Hip Pathology of the Young Adult
There are two hip pathologies that most frequently affect the young adult and which knowledge is necessary to establish a diagnosis of suspicion and request the complementary tests necessary for its confirmation.
- Femoroacetabular syndrome
- Hip dysplasias
The mechanism responsible for non-dysplastic hip osteoarthritis has been unknown for many years. However, there are clinical evidences that relate the femoroacetabular impingement with an early hip arthrosis.
The femoroacetabular syndrome is a conflict that occurs between the proximal femur and the acetabular rim, due to morphological abnormalities affecting the acetabulum, the proximal femur, or both. The repeated mechanical conflict occurs during movement, particularly internal flexion and rotation, which can produce lesions in the acetabular labrum, and even more serious at the level of the adjacent acetabular cartilage.
Types of Femoroacetabular Syndrome
There are two types:
The first, called the CAM type, is caused by an abnormality of the femoral head, a bulge or hump in the transition area between the femoral head and neck, and which in the bending movements hits the anterosuperior edge of the acetabulum, causing an injury in the articular cartilage of the acetabulum and in the acetabular labrum.
The second type is the so-called PINCER, in which the femoral head is morphologically normal and it is in the acetabulum where there is the alteration that causes the conflict. This alteration can be of two types, an overall overcoverage of the femoral head or deep coxa, or else an anterior overcoverage of the femoral head, which is what occurs in the acetabular retroversion. In both situations, the first structure that is injured here is the acetabular labrum. If the conflict persists, the acetabular cartilage will be altered secondarily, this lesion being more circumscribed and less aggressive than that which appears in the CAM type. The PINCER type is seen more in middle-aged women, while the CAM type is seen more in young men.
- Conservative treatment
The conservative treatment consists in the restriction of the sporting activity and of the forced hip movements.
The persistence of the symptoms, as well as the evidence through MRI of labral or chondral lesion in the hip, make surgery necessary.
- Surgical treatment. In the acetabular area, the local or global overcoverage, will be treated by osteoplasty of the excessive acetabular rim or reorientation of the acetabulum by a periacetabular osteotomy. On the femoral side, the anesthesia of the femoral head causing the conflict will be treated by osteoplasty of the remaining bone at the level of the femoral head-neck.
In cases of anterior overcoverage, an osteoplasty of the anterior superior acetabular rim should be performed, for which the acetabular labrum must be previously mobilized. Once the labrum has been disinserted from the bone in the anterosuperior rim of the acetabulum, excess bone is removed from the acetabulum causing the femoroacetabular impingement by means of a osteotome. The area of damaged cartilage in the anterosuperior area of the acetabular cavity should be included in the resection.
The term dysplasia of hip development (DDH) includes alterations in the shape of the head of the femur, the acetabulum (where it fits into the pelvis) or both, which can cause problems of development and stability of the joint. The hip joint develops without a correct anatomical relationship between the acetabular cavity and the femoral head, resulting in adulthood in functional alterations of the hip, secondary coxarthrosis or hip pain (coxalgia). Previously, the term "congenital hip dislocation" was used, but it has been replaced by dysplasia since not all hips are dislocated at birth nor do they all progress to dislocation.
According to the displacement of the femoral head in relation to the acetabulum and the secondary development of coxarthrosis, hip dysplasia is classified in adulthood according to the Hartofilakidis classification:
Type A: Relationship and contact between the femoral head and the acetabulum is maintained
Type B: Femoral head and acetabulum maintain minimal contact
Type C: Complete loss of relationship between femoral head and acetabulum
According to the type of Hip Dysplasia, the development of secondary coxarthrosis and the age of the patient, there are several surgical interventions that can be performed on this type of pathology.
- Femoral osteotomies: Their objective will be to redirect the femoral head to improve its contact with the acetabulum. Indicated mainly in young patients with scarce Arthritis development
- Pelvic Osteotomies: Pelvic cuts are made that will reorient the acetabulum over the femoral head. Currently, the pelvic osteotomy of greater use will be the "Triple Osteotomy".
- Hip prosthesis: They will be used in case of advanced coxarthrosis secondary to dysplasia. The difficulty will be greater in cases of severe dysplasia. These are interventions of high technical difficulty where we use complex prosthetic models to correct the deformities. Sometimes it will be necessary to perform femoral shortening osteotomies in order to correctly implant the hip prosthesis.