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Travis Matheney, MD, MLA
Orthopedic surgeons may have questions about how to counsel patients with hip dysplasia prior to periacetabular osteotomy (PAO surgery). Patients — typically active teens and young adults — may wonder about their outcomes after surgery, particularly their expected activity level, quality of life and time to total hip replacement.
In this 15-minute video, Dr. Matheney summarizes multiple clinical studies that review these outcomes and provides information about patient satisfaction for PAO surgery.
An expert team from Boston Children’s Hospital’s Child and Young Adult Hip Preservation Program hosted a conference in 2014, where they shared the latest practices, research and innovations in the causes and treatment of hip pain. Topics included surgical and non-surgical approaches to hip pain, imaging considerations and special considerations for athletes.
Watch the following videos in the playlist below.
• Non-Surgical Approach to Hip Pain - Andrea Stracciolini, MD
• High-level Athletes & Return to Play Criteria - Mininder Kocher, MD, MPH
• Arthroscopic Interventions in Hip Pain - Yi-Meng Yen, MD, PhD
• Peri-articular Hip Problems - Pierre d'Hemecourt, MD
• Open Surgical Considerations with Hip Pain - Young-Jo Kim, MD, PhD
• Natural History of Hip Problems - Travis Matheney, MD, MLA
Developmental dysplasia of the hip (DDH), or hip dysplasia, is the most common cause of hip problems in children. It also has been at the center of two controversies in the last several years.
The United States Preventive Services Task Force in 2006 concluded there was insufficient evidence to recommend routine screening of all infants for DDH. A recent decision analysis study, conducted at Boston Children’s Hospital, suggests that with universal screening and selective ultrasound screening of some infants for DDH, there is less chance of the hip becoming prematurely arthritic.
Ultrasound screening can be ordered by the primary care provider and should be targeted to infants with a family history of hip dysplasia and breech babies or those with any clinical suspicion of hip dysplasia on physical exam. The ultrasound exam should be performed at approximately 6 weeks of age, if the hip is stable, because exams performed earlier than 6 weeks have a fairly high false-positive rate.
If ultrasound findings are questionable or positive, the child should be referred to an orthopedic surgeon.
The second controversy relates to swaddling, which is recommended as a way to soothe infants. However, infants should be swaddled at the torso level only, as swaddling the legs can increase the risk of hip dislocation. Earlier studies looking at cultures that swaddled their children had made this connection. Providers should teach new parents how to safely and appropriately swaddle infants.
The conventional treatment model for correction of residual hip dysplasia after initial treatment has been to perform an osteotomy before the patient reaches maturity. But some orthopedic surgeons, like Young-Jo Kim, MD, PhD, now recommend a wait-and-see approach.
Approximately 20-30 percent of patients treated for developmental dysplasia of the hip (DDH) present with x-ray signs of residual dysplasia during childhood. However, some of these children, who range in age from 3 to teenage, are clinically stable and lack symptoms of dysplasia such as pain with prolonged walking or running. “It’s not a small problem,” comments Boston Children’s Hospital orthopedic surgeon Young-Jo Kim, MD.
Kim outlined the wait-and-see model during a debate at the Pediatric Orthopedic Society of North America meeting in May 2014, while a colleague espoused early action for children who present with x-ray evidence of dysplasia.
The debate focused on the question: Can surgeons postpone osteotomy until maturity, when the deficiency in the acetabulum is certain?
“It’s technically easier to perform the surgery when patients are younger, but to some extent the surgeon is over-treating, because she is projecting into the future,” says Kim.
In contrast, surgery at maturity is more complicated, but x-rays acquired at maturity will show clear evidence of deficiency in the acetabulum.
This modest shift in treatment has occurred because some orthopedic surgeons have developed techniques to perform the surgery in adolescence and adulthood.
While it’s important for pediatricians to be aware of the new option, it’s critical to remember that all children with DDH should be followed on a regular basis by an orthopedic surgeon, says Kim. Patients who were braced should be followed until 4 or 5 years of age, and those treated surgically should be followed until maturity, says Kim. “We want primary care providers to know that if we miss the window of treating at age 7 or 8, patients can be treated as adults. However, we don’t want them to disappear completely and return as an adult with arthritis,” says Kim.
The future of pediatrics will be forged by thinking differently, breaking paradigms and joining together in a shared vision of tackling the toughest challenges before us.”