Pelvic Osteotomy for Acetabular Dysplasia Clinical Presentation

Updated: Sep 22, 2017
  • Author: Dinesh Thawrani, MBBS, D'Ortho, DNB(Orth), MNAMS; Chief Editor: Jeffrey D Thomson, MD  more...
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Presentation

History

The symptoms of acetabular dysplasia are directly related to its severity. Patients with mild acetabular dysplasia may remain pain-free until the fourth or fifth decade of life, or they may experience only vague discomfort with strenuous weightbearing activities, particularly during the most productive years of their life. In the mild forms of pain-free acetabular dysplasia, abductor lurch or a limp is the only presenting symptom. Patients with severe acetabular dysplasia begin to experience pain in the second decade of life.

The patient’s activity level, functional status, and expectations are also contributing factors in the genesis of the symptoms. For instance, a severely dysplastic acetabulum in a nonambulatory cerebral palsy (CP) patient may be asymptomatic, whereas mild dysplasia in an adolescent athlete may be painful and may limit the activity level significantly. Thus, characterization of the patient’s symptoms should be individualized and should be correlated with the pathology underlying the residual acetabular dysplasia.

Lateral abductor-fatigue pain should be differentiated from anterior groin pain that is intra-articular in origin and indicates joint overload, with possible labral pathology or cartilage damage; the onset of degenerative changes is expected in such cases.

In deciding whether to reduce the hips, a distinction should be made between a patient who presents later with a unilateral dislocation and one who presents with bilateral hip dislocations. There are differences in the long-term health of the hip: Bilateral dislocated hips tend to have better function without symptoms into adulthood, whereas a unilateral dislocation is more likely to have significant disability. In general, reduction of a unilateral hip dislocation is recommended up to 6-8 years of age; bilateral dislocations are more likely to be left alone at that age.

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Physical Examination

Physical examination starts with assessment of the patient’s gait. Any obvious limp or abductor lurch should be documented. A positive Trendelenburg test result (ie, dropping of the opposite pelvis with single-limb stance) indicates relative incompetence of the abductor mechanism, either from disuse atrophy secondary to pain or from a laterally displaced hip joint center requiring greater hip abductor muscle function. Extremities should also be carefully examined for muscle wasting and limb-length discrepancy.

Any abnormal limitation of rotational, sagittal plane, or coronal plane motions should be documented appropriately. Joint contracture, lower lumbar spine status, and pelvic obliquity should be assessed carefully. Significant pain with active or passive range of motion of the limb reflects synovitis or cartilage injury and should be documented correctly. The impingement test should be performed by means of hip flexion followed by adduction and internal rotation to assess the abnormal femoral head neck offset or labral damage. [21]

Further radiographic confirmation of the underlying cause of a positive anterior impingement test result can be obtained through magnetic resonance arthrography. This documentation is essential for finalizing the treatment protocol, in that a positive impingement test result is highly sensitive for diagnosing labral pathology that may be due either to overload that is secondary to a deficient anterior wall or to impingement that is the precursor of osteoarthritis. [14, 22]

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