can be tested by having the
an insidious onset of hip pain without an inciting event. patient lie on his unaffected side and asking him to abduct
Seventy-two percent of these patients localized their pain the leg against resistance.
to the groin. Eighty-eight percent of patients noted activity
related pain with 81% reporting that their symptoms were Radiology
exacerbated by walking and 80% while running. At least one
mechanical symptom was reported by 80% of their patients. The evaluation of a patient with suspected hip dysplasia is
Almost half of the studied patients reported a limp. Night confirmed with imaging. The radiographic features of adult
pain was also found in more than half of the patients.60 hip dysplasia may range from subtle acetabular dysplasia
to complete dislocation of the femoral head from the native
Physical Exam acetabulum. The goals of imaging are to assess the struc-
tural anatomy of the hip, determine the congruency of the
The physical examination of the patient with suspected hip articulation, examine the integrity of the joint space, and to
dysplasia should take into account general condition and assess the soft tissues.64 Table 1 describes the commonly
body habitus, the patient’s sitting posture, and their gait used radiographic parameters and measurements used in the
pattern. It is also important to assess for a leg length dis- diagnosis and categorization of hip dysplasia.
crepancy. Standing measurements will allow an assessment The anterior-posterior (AP) view of the pelvis is the single
of pelvic balance and are therefore considered the best way most important view for defining acetabular dysplasia. It al-
to assess a leg length discrepancy.59,61 lows for the assessment of acetabular coverage of the femoral
Resting lower extremity rotation should be assessed with head, femoral head sphericity,67 the contour of the femoral
the patient lying supine on the exam table. Normal lower head-neck junction, the height of the greater trochanter, posi-
extremity rotation is between 10° and 30° of external rota- tion of the joint center, the joint space, and Shenton’s line.
tion. Abnormal rotation may result from abnormal acetabular Lateral radiographs allow better definition of the osse-
version, abnormal femoral version, or femoral head-neck ous anatomy of the proximal femur, anterior and posterior
abnormalities.59 joint spaces, and the acetabular rim. Lateral radiographs
Hip range of motion testing is essential for not only di- include the cross table lateral and frog lateral. Also among
agnosis but also for pre-procedure planning.62 The examiner the lateral views is the false profile view.68 This image is
should steady the pelvis with one hand while performing obtained by having the patient stand with their foot parallel
range of motion testing, including hip flexion and internal to the radiographic plate and their pelvis rotated 65° relative
and external rotation both in 90° of flexion and full exten- to the film. This view constitutes a true lateral view of the
sion. In contrast to classic FAI, which may demonstrate acetabulum. It allows measurement of the anterior coverage
restricted hip flexion and internal rotation, patients with of the acetabulum, and may also allow better detection of
classic dysplasia will generally demonstrate normal hip the degenerative changes that tend to begin at the anterior
flexion and normal internal rotation.47,63,64 aspect of the joint.
Some special tests may help elucidate the nature of the Computer tomography (CT) is a complementary study
hip pathology. The anterior impingement test is a special in evaluating hip dysplasia when dysplastic signs have
maneuver that is indicative of disorders of the anterior ac- been recognized on plain films and surgical correction is
etabular rim.65,66 It is very sensitive for a range of anterior anticipated. It allows reliable measurements of acetabular
hip lesions, including labral tears and rim fractures, but fairly coverage, femoral neck anteversion, and the appearance
non-specific for intra-intrarticular disease and joint irritabil- and position of the femoral head.69 It also allows better
ity.65 The patient is placed supine, and the affected extremity characterization of osseous impingement lesions.6,64
is passively flexed, adducted, and internally rotated. The Magnetic resonance imaging (MRI) is not routinely
test is considered positive if this maneuver reproduces the necessary in hips with obvious structural abnormalities. It
patient’s pain. Nunley reported that 97% of the patients in may assist in the evaluation of a painful hip in the absence
his study had a positive impingement sign.60 of structural osseous abnormalities and can be useful in
The apprehension test is another special maneuver that is the diagnosis of osteonecrosis of the femoral head, stress
useful to assess for anterior hip instability, though it may be fracture, neoplasm, or infection. MRI and MRI arthrogram

32 Bulletin of the Hospital for Joint Diseases 2014;72(1):28-42

are useful adjuvants to evaluate the labrum and should be planning for osteotomies but is more frequently utilized for
obtained in patients with mechanical symptoms. research purposes (Table 2).
The Crowe classification describes the degree of femoral
Classification head subluxation or dislocation (Table 3).71 The classification
is determined by measuring the vertical distance between the
Two classification systems are routinely used in describing inter-teardrop line and the junction between the femoral head
dysplastic hips. The Tonnis classification groups hips by the and the medial edge of the neck. The amount of subluxation
degree of secondary osteoarthritis changes.70 It is useful in

Table 1 Radiographic Findings in the Evaluation of Hip Dysplasia

Radiographic Finding Description Implication

On AP Pelvis Projected arc from the inferior border of the femoral A break in the line (arc)
Shenton’s Line132,133 neck to the superior border of the obturator foramen reflects superior femoral head
subluxation indicative of
Pistol-Grip Deformity55 Femoral head extends laterally in a convex shape to the acetabular dysplasia
Protrusio base of the neck
Femoral head overlaps the ilioischial line medially Represents an anterior
deformity and hip dysplasia

Profunda Floor of the fossa acetabuli touches the ilioischial line

Crossover Sign134 The contours of anterior and posterior wall cross medial Acetabular retroversion
Projection of Ischial Spine135 to the superolateral aspect of acetabulum
Lateral Center Edge Angle56 Increased retroversion
Projection of ischial spine Assesses the superior and
Tonnis Angle136 lateral coverage of the
Angle between horizontal line through center of both femoral head by the bony
Acetabular Angle of Sharp137 femoral heads and a line from center of femoral head to acetabulum
most superolateral point of acetabulum Evaluates orientation of
Femoral Head Coverage acetabular roof or inclination
Angle between horizontal line through both femoral of the sourcil
Neck Shaft Angle heads and a line from the most medial point of the
On False Profile View weightbearing acetabulum to the most lateral point of the Measures the acetabular
Vertical Center Anterior Angle68 acetabulum inclination or opening

Computed Tomography Angle between horizontal line through both inferior Measures the percentage of
Anterior Acetabular Sector Angle teardrop and a line from the inferior aspect of the the femoral head covered by
(AASA)/Posterior Acetabular Sector teardrop to the superolateral aspect of the acetabulum the bony acetabulum
Angle (PASA)
Distance between a line through most medial aspect of Evaluates the angle of the
Femoral Neck Version the joint space and align through the lateral aspect of femoral neck
the acetabulum, divided by the distance between a line
through the most medial aspect of the joint space and a
line through the most lateral aspect of the head

Angle between the axis of the femoral shaft and the axis
of the neck passing through the femoral head center

Angle between a vertical line through the center of the Evaluates the anterior and
femoral head and an oblique line running from the center superior coverage of the
of the head to the most anterior point of the acetabulum femoral head

Angle between a line formed through center of femoral Describes the relationship
heads and an oblique line from the center of the head to between the femoral head and
the most anterior portion of the acetabulum to determine the acetabulum. These values
the AASA and to the most posterior portion of the are decreased in acetabular
acetabulum to determine the PASA dysplasia

Angle between the femoral neck and the posterior aspect Evaluates the version of the
of femoral condyles femur

Bulletin of the Hospital for Joint Diseases 2014;72(1):28-42 33

Table 2 Tonnis Classification of Hip Dysplasia
Grade Description
0 No arthritic changes
1 Sclerosis, mild joint space loss, minimal osteophyte formation
2 Small cystic changes with moderate joint space loss
3 Large cysts and moderate to complete joint space loss

Table 3 Crowe Classification of Hip Dysplasia
Type Description
I subluxation < 50% of vertical diameter of femoral head
II subluxation of 50% to 75% of vertical diameter of femoral head
III subluxation of 75% to 100% of vertical diameter of femoral head
IV proximal migration of > 100% of vertical diameter of femoral head

is the ratio between this distance and the vertical diameter hip dysplasia is protective against microinstability. Labral
of the normal femoral head. This classification system can debridement performed during hip arthroscopy may actu-
be used to guide treatment algorithms for patients being ally allow for increased microinstability leading to further
considered for total hip arthroplasty. articular degeneration.3,76 Support for this theory can be seen
in the progression of osteoarthritis and anterolateral migra-
Treatment tion of the femoral head which has been described following
arthroscopic labral debridement in hips with underlying
Hip Arthroscopy dysplasia.73,75,76
While hip arthroscopy alone has limited applicability
Hip arthroscopy is an option for the treatment of mild hip in the treatment of hip dysplasia, it is a useful adjuvant
dysplasia. This technique can address mechanical symptoms, treatment when combined with bony reconstructive pro-
loose bodies, labral tears, chondral defects, and synovial cedures.5,6,74,76 Acetabular dysplasia typically results in
disease (Fig. 2). However, it is limited in that it does not intraarticular pathology, and hip arthroscopy may provide
address the osseous abnormalities of the dysplastic hip that an opportunity to address this pathology.57,77 Kim and col-
are the underlying cause of the mechanical symptoms. leagues published their results of combined hip arthroscopy
Several investigators have looked at the outcomes of and periacetabular osteotomy. They found that 88% of their
dysplastic hips treated with hip arthroscopy. Byrd and Jones patients had a labral lesion. All patients with labral lesions
published a report in 2003 of 48 patients who underwent underwent arthroscopic labral debridement at the time of
hip arthroscopy for intraarticular pathology and were ret- arthroscopy. The mean Harris Hip Score improved from
rospectively determined to have acetabular dysplasia. The 72.4 preoperatively to 94 at a mean of 74 months.78
investigators found that 67% of the hips had labral lesions,
and 60% had chondral lesions that were addressed at the Osteotomies
time of surgery. Patients were followed for an average of
27 months, and the investigators found that all patients had Osteotomies are useful in the treatment of hip dysplasia as
improved Modified Harris Hip Scores at final follow-up.72 they can address the underlying morphologic abnormality.
In contrast, Parvizi and colleagues published a report in They can reorient the articular surfaces of the hip joint and
2009 in which they described the outcomes in 36 dysplastic allow load transmission through a broader surface area,
hips treated with hip arthroscopy for intraarticular pathology. subjecting the joint to less force.79,80 Osteotomies can also
At an average of 3.5 years of follow-up, they found that two- medialize the center of hip rotation and as a result decrease
thirds of the patients had failure to control their symptoms, the joint reactive forces.80 These changes can reduce pain,
and that 44% of their study population went on to require protect the articular cartilage, and improve the functional
additional open procedures. They did note that the patients arc of motion.80,81 These procedures are generally indicated
largely demonstrated improved functional scores at 6 weeks; in young patients with symptomatic hip dysplasia without
however, these improvements deteriorated with time.73 excessive proximal migration of the hip center of rotation,
The deterioration of function after hip arthroscopy in dys- who have preserved range of motion and no more than mild
plastic hips is likely multifactorial.5,72,74,75 Some investigators degenerative changes.
argue that the pain relief following labral debridement may Osteotomies about the hip joint can be carried out at the
mask the underlying mechanical abnormalities, resulting in acetabulum, at the proximal femur, or using some combi-
progressive damage to the anterolateral acetabular articular nation of both. Pelvic osteotomies address the location of
cartilage.73,75-77 Moreover, the hypertrophied labrum seen in

34 Bulletin of the Hospital for Joint Diseases 2014;72(1):28-42

the primary pathology. They correct the major anatomic the acetabulum and medialization of the hip joint center.
abnormality and do not create a secondary deformity, which The fundamental goal of this procedure is to correct the
can affect future reconstructive procedures.82 The femoral acetabular insufficiency and improve femoral head cover-
osteotomy can be added if significant femoral deformity age by repositioning the weightbearing surface laterally and
exists; however, it is rarely indicated as an isolate procedure anteriorly.80,81 Secondary goals include improved hip stability
in patients with acetabular dysplasia.82,83 and medialization of the hip center of rotation.80,81
The ideal patient for these procedures is one with a symp-
Pelvic Osteotomies tomatic structural abnormality, a congruent joint, and the
absence of advanced secondary arthritis. These patients also
Pelvic osteotomies can be categorized into two types: re- need to have a well-maintained hip range of motion. These
constructive and salvage. Reconstructive osteotomies are osteotomies are contraindicated in patients with excessive
intended to restore normal hip anatomy and biomechanics. posterior wall coverage. These patients require a surgical dis-
They improve symptoms and possibly prevent degenerative location in order to adequately address their deformities.80,81
changes. These types of osteotomies require a hip joint in Patients with advance cartilage degeneration anteriorly also
which the femoral head and the acetabulum are congru- should not undergo this procedure as the degenerative area
ent. Salvage osteotomies are used to relieve pain when will wind up in the weightbearing zone after osteotomy.
the articular surface congruency cannot be restored. These There are numerous advantages to the periacetabular oste-
osteotomies are performed in patients who have a hip joint otomy as a treatment for hip dysplasia. The Ganz osteotomy
in which the femoral head and the acetabulum are not the is generally performed through a modified Smith Peterson
same shape (Fig. 3). approach, and this abductor sparing dissection through a
Various periacetabular osteotomies have been developed single incision decreases the risk of postoperative gait abnor-
to reorient the hyaline cartilage of the hip in mature patients. malities.80,81,89 The osteotomy utilizes straight, reproducible,
Salter’s innominate osteotomy was first used in mature hips extra-articular cuts that preserve the posterior column and
more than 50 years ago.84 It proved useful in the treatment do not change the shape of the true pelvis. The osteotomy
of mild dysplasia but was inconsistent in major acetabular also allows major multi-planar corrections, including lateral
reorientation. More consistent major acetabular reorientation and anterior rotation and medialization of the hip joint. This
was introduced independently in Germany85 and Japan86 with approach preserves the acetabular fragment blood supply,
spherical osteotomies. This technique allows excellent femo- provides reliable healing, and allows for accelerated reha-
ral head coverage, but medialization of the joint center can bilitation.80,81,89 Most importantly, this intervention is a joint
be difficult. Other complex osteotomies were subsequently preserving treatment.
introduced by Tonnis87 and Steel.88 The Ganz osteotomy is performed from the inner aspect
In 1988, Ganz and colleagues introduced the Bernese of the pelvis and generally consists of three cuts: a partial
periacetabular osteotomy.81 This procedure, which is also osteotomy of the ilium, a complete osteotomy of the pubis,
known as a “Ganz osteotomy,” allows both redirection of

Figure 3 Flowchart of pelvic osteotomies.

Bulletin of the Hospital for Joint Diseases 2014;72(1):28-42 35

and a biplanar osteotomy of the ilium.81 The osteotomized weightbearing surface of the acetabulum. This procedure
acetabulum is then displaced medially, rotated anteriorly, does not change the relationship of the femoral head to the
and rotated laterally. The osteotomy is then secured with true acetabulum, nor does it medialize the hip center of
several screws. Postoperative radiographs are used to assess rotation.
the adequacy of the correction. The Chiari osteotomy is recommended for patients with
Acetabular osteotomies address the underlying bony inadequate femoral head coverage and an incongruous
abnormality, but most patients will have intraarticular pathol- joint.100-102 An osteotomy is made above the acetabulum
ogy at the time of presentation.57,76-78,82,86 Most investigators and extends into the sciatic notch. By abducting the hip,
recommend opening the joint and evaluating for labral le- the distal portion of the osteotomy moves medially, shifting
sions as well as impingement between the anterior femoral the ilium laterally beyond the edge of the acetabulum. The
neck and anterior acetabulum.74,77,90-93 An anterior arthrotomy procedure thus medializes the hip center. The interposed
performed in associated with a PAO allows resection of capsule undergoes metaplasia and becomes fibrocartilage
anterior labral tears and limited femoral neck osteoplasty. over time.
However, joint exposure is limited unless an extensive ab-
ductor dissection is performed.78 Other investigators have Femoral Osteotomies
suggested either simultaneous or staged hip arthroscopy to Proximal femoral osteotomies have been used in the treat-
assess and treat the intraarticular pathology.76,78 ment of hip dysplasia for approximately a century with
Several studies have reported on outcomes after periace- a varus osteotomy to correct the coax valga and a distal
tabular osteotomies.60,79,80,89,94-97 In 2011, Nunley and col- transfer of the greater trochanter to correct for trochanteric
leagues reported their outcomes with PAOs in 65 hips with overgrowth.83 However, proximal femoral osteotomies along
symptomatic hip dysplasia at an average of 27 months. They are rarely useful in stabilizing hips with acetabular dyspla-
found an improvement in mean Modified Harris Hip Scores sia in skeletally mature patients. They are useful when the
from 66.4 to 91.7 at final follow-up. Only one hip in their femur is the primary source of deformity or when the pelvic
series required conversion to a total hip arthroplasty. One osteotomy alone provides insufficient correction.83,103
hip required revision for symptomatic femoral-acetabular In order to perform an isolated proximal femoral oste-
impingement. Postoperative radiographs demonstrated otomy, several criteria need to be met: the osteotomy must
consistent correction, including improved femoral head completely correct the deformity, the patients must have a
coverage and improved acetabular inclination.60 functional arc of motion, the joint needs to congruent, and
In the longest follow-up study published to date, the Bern placing the hip in the position of proposed correction should
group reported their long-term outcomes with the Bernese provide comfort to the patient.83 This situation is generally
periacetabular osteotomy.97 When evaluating the first 75 only found in patients with coax valga and mild acetabular
hips in which they performed the procedure at the 20-year dysplasia.
follow-up, they found that 40% had gone on to require total
hip arthroplasty or fusion at an average of 12 years after the Hip Arthrodesis
index procedure. The group also identified several factors as In patients with severe unilateral hip dysplasia and who are
predictive of a poor outcome: older age at surgery, positive poor candidates for osteotomies or total hip replacement, an
anterior impingement test, limp, higher osteoarthritis grade, arthrodesis may be considered. However, currently, these
and postoperative extrusion index. procedures are rarely indicated. Arthrodesis may provide
Though results with the Ganz osteotomy tend to be favor- good pain relief for patients with severe unilateral disease;
able, complications can arise. Excess posterior coverage can however, this procedure will limit a patient’s physical activi-
be caused by excessive anteversion of the osteotomy.95,98 This ties and can lead to progressive degenerative changes in the
can lead to posterior acetabular impingement and limited ipsilateral knee and lower back.104-107
extension and external rotation. The osteotomy can also be The ideal position for hip arthrodesis is neutral abduction,
malpositioned anteriorly, resulting in an acetabular index external rotation of 0° to 30°, and 20° to 25° of flexion. It is
of less than zero, which may result in secondary anterior essential to avoid abduction and internal rotation in order to
impingement.98 minimize excessive lumbar spine and contralateral knee mo-
In patients with severe acetabular dysplasia that do not tion.108,109 Contraindications to performing a hip arthrodesis
have a congruent joint, but have minimal arthritic changes, include morbid obesity, systemic arthritis, contralateral hip
a redirectional osteotomy cannot correct their abnormal dysfunction, lumbosacral spine disease, or ipsilateral knee
morphology. These patients may be candidates for a salvage abnormalities.110
osteotomy. The two most commonly performed salvage os-
teotomies are shelf99 procedures and the Chiari osteotomy.100 Pelvic Support Osteotomy
Shelf procedures generally use corticocancellous graft to Another option for treatment of severe hip dysplasia is a
augment the anterolateral portion of the acetabulum.99 The resection of the femoral head with valgus-producing pelvic
graft is inserted into a slot created above the acetabulum and support osteotomy (Fig. 4).111 This treatment is generally
acts as a buttress to increase joint stability and increase the reserved for patients with severe pain and low functional

36 Bulletin of the Hospital for Joint Diseases 2014;72(1):28-42

demands, such as those with underlying neuromuscular to joint preservation surgery.9,115 Because of the anatomic
disorders or poor medical conditions. abnormalities associated with hip dysplasia and the younger
The goals of this procedure are to create and abduction mean age of patients with this diagnosis who go on to require
and extension effect in the femur at the level of the ischium arthroplasty, special considerations need to be made when
to increase the range of abduction, support the femur on the considering total hip arthroplasty (THA) in this popula-
pelvis, to reduce lumbar lordosis, and to prevent a Tren- tion. In the very young patient, the long-term implications
delenburg limp by tightening the gluteus medius muscle of performing a THA make secondary goals like bone and
as the distance of the greater trochanter from the pelvis is muscle preservation and prolonged implant durability almost
increased.111-113 The disadvantages of this procedure include as important as the primary goal of pain relief.115
the limb length inequality it produces, overall lower ex- Abductor deficiency is a common problem in patients
tremity weakness, the need for ambulatory aids, increased with severe hip dysplasia. As the greater trochanter becomes
oxygen consumption with ambulation, and decreased gait displaced posteriorly and the neck shaft angle decreases, the
velocity.112,114 abductor lever arm becomes oriented more transversely. This
A Japanese group reported on their 20-year follow-up abductor deficiency can result in serious complications after
of 53 patients who had undergone 58 pelvic support oste- a THA, including high rates of dislocation116 and chronic
otomies for osteoarthrosis of a dysplastic hip. Thirty-five limp.115
percent of these patients underwent total hip arthroplasty at Deficient acetabular bone may limit the surgeon’s ability
an average of 14 years after the index procedure (range: 7 to place the acetabular component fully on native bone in
to 24 years), and only one patient required corrective varus the true acetabular region (Fig. 5). Three common alterna-
osteotomy to pass the stem. The Kaplan Meier’s survivor- tive methods to reconstruct dysplastic acetabuli have been
ship was 66% at 10 years and decline to 38% and 19% at described: augmentation with bone grafting, a high hip
15 and 20 years, respectively.103 center, or medialization of the cup.
Acetabular augmentation with structural grafting of the
Total Hip Arthroplasty deficient acetabulum in combination with placing the com-
ponent in its anatomic position has some desirable features.
Despite the availability the recent advances in joint-preserv- Autograft bone is readily available by using the patient’s own
ing techniques, many patients with hip dysplasia present femoral head, the hip center can be restored to a biomechani-
with advanced degenerative disease that is not amenable

AB

Figure 4 A 14-year-old male with neglected congenital hip dislocation (A). After proximal femoral valgus osteotomy and distal femoral
varus osteotomy with lengthening (B).

Bulletin of the Hospital for Joint Diseases 2014;72(1):28-42 37

Figure 5 Deficient acetabular bone may limit the surgeon’s ability abnormal hip biomechanics. The high hip center needs to
to place the acetabular component fully on native bone in the true be high and medial, or it will fail early.
acetabular region. A third alternative for acetabular reconstruction is
medialization of the acetabular component by internally
cally normal position, and bone grafting may increase bone overreaming or deliberate fracture of the medial wall of the
stock.117,118 There are also disadvantages to this technique, acetabulum.122,123 This technique provides increased lateral
including that bone grafting increases the complexity of coverage of the acetabular component by native iliac bone
the procedure, and when a large amount of the component and decreases joint reactive forces through medialization of
is supported by the graft, there is a risk of long-term graft the hip center of rotation. Its main disadvantages include the
resorption and collapse, leading to cup failure.119 loss of medial bone stock and the risk of early catastrophic
Purposefully creating a high hip center or placing the acetabular component migration.
component superiorly allows the component to be covered For the femoral component, a proximally coated mono-
more completely by native bone, which facilitates biologic lithic stem can be used in mild dysplasia. However, for more
fixation and avoids the need for bone grafting.120,121 It also marked deformities, extensively coated stems or modular
requires smaller acetabular components with thinner poly- stems may be required. Moreover, a subtrochanteric or
ethylene liners, does not increase acetabular bone stock, metaphyseal osteotomy may be required in more severely
affords a limited amount of leg lengthening, and leads to dysplastic cases. A subtrochanteric osteotomy allows both
shortening and correction of the rotational abnormalities
while preserving the metaphysis (Fig. 6).124-126 The resected
bone may then be used as an onlay autograft.
Several studies have addressed the outcomes in patients
undergoing total hip arthroplasty for hip dyspalsia.123,127-131
Pain relief in patients with hip dysplasia undergoing total
hip arthroplasty parallels the excellent results of total hip
arthroplasty in the general population.115,123,127-129 Notable
overall improvements in hip scores were also reported in
most series.127-131
Patients with very stiff hips preoperatively may have
residual postoperative stiffness. Functional results tend to
be excellent in patients with Crowe I and II dysplasia but are
less good in patients with Crowe III and IV disease. Patients
with Crowe III and IV dysplasia tend to have a persistent
limp with a waddling gait, as well as a higher rate of aseptic

AB

Figure 6 A, A patient with bilateral Crowe 4 hip dysplasia. B, Status bilateral total hip arthroplasties with modular stems and subtro-
chanteric shortening osteotomies.

38 Bulletin of the Hospital for Joint Diseases 2014;72(1):28-42

Figure 7 Flowchart of the approach to hip dysplasia in the skeletally mature individual.

loosening and mechanical failure than the general population 4. Felson DT. Risk factors for osteoarthritis: understanding
undergoing total hip arthroplasty. joint vulnerability. Clin Orthop Relat Res. 2004 Oct;(427
Suppl):S16-21.
Conclusion
5. Wenger DE, Kendell KR, Miner MR, Trousdale RT. Acetabu-
The treatment of hip dysplasia in adult patients is based lar labral tears rarely occur in the absence of bony abnormali-
on the degree of dysplasia and the amount of concomitant ties. Clin Orthop Relat Res. 2004 Sep;(426):145-50.
arthritis. Patients with mild dysplasia who are asymptomatic
can be observed. Those with mechanical symptoms alone 6. Clohisy JC, Beaule PE, O’Malley A, et al. AOA sympo-
can undergo arthroscopy with close follow-up. Patients sium. Hip disease in the young adult: current concepts of
with moderate to severe dysplasia and minimal arthritis are etiology and surgical treatment. J Bone Joint Surg Am. 2008
candidates for reconstruction. Those patients with moderate Oct;90(10):2267-81.
to severe arthritis can undergo a salvage procedure, such as
arthrodesis or pelvic support. However, a vast majority of 7. Murphy SB, Ganz R, Muller ME. The prognosis in untreated
these patients are best served with a total hip arthroplasty dysplasia of the hip. A study of radiographic factors that pre-
(Fig. 7). dict the outcome. J Bone Joint Surg Am. 1995 Jul;77(7):985-9.

Disclosure Statement 8. Engesaeter IO, Lie SA, Lehmann TG, et al. Neonatal hip in-
None of the authors have a financial or proprietary interest stability and risk of total hip replacement in young adulthood:
in the subject matter or materials discussed, including, but follow-up of 2,218,596 newborns from the Medical Birth
not limited to, employment, consultancies, stock ownership, Registry of Norway in the Norwegian Arthroplasty Register.
honoraria, and paid expert testimony. Acta Orthop. 2008 Jun;79(3):321-6.

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