174. Hip Dysplasia

In this episode, we defines hip dysplasia, review risk factors (female sex, breech birth, family history, etc), infant screening, adult presentation and functional testing, and outlines PT goals (pain-free motion, strengthening, activity modification) versus surgical consideration such as periacetabular osteotomy and its recovery expectations.

00:00 Welcome to PT Snacks
00:24 Podcast Schedule Update
01:50 Support the Show
02:12 Hip Dysplasia Explained
04:22 Who’s at Risk
06:25 Infant Screening Basics
08:15 Imaging and Measurements
09:47 Adult Signs and Testing
11:33 Physical Therapy Approach
13:31 When Surgery Is Needed
15:57 Wrap Up and Contact

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Transcript

Hey everyone. Welcome to PT Snacks podcast. This is Kasey, your host, and if you're tuning in for the very first time, what I want you to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals in bite-size segments of time. Now, today we're gonna be covering hip dysplasia and essentially what that is and how we assess for it, who can get this, all that good stuff. Uh, but before we do, I have a short announcement. PT snacks, I'm essentially gonna be taking this down to one episode every two weeks or. Two a month. And the reason why is not because I'm not enjoying making this podcast, but because I am in the process of several projects all at the same time, and it seems a little hypocritical for me to overextend myself versus spending all of my energy. To few things and doing as well as possible I can with those things. So with taking down the frequency of PT snacks, that just allows me more time to work on other things that I'd like to, that are in the works and still be able to deliver free content to people who want to learn from it, who want to invest in it. So I hope you understand. Will it be twice a month for forever? I don't know, uh, but we're just gonna do this for a season right now and see how it goes. If you have any strong feelings towards it, feel free. You can shoot me a message. Email me at pt Snacks podcast@gmail.com. But keep in mind, this is a one woman show. And I do everything and I also treat in the clinic, and I also have a whole separate continuing education business that I run. In addition to this podcast is essentially something that I like to do to serve my community and. Give content for free. So, uh, if you would like to support PT Snacks podcast in the future, you can do so in two ways. You can tell a friend about it. You can write a review technically. Okay, I have three. And the third thing is there is this. Support link where you can support the show, but do whatever seems right to you. And then, uh, yeah, we'll just keep on going with the show. So with all that being said, let's dive into exactly what hip dysplasia is and then go from there. So remembering that the hip is a ball and socket joint. Hip dysplasia is essentially a malformation of this joint in itself, so we can capture it in infants and we can also capture it if it was missed in adolescents and adults too. But a more specific definition that I have would be, it's a spectrum of structural abnormalities of the developing hip from mild acetabular shallowness to frank dislocation. Big spectrum there. It's common in infants and through grown adults and a major cause of early hip osteoarthritis and total hip replacement in younger adults. So essentially, this is where we're looking at an abnormal shape or a relationship between the acetabulum and the femoral head leading to instability. Maybe even subluxation or dislocation. It just depends on how big of an abnormality is there. But we are essentially looking at less stability in this hip. So in if infants and children, normal acetabular development depends on a ally. Reduced femoral head. Uh, subluxation and dislocation, impairs acetabular growth and leads to persistent dysplasia in if we're looking further along the lifespan with adolescents and young adults. A shallow or a mal oriented acetabulum can create some capsular laxity and with reduced weight-bearing surface, that can also cause increased joint contact stress. Which then can cause pain in, in some, potentially even some early onset osteoarthritis. So in summary, we're looking at an abnormal shape of the acetabulum and the femoral head and how they fit together in a way that is making the joint more unstable. In that instability is causing increased forces, which down the road can cause untreated more problems down the road. So. Who gets this? There are several risk factors, uh, that we can attribute to this now, in terms of hip dysplasia. This can happen in roughly two to five infants per 1000 live births. So it just varies by region and also screening method, right? If you have different screening methods, you may not report the same amount just depending on where you are. So keep that in mind. But there is some large cohort data that shows that even with people who have hip dysplasia that doesn't always necessarily mean if they have it, that it is symptomatic. So you can have this and be completely unaware of it and operate through life fine. We are treating the people who are symptomatic for their hip dysplasia. So strong risk factors are gonna be if they are female. The female to male ratio is like three to six per one. Uh, so pretty big difference there. If a child was born in a breach position, this is also a risk factor. Positive family history of this condition. And then there are many aspects in terms of, uh, pregnancy such as oligo Hinos is like reduced amniotic fluid. Um, associated deformities like clubfoot or torticollis are also additional risk factors. So if someone is coming in as an adult or an adolescent and they know their birth history or they're coming in with a parent who. Gave birth to them and was there, um, that's can be helpful information to glean from the people that are there. So many cases are still diagnosed late. Often after they're of walking age or even in early adolescence and adulthood. But we do know that a later diagnosis does tend to worsen outcomes 'cause it's just not quite as addressed. So let's go into, okay, well if a later diagnosis is not as great early diagnosis. Is probably something that we should get really good at for these people, right? So they have better outcomes. Let's start off as early as how this is detected in our infants and children. Then we'll go into adolescents. So in our infants and children, normal newborn screening usually focuses on instability maneuvers like Barlow and Ortolani tests. While Inc at birth often resolves, just as that child is growing. If there is instability found at that time, usually they're going to start some sort of immediate treatment. So after like two to three months of age, a limited hip ab abduction, ab deduction becomes the most important clinical sign. So with regards to Barlow and Ortolani test. Those are what I mentioned before, essentially I won't go into large detail on these, but these are very commonly used in infants and essentially it's just testing for hip instability. 'cause that's what the screen is for. So a meta-analysis actually showed that Barlow and Alani have low sensitivity, like around 36%, but high specificity. So around 98%, which is pretty good. As a reminder with specificity, this just means that if we are doing a test for a particular condition and that test is positive, we can be pretty confident if it is of good specificity that the condition we are testing for is there. Sensitivity is where we're essentially trying to rule things out. Now other tests. That have have been tested for sensitivity and specificity. Limited hip abduction has sensitivity of around 45% and specificity of 90, 78%. Combining all of these tests together actually improves sensitivity to 57%. So it's better. And we know that a combination of tests tend to help our accuracy. Um, but imaging can also be really helpful in this scenario. So ultrasound is typically preferred before four to six months. Um, selective ultrasound is recommended for abnormal exams, uh, or high risk infants. So remember someone who had a breach birth or has a family history of this condition. Pelvic radiographs are also really helpful. Um, and those are usually taken after ossification around four to six months of age and into childhood. Now some of these measurements that are taken on are radiographs would include things like the lateral center edge angle. So if it's less than 25 degrees, they're considered dysplastic. Uh, this is a pretty crucial radiographic. Measurement to help evaluate how much bony coverage of the formal head by the ace, tablum or hip socket there is. So if there is less coverage, less stability, more dysplasia, um, the tous angle is also a common measurement that is utilized. Again, it's, basically the angle between the horizontal line, teardrop to teardrop and a line tangential to the acetabular roof. Greater than 10 degrees is considered dysplastic. They also will look at things like femoral head lateralization, uh, extrusion index acetabular depth and width ratio. Essentially the whole goal of all of these measures is to see if there is more instability of this joint, less as tabular coverage that sort of. Now in terms of testing, this kind of depends on how old that patient is. 'cause testing for an infant's gonna be a little different than testing for an adult, as you can imagine. So in young adults who have symptomatic dysplasia. We find that in those patients, they tend to have a slower, self-selected walking speed. A slower sit to stand test, a slower four square. Uh, step test, slower stare, ascent compared to controls who are asymptomatic. So those are some tests that you could look at, uh, just depending on what is appropriate for their functionality. These also strongly correlated with patient reported outcomes like. The whos, and there's all sorts of hip tests that are out there. For adults, essentially we're gonna be looking at their range of motion, especially their abduction and internal rotation. Um, is there pain with this? Is there a difference between their active range of motion and their passive range of motion? What's their strength like? Do they have good strength in their hip abductors, their external rotators extensors. And gait. Do they have antalgic gait? Do they have a trendelenberg compensatory trunk lean, et cetera. And then you can look at the functional test that I mentioned before. What are they having issues with? Let's see what they look like. Do they have issues with stairs going up and down? Well, let's look at that functional sit to stand. We can do that test, multi-directional stepping, walking, speed, all those things. But this pain characteristically tends to have groin or lateral. Hip pain, instability and fatigue with prolonged standing and walking. So they would be positive for any tests that we do that are stability related. Now, there are several tracks that a patient can go through. So depending on the level of instability, that can have a factor on how well they do with physical therapy versus surgical options, which we'll talk here about in a minute. But in terms of. Pt. Our goal is essentially to best that we can, if they are having instability issues, create a sense of stability. So we're trying to improve pain-free motion wherever it is lacking, and strengthen all the muscles that are around that hip joint. So hip abductors, extensors, deep rotators, trunk, and public control. We're not trying to crank on their hip at end range. We're trying to create a healing environment, and so we are trying to meet their body where it's at, and maybe even try and create some factors in their environment where we can reduce excessive aggravation. So things like avoiding repetitive deep flexion of the hip. Uh, high impact loading extremes that provoke instability, weird positions like that. Um, the more that we can do that and reduce aggravation, the better the hip is going to be able to respond to our strengthening program and try and create more active stabilizers around that joint because the passive stabilizers are lacking. Okay. So in a broader systematic review of non-operative treatment for hip related pain, including dysplasia, so there were other types of hip pain. In this study, they found that 54% found satisfactory response, but optimal PT in terms of what exact exercise routine they gave. It's pretty unclear. So there's not a specific top five exercises to help with hip pain, although there's probably some overlap. Right now it's probably best to look at the patient in front of you and see what they need and try and build a bridge of where they are now and where they're trying to go in terms of their activity level or tolerance to different activities. So in a scenario where maybe that patient is not responding to physical therapy. This is someone where they may need a surgical procedure that helps to create more stability around the joint. One surgery in particular that's very common for this condition would be a per acetabular osteotomy. So PAO for short. And that's gonna be what I use moving forward in the rest of this episode. But essentially this is utilized to, this is kind of the gold standard for preserving. Hip preservation in adults with this. Now this surgery, I'm not gonna cover the surgery itself in today's episode, but if you've never heard of this before, this is a pretty involved procedure that the patient is going to go through. I would invite you to find a YouTube video on the procedures of how this is done. Um, just to grasp what, if you are seeing these patients, what they're going through. Um, because the recovery time is not quick. There's often a period of time where. Well, every protocol I've ever seen has a period of time where there's a limited amount of weight bearing, uh, whether it's toe touch or non-weight bearing, et cetera. Um, that patient is trying to allow that joint area to heal before we are able to put our full weight through it. And then. They're trying to activate all the muscles around it and prepare their selves for being able to walk, being able to squat, be able to do single leg strength, and then eventually more return to sport activities. So a lot of patients do really well with this, but uh, it is quite the ordeal that these patients have to go through. You just wanna be forthcoming in terms of building those patient expectations on what to expect. What's this gonna look like? What do they need to, uh, tell their workplace environment? Uh, what do they need to communicate with their family, especially if they are responsible for any. Chores, tasks, et cetera, that are activity related. So make sure you talk to 'em about that. But the more that we can recognize when someone is gonna do well with PT versus maybe they need another opinion and another specialty, the more quickly we can guide that patient through our medical system and get them the outcome that we want to. So. All that to be said. What you should have learned from this episode is what is hip dysplasia, how is it screened, and what do we do about it, whether it's PT or surgical options. If you have any questions, feel free to reach out at PTs Snacks podcast@gmail.com. I am also on Instagram at PT Snacks podcast. No, I don't solve vending machines snacks. So if you're looking at that page, it is not me. There is also an email list that you can get plugged in with and, um, and I've started a YouTube channel and a TikTok, so lots of ways to get in touch with me if you want to. But also just let me know if there's any topics. Topics in particular that you'd like me to go over in the future, and I'd be happy to do so to the best of my abilities as long as it's around. Um, as long as it's centered around physical therapy, uh, orthopedics and sports outside of that realm, I'm not in, that's not in my specialty. So I hope you guys have a great rest of your day, and until next time.