What are the treatment options for hip dysplasia in adults?

Treatment Options for Hip Dysplasia in Adults

For young adults with symptomatic hip dysplasia, osteotomy and joint-preserving surgical procedures (particularly periacetabular osteotomy) should be the primary treatment consideration, especially in the presence of dysplasia or varus/valgus deformity, while total hip replacement is reserved for patients with advanced osteoarthritis who have refractory pain and disability despite conservative management. 1, 2

Surgical Management: The Primary Treatment

Joint-Preserving Surgery (First-Line for Young Adults)

• Periacetabular osteotomy (PAO) is the most commonly used procedure for treating the majority of dysplastic hips in adults, particularly those with frank dysplasia (lateral center-edge angle <20°) 3, 4
• PAO aims to restore hip anatomy as close to normal as possible and should be customized based on radiographic findings, patient age, and articular cartilage status 4
• This procedure shows encouraging hip joint survival and clinical outcomes at medium-term follow-up, with preservation of cartilage thickness up to 2.5 years post-operatively 2
• Derotational femoral osteotomy may be combined with PAO when associated femoral deformities are present (seen in >50% of dysplastic hips) 3
• Joint-preserving procedures are specifically recommended for young adults with symptomatic hip osteoarthritis in the presence of dysplasia 1, 5

Total Hip Replacement (For Advanced Disease)

• Total hip replacement must be considered in patients with radiographic evidence of hip osteoarthritis who have refractory pain and disability despite conservative management 1, 5
• Modern total hip replacement remains an excellent option for more arthritic joints, though anatomical abnormalities and previous operations can create technical difficulties 3

Conservative Management: Initial Approach

Non-Pharmacological Interventions

• Optimal management requires a combination of non-pharmacological and pharmacological treatment modalities 1, 5
• Regular education about the condition and self-management strategies should be provided to all patients 1, 6
• Exercise therapy (land-based cardiovascular and/or resistance exercise under physical therapist supervision) is recommended with high-strength evidence 1, 6, 5
• Weight reduction is essential for overweight or obese patients, as obesity is a specific hip risk factor in dysplasia 1, 6
• Assistive devices such as walking sticks or canes should be used to reduce joint load 1, 6, 5
• Aquatic exercise may be considered as an alternative, particularly for patients with mobility limitations 6

Pharmacological Management

• Paracetamol (up to 4 g/day) is the oral analgesic of first choice for mild-moderate pain due to its efficacy and safety profile 1, 6, 5
• NSAIDs at the lowest effective dose should be added or substituted when paracetamol provides inadequate relief 1, 6, 5
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus gastroprotective agents or selective COX-2 inhibitors 1, 6
• Opioid analgesics (with or without paracetamol) are useful alternatives when NSAIDs are contraindicated, ineffective, or poorly tolerated 1, 6, 5

Interventional Options

• Intra-articular steroid injections (guided by ultrasound or x-ray) may be considered for patients with flares unresponsive to analgesics and NSAIDs 1, 6, 5

Treatment Algorithm Based on Patient Characteristics

Key Decision Factors

Treatment should be tailored according to:

• Hip-specific risk factors: obesity, adverse mechanical factors, physical activity level, and degree of dysplasia 1, 5
• General risk factors: age, sex, comorbidity, and co-medication 1, 5
• Disease severity: pain intensity, disability level, location and degree of structural damage 1, 5
• Patient factors: wishes and expectations 1

Age-Based Approach

• Young adults with symptomatic dysplasia: Prioritize joint-preserving surgery (PAO) before significant osteoarthritis develops 1, 3, 4
• Older adults or those with advanced arthritis: Consider total hip replacement as the definitive treatment 1, 5, 3

Special Considerations and Pitfalls

Diagnostic Complexity

• Hip dysplasia can be difficult to diagnose in adolescents and young adults, with patients often seeing multiple providers before accurate diagnosis 7
• The lateral center-edge angle is an unreliable sole marker for dysplasia; additional radiographic parameters should be utilized 8
• Acetabular retroversion is present in 33% of dysplastic hips, contradicting the historical assumption of purely insufficient anterior and lateral coverage 2
• Acetabular labral tears are present in nearly all dysplastic hips (all but 1 in one study), but their presence does not accelerate cartilage degeneration after PAO 2

Borderline Hip Dysplasia

• Patients with borderline hip dysplasia (lateral center-edge angle 20-25°) present a challenging treatment dilemma 8
• Selective use of arthroscopic labral and capsular treatment alone may provide good results in carefully chosen patients with borderline dysplasia, while others may require bony realignment 8

Medications to Avoid

• Do not recommend glucosamine and chondroitin for hip osteoarthritis, as these are not supported by current guidelines 6
• Intra-articular hyaluronic acid injections are not recommended for hip osteoarthritis due to insufficient evidence 6
• SYSADOA (symptomatic slow-acting drugs for osteoarthritis) have small effect sizes, and suitable patients are not well defined 1

Monitoring and Safety

• Monitor for gastrointestinal adverse effects with NSAIDs, particularly in elderly patients or those with comorbidities 6
• Exercise caution with acetaminophen in patients with liver disease 6
• Limit opioid use due to higher rates of side effects including gastrointestinal upset, constipation, and dizziness 6