Name: How Much Dysplasia is Too Much?
Uploaded: 2016-07-19T00:00:00Z
Channel: Arthrex

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VPT1-00676-EN | A | How Much Dysplasia is Too Much?

Bryan Kelly

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How Much Dysplasia is Too Much?

Question is how much dysplasia is too much for arthroscopy? And Tom touched on this a little bit. I think in general, hip arthroscopy indications have greatly expanded over the last decade. It's generally considered to be indicated for the treatment of symptomatic dysplasia, depending on what your definition of dysplasia is. I think it's become less and less controversial as an adjunct to the acetabular osteotomy. So we're doing more and more combined scope to address the intra-articular pathology. There's a big question of the indication when you have a combined complex deformity, which includes impingement and dysplasia, and you're trying to figure out what the primary mechanical deformity is. But the big question is what is the indication in quote unquote, borderline dysplasia. So I think the borderline dysplasia is a is a term that I'm trying to get away from using. It's the morphology that is too mild for an open surgical correction and maybe too unpredictable for arthroscopy. But a universal definition of borderline dysplasia doesn't really exist, and I think we should really abandon it and come up with Definitiv mechanical treatment, diagnosis, diagnoses that are determined prior to the surgical indications. If a patient has structural instability with or without classic radiographic findings, arthroscopy should be approached with great caution. Is the is the general conclusion I would make. But I think we do have to look at this a lot more closely than just that general feeling. The consensus is that over the long term, in dysplastic hips, the mechanical overload is not fixed, and thus the labral injury cannot really be corrected without without a high risk for reinjury. It's very clear that labral excision in the setting of dysplasia has a high likelihood of rapid deterioration of the hip joint, as the labrum is functioning as a stabilizing structure in the joint. And there is some question as to whether failed arthroscopy prior to Pao may have an effect on the patient outcome compared to a Pao as a primary procedure. So are we doing some harm to a patient if we try a scope in the borderline one first and then and then convert it to a Pao. So I'm going to suggest that Suggests that there are some what I consider to be good indications for arthroscopy in the setting of radiographic dysplasia. And then there's some questionable ones. The first is combined radiographic pattern of dysplasia and impingement when the clinical exam is consistent with primary impingement. And this is a patient. This was a the time I saw her. She was a 18 year old tennis player who had a center edge angle of about 15, had an alpha angle, but she had no internal rotation across her hip joint and only started to develop symptoms in a flexed position when she changed her stance when she was playing tennis and she had no symptoms of instability in her clinical exam. And we went and did a arthroscopic osteoplastic of that neck. And she did well. This is a four year post-op. She went on and played four years at college and continues to do well from it. So I think if you can, if you can really confirm based upon your clinical exam that the dysplasia may be radiographic finding, but it's not a clinically relevant mechanical problem, and they do have impingement that can be treated. I think that's a reasonable indication for it. The second is this is what we see more commonly in the male athlete, particularly male hockey players, where a Cam lesion is present and there's dysplasia, but the dysplasia is not the primary mechanical problem because really the head is just too big for the socket. This is a hockey player with a center edging of 11 degrees alpha angle of about 85. And we went and treated his impingement primarily never, never did anything with dysplasia. And he's five years out from this and continues to play hockey at a very high level. So I think this is one if you again, if you're looking at these and say what is the reason for the shallow socket? Is it because the head's too big for it. And it's not really because it's an unstable hip? So what about potential indications with mild dysplasia, when the lateral center edge angles between 20 and 25, or maybe even 18 and 25, without secondary soft tissue changes, that would suggest there is not static overload or instability, such as a hypoplastic labrum, hypertrophy of the iliac capsularis and the abductor mechanisms and snapping of the iliopsoas and the IT band for dynamic stabilization. So what do we do in that in that category? And what's the role for it as an adjunct to POW? I think if the primary mechanical problem is static overload, then instability is really a concern for you. Then arthroscopic treatment of any intra-articular derangement from overload is unlikely to have any lasting benefit unless you're doing it in conjunction with a POW. So if you if you really believe clinically that the instability is the problem, isolated arthroscopy is not a good solution. So I want to talk a little bit more about this concept of borderline dysplasia, because it's not always obvious in a clinical exam you might say, well, impingement hurts in the front when you sit. Dysplasia. Instability hurts out laterally when you walk. But you have somebody who says, well, do you hurt when you sit or when you walk? And they said, it hurts all the time. And so you really don't know what their problem is. They have limited internal rotation, but they have some snapping out in the outer aspect of their hip. So there are there are many patients who have a combined complex pathology. And we really need to sort this out before we make treatment recommendations. I know she's talked a little bit about this, but I want to talk about this more morphological matrix in the context of the decision making for borderline dysplasia. And we went through over 1000 patients and tried to identify very specific ways to look at the lateral center edge angle, the alpha angle and femoral version to try to determine whether patients were primarily unstable or primarily impinging. And I think if you look at patients like this and correlate it with their clinical exam findings, you may be able to tease out which patients can get. You can get away with arthroscopic procedures. So this is the matrix that was developed basically came up with four categories for center edge angle four for alpha and three for femoral version. And if you look at it, if you have a low center edge angle, a spherical femoral head, an excessive femoral version, we would categorize that as A111. And those are unstable hips. These have shallow sockets high angles oftentimes anteverted valgus hips. These are they have a lot of motion. When you examine them on clinical exam they hurt when they walk. These I think are very very unusual patients to be a good candidate for an arthroscopic procedure because they're truly an unstable hip. And this and this. You probably find some secondary fine findings on their MRIs suggestive, suggestive of soft tissue compensation to try to help stabilize the hip dynamically. Conversely, if you have a highly impinging hip so a large center edge angle, a deep socket, a large alpha angle greater than 80 degrees, and femoral retroversion, these are these are tightly over contained hips. And these are these may also may not be a candidate for an arthroscopic procedure because it's too much impingement to adequately address arthroscopically. And this really is dependent upon your skill set as to how how much of these you want to get involved in. Then you've got the the sort of the sweet spot and what I would consider the arthroscopic safe zone. Your three three to's the 3223, three twos. These are the ones that are perfect there anteriorly located cam lesions. A little bit of over coverage maybe in the sub spine region, but a stable hip with with focal impingement. And this if you can focus your practice on this group of patients I think you'll find that you'll have a have very successful outcomes. When we looked at our the categories of patients that we that I treat in my practice in this, in this series of 1004 categories represented 50% of the cases. So we really spent a lot of time in that arthroscopic safe zone. And although I don't think we had any one on ones, we had a couple of one two twos and ones that were a little bit more unstable. But just in terms of the demographics of it, this teases out the ones that you that you want to focus on arthroscopically and and you really want to stay away from the unstable ones as best you can. The most common one that we saw was a three, three, two. So that's a normally contained socket, maybe some focal retroversion under the sub spine region, a moderate sized alpha angle between 65 and 80 and femoral version between 5 and 25. So again this is kind of the perfect hip to to treat arthroscopically. The second one is the second most perfect hip. And if we looked at it through around how it was distributed, again, 75% of them represented were represented in 15 different categories, all away from the unstable hip. And I think the take home message here with regard to dysplasia is we really want to try to avoid the unstable hip when it comes to arthroscopy. This is another way of looking at how the frequency distribution based upon center edge angle less than 18 and greater than 40. So the over contained and the and the shallow sockets represented only a small percentage of the patients that we treated. Arthroscopically. And if we did treat them Arthroscopically, there were specific reasons based upon their clinical exam why we thought that was okay. The distribution between males and females in my practice is almost 60% males versus 40% females. And I only include this because the female population tends to have a higher degree of instability associated with it, and even in the setting of relatively normal bony coverage and bony stability, there may be some soft tissue laxity that makes them an unstable hip even when they don't look like they're unstable based upon their mechanical parameters. If we look at the outcomes in these based upon the morphological matrix, we saw a good improvement of over of approximately 20 points in all categories. But what you'll notice, there's an absence of unstable hips in these categories. So we don't we don't have enough patients to even look at. And the unstable population and based upon the most frequently occurring outcomes, the hot 33 showed similar improvements in symptoms. So when we look at this matrix in terms of trying to come up with an algorithm as to who should we be treating when it comes to these borderline dysplastic ones, I think we can it can more objectively allow us to quantify who's unstable and who's got dysplasia. 90% of our arthroscopic procedures fell within 17 different matrices. The most common ones were the the moderately impinging ones. We had very low numbers of unstable ones. And I think we currently need more data to prove that certain mechanical matrices are at a higher risk for failure. But we have low numbers in this instability group. So this is really based upon clinical selection process. Ultimately looking at differences between groups for outcomes that ultimately will help treatment recommendations is what we're trying to achieve. Isolated arthroscopic management of non arthritic hip pain requires a detailed knowledge of underlying mechanics and precisely defining the mechanical diagnosis. In my opinion, is critical to determining treatment options and appropriateness of hip arthroscopy. Dysplasia is a particularly challenging one because there's a lot of overlap with dysplasia and impingement. So I think you really have to look at your clinical exam closely with your mechanical and radiographic diagnoses. But I think you should really shy away from these highly unstable hips, the one on ones and the one one twos. And focus your practice in the in the moderate impingement group. And we're currently looking at outcomes based upon this morphological matrix to try to have some more objective proof that these unstable hips really are more challenging.

How Much Dysplasia is Too Much?

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