Focus On

Acetabular dysplasia in adults

Introduction

Pathology

Interest in acetabular dysplasia in adults has increased as its surgical treatment has advanced and as the understanding of young
adult hip disorders has grown. It is an important cause of hip
pain, often affecting young women at a time when they must be
active for employment, parenthood and sports and leisure activities. Symptoms may be experienced for many years before osteoarthritis develops, and it is important that an accurate diagnosis
is made so that treatment opportunities are not missed.1
Acetabular dysplasia describes an underdeveloped or shallow, upwardly sloping acetabulum, which may occur with varying
degrees of deformity of the proximal femur such as excessive
femoral neck anteversion, coxa valga or femoral neck cam
deformity. Historically, developmental dysplasia of the hip (DDH)
was thought to occur in 1 in 1000 live Caucasian births,2 but the
criteria for its definition are controversial. The number that will
require treatment can be as high as 5 in 1000 live births.3,4
The condition may be the result of in utero positioning, with
hip flexion and adduction stretching the posterior hip structures.
This results in a spectrum of disorders from neonatal hip instability, joint subluxation and frank dislocation, through to adolescent and adult dysplasia. Risk factors for hip dyplasia include
joint hypermobility, a large neonate,5 or small uterus, when there
is an increased risk of DDH to the first-born child.6
A breech presentation increases the risk of DDH to more than
40%; even after normal ultrasound screening the risk is 29%.7
Children, particularly daughters of fathers with DDH, have
12 times the risk of developing the condition themselves.8,9
While these risk factors, or a history of childhood dysplasia, may
be present in adolescent or adult patients, at least 40% of cases
with DDH have no identifiable risk factors.10
DDH more commonly affects the left hip and more than 80%
of cases occur in females.6 The deformity is bilateral in 40%,
with varying severity on either side.11 It is also important to
appreciate that not all acetabular dysplasia is due to DDH. A concave acetabulum cannot develop without a concentric force
being exerted by a reduced femoral head. Acetabular development may be affected by a variety of conditions including
cerebral palsy, hereditary motor and sensory neuropathy, poliomyelitis, hyperlaxity, and Down's and Ehlers-Danlos syndromes.
Skeletal dysplasias, proximal femoral focal deficiency and
Perthes' disease can also affect acetabular development, while
the triradiate cartilage can be injured by sepsis or trauma, which
can also cause incomplete lateral acetabular growth.

In a dysplastic socket, the acetabular labrum hypertrophies in

response to the increased load experienced by the front of the
acetabulum in order to improve femoral head coverage and
maintain joint lubrication. This labral hypertrophy can be
remarkably successful at maintaining the mechanical equilibrium and preventing symptoms until adulthood. Eventually, in
response to the higher level of stress, the anterosuperior
labrum tears. The articular cartilage is exposed to forces above
its normal tolerance and symptoms develop.12 In a similar process to that which causes subchondral cysts, the damaged
labrum may act as a valve, leading to the development of ganglion cysts. Dysplasia should always be considered when cysts
are seen on magnetic resonance imaging (MRI). A stress fracture may also develop at the periphery of the acetabulum producing an 'os acetabulare'.
Restoration of the biomechanical environment can prolong
the life of the articular cartilage, provided that it is not irreversibly damaged.13 It thus seems logical that surgical correction
should not be delayed once symptoms have developed. It
should, however, be noted that some patients only display symptoms once the hip has developed significant osteoarthritis and
there may then not be the opportunity for surgical correction.
Corrective surgery on asymptomatic adults is not justified, as the
onset and progression of osteoarthritis in dysplastic hips is
unpredictable in the absence of subluxation.14

Clinical assessment
Patients describe a sharp, activity-related groin pain, which
increasingly affects their lifestyle. Initially, it may only affect running and sporting activities but, as symptoms progress, travel,
employment, childcare and even sedentary activities may be
affected. The onset of pain may be insidious. Alternatively, it may
start acutely after a period of increased activity, such as racetraining or following an active holiday. Pregnancy and weight
gain may also cause a dysplastic hip to deteriorate.
Symptoms may be exacerbated by rising from a seated position, climbing in or out of a car, going down stairs, or sudden rotational movements. These symptoms arise from the anterior
labral tear and adjacent articular cartilage damage and, therefore, are very similar to those of femoroacetabular impingement
(FAI). Instability, weakness, the feeling of a 'dead leg', and trochanteric symptoms because of abductor dysfunction may be
additional features of the dysplastic hip. Patients may also

2010 British Editorial Society of Bone and Joint Surgery

S. STURRIDGE, M. J. K. BANKES

describe clicking at the front of the hip, commonly originating

from the psoas tendon.
Clinical examination may be surprisingly normal, although
symptoms can usually be recreated by internal rotation and
adduction of the flexed hip - the impingement sign. Other signs,
such as an antalgic gait or a Trendelenburg sign, may only
develop after activity. Shortening of the affected side may indicate subluxation, osteoarthritis or previous femoral osteotomy.
Mild femoral overgrowth may also be present, and failure to identify this pre-operatively may lessen the effectiveness of acetabular correction, as the patient may stand with their longer leg
adducted and continue to overload the lateral acetabulum; this
is so-called long-leg dysplasia.
The range of movement of the hip is often preserved,
although internal rotation in flexion may be painful. A reduced
range of movement may indicate osteoarthritis. Instability may
be demonstrated by apprehension on external rotation of the
extended abducted hip. There may be additional signs of previous hip surgery, hypermobility, or underlying neurological
disorder. In cases of gross uncovering, the femoral head may be
palpable in the groin the lump sign.

Imaging
A standing pelvic radiograph remains the most useful investigation to diagnose dysplasia.15 The lateral centre edge (LCE) angle
is considered normal above 25, borderline between 20 and
25 and dysplastic below 20; the Tnnis (sourcil) angle is
abnormal above 10. Murphy, Ganz and Mller16 have shown the
importance of these measurements by demonstrating the poor
prognosis of patients with an LCE angle less than 16 and a
sourcil angle greater than 15.
The false profile view, also taken with the patient standing,
provides a true lateral view of the acetabulum. It may show anterior subluxation and anterior deficiency, as measured by the
anterior centre edge (ACE) angle, which has a similar normal
range to the LCE angle. A functional pelvic view, taken supine
with the hips in maximum abduction and with internal rotation,
can demonstrate incongruence or a reduction of subluxation.
Early degenerative change, cysts and acetabular and femoral
version can be demonstrated on computer tomography (CT)
scans. Three-dimensional CT reconstructions can be useful for
analysing the deformity in cases of previous pelvic surgery and
for identifying the cam on the anterior femoral neck. MRI can
reveal labral cysts as well as excluding other sources of hip pain
not demonstrated on radiographs, such as stress fractures or
avascular necrosis.
Magnetic resonance arthrography (MRA) may have greater
precision in the diagnosis of labral tears and in assessing the
condition of the articular cartilage - it is seldom necessary in routine cases of dysplasia. The modality of delayed gadoliniumenhanced MRI of cartilage (dGEMRIC) is sensitive to very early
cartilage degeneration, and can be useful for identifying poor
candidates for pelvic reorientation.17 If doubts persist about the
condition of the articular cartilage, a more accurate assessment
can be made with arthroscopy.

Treatment
It seems obvious that reorientation of the acetabulum to normalise joint-contact pressures would be most appropriate treatment, providing degenerative changes are not too advanced.
Fortunately, dysplastic hips often become symptomatic well
before arthritis has developed. Peri-acetabular osteotomy (PAO)
is a very powerful means of relieving pain, improving or normalising function, and delaying or even preventing arthritis completely.18 When performed in specialist units, it is safe,
predictable surgery which can be performed without allogeneic
blood transfusion in three hours or less, and in under 90 minutes for minimally invasive techniques.19
Corrective surgery should be offered when it is apparent to
both the patient and the surgeon that symptoms are progressive
and are not going to improve with conservative treatment. This
requires careful judgement, and patients should be referred
early. Even if an osteotomy is not required initially, it gives the
patient an opportunity to become familiar with the procedure
and the specialist institution, as well as to meet patients who
have had the procedure. While the initial presentation may be
acute and largely self-resolving, the situation seldom returns to
normal, and often deteriorates. It is also important to appreciate
that the aim of an osteotomy is prevention rather than cure, and
therefore the level of symptoms required to justify an osteotomy
is less than that required for arthroplasty.
In cases of mild dysplasia, hip arthroscopy is occasionally
used to treat labral pathology. However the results are unpredictable and may lead to a worsening of symptoms, as the stabilising
effect of the labrum may be lost. Arthroscopy may be used to
assess the joint before an osteotomy.20 Femoral osteotomy is
seldom used in isolation where PAO is available as it is less effective, does not address the main deformity, and complicates subsequent total hip replacement (THR). It can, however, be an
additional procedure in the presence of incongruence or severe
femoral deformity. THR remains the most appropriate treatment
for the painful, arthritic, dysplastic hip, and the results are
uncompromised by a previous PAO.21
Sabastian Sturridge BSc, MSc, FRCS (Orth), Hip Fellow
Marcus J K Bankes BSc, FRCS (Orth), Consultant Orthopaedic Surgeon
Department of Orthopaedics, 1st Floor, Bermondsey Wing,
Guy's Hospital, Great Maze Pond, London SE1 9RT
Correspondence to Mr Bankes: marcus@bankes.org.uk

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