Hip dysplasia in a young woman: How should I treat?

20th February 23

Hip

PAO (periacetabular osteotomy)

A 24-year-old female patient presents with hip pain. Pre-op X-rays reveal total lysis of the shelf: What causes the patient's symptoms and how would you manage this condition?

Nicolas Reina

CHU, Toulouse, FRANCE

Chairman & Course Director

Professor Reina is Head of Hip and Trauma department, of the University Hospital in Toulouse, France. He holds a PhD in Anthropobiology. He completed a fellowship in Oxford, UK and worked in Mayo Clinic, Rochester for research.

His main focus is hip & pelvis surgery. His clinical practice comprises conservative surgery, primary and complex revision total hip arthroplasty as well as trauma for complex acetabular fractures.

Board member of French Hip Knee Surgery, he is also member of the European Hip Society and the International Board of the American Association of Hip Knee Surgeons. He published more than 150 peer reviewed publications and book chapters, and lectured in various international conferences. His research interests integrate big data in orthopedics, modern care in hip surgery such as minimally invasive techniques, and musculoskeletal system’s ability to adapt to its environment (biomechanics and anthropological variability).

Part one

Clinical presentation

24 Y.O. female
Index surgery: a hip shelf acetabuloplasty was done 5 years ago because of disabling pains during sports activities. The screw was removed 4 years ago because of inconvenience but she reported no pain at the time.

X-ray after index surgery

Her complaint is now pain despite a complete range of motion
On physical examination, she presents with positive FADIR and FABER tests.

Current pre-op X-rays: A total lysis of the shelf is observed

Part two

What are the causes of the patient’s symptoms?

Hip dysplasia ✔️
Coxa plana due to a Legg-Calve-Perthes disease ✔️

Was the index surgery a good option?

Yes, it has been shown to be a surgery with good results¹ ✔️

How would you manage this condition?

Peri-Acetabular Osteotomy ✔️

« Modern total hip replacement remains an excellent option for the more arthritic joints »^2,3

What are the indications for PAO⁴?

Acetabular retroversion and anterior over-coverage ✔️
Lateral centre edge angle (LCEA) < 22°✔️
Acetabular index: >14°✔️
Extrusion index: >27%✔️

Final strategy decision: Peri-acetabular osteotomy

Unfortunately, the patient presented with a non-union of the peri-acetabular osteotomy. A good consolidation was obtained with iliac bone autograft.
The patient is now free of pain with a complete range of motion.

References

^{1 Terjesen T. Residual hip dysplasia: is there a place for hip shelf operation? J Child Orthop. 2018 Aug 1;12(4):358-363. doi: 10.1302/1863-2548.12.180042. PMID: 30154926; PMCID: PMC6090190.}
^{2 Gala L, Clohisy JC, Beaulé PE. Hip Dysplasia in the Young Adult. J Bone Joint Surg Am. 2016 Jan 6;98(1):63-73. doi: 10.2106/JBJS.O.00109. PMID: 26738905.}
^{3 Kim CH, Kim JW. Periacetabular osteotomy vs. total hip arthroplasty in young active patients with dysplastic hip: Systematic review and meta-analysis. Orthop Traumatol Surg Res. 2020 Dec;106(8):1545-1551. doi: 10.1016/j.otsr.2020.08.012. Epub 2020 Nov 12. PMID: 33189660.}
^{4 Ahmad SS, Haertlé M, Konrads C, Derksen A, Windhagen H, Wirries N. The Scientific Evolution of Periacetabular Osteotomy: A Global Review. J Clin Med. 2022 Oct 17;11(20):6099. doi: 10.3390/jcm11206099. PMID: 36294420; PMCID: PMC9604972.}