Skeletally Mature Acetabular Dysplasia: Epidemiology, Natural History, Clinical Presentation, Imaging Studies, Non-Operative Treatment, Operative Treatment

  • Anay Patel
  • John P. Manalo
  • Michael D. Stover
Reference work entry


Skeletally mature acetabular dysplasia (SMAD) is a recognized cause of hip pain in active young adults. The majority of hip dysplasia is treated in childhood by improving the physiologic and anatomic environment of the hip allowing it to develop into a morphologically sound structure. The abnormal morphology of the mature dysplastic hip can be subtle both clinically and radiographically which can often lead to a delay in diagnosis.

The goal of treatment with SMAD is first and foremost to recognize the specific pathology causing the common complaints of hip pain. Hip pain, limp, and mechanical symptoms that can present with SMAD may be the same presenting complaints in patients with either femoroacetabular impingement (FAI) or mild osteoarthritis (OA). Plain radiographs and MRI provide the diagnosis, which in turn allows the treating physician to choose the appropriate treatment course.

Treatment of SMAD generally falls into one of two categories. For patients who present without radiographic signs of OA, the goal is to preserve the native cartilage of the hip by creating a more mechanically sound hip. The periacetabular osteotomy (PAO) reorients the acetabulum, providing stability to the hip and decreasing cartilage stress. Patients who present with moderate to severe OA generally do not obtain good results with hip preservation procedures and, therefore, may require total hip arthroplasty to address their hip pain. Although results are excellent with total joint replacement, the mainstay of treatment for SMAD should be recognition via clinical and radiographic examination followed by prompt treatment, if indicated, to help preserve the native hip joint.


Femoral Head Joint Space Width Labral Tear Femoral Anteversion Periacetabular Osteotomy 
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  1. 1.
    Crawford MJ, Dy CJ, Alexander JW, Thompson M, Schroder SJ, Vega CE, et al. The 2007 Frank Stinchfield award. The biomechanics of the hip labrum and the stability of the hip. Clin Orthop Relat Res. 2007;465:16–22.PubMedGoogle Scholar
  2. 2.
    Ferguson SJ, Bryant JT, Ganz R, Ito K. An in vitro investigation of the acetabular labral seal in hip joint mechanics. J Biomech. 2003;36(2):171–8.PubMedCrossRefGoogle Scholar
  3. 3.
    McCarthy JC, Noble PC, Schuck MR, Wright J, Lee J. The watershed labral lesion: its relationship to early arthritis of the hip. J Arthroplasty. 2001;16(8 Suppl 1):81–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Li PL, Ganz R. Morphologic features of congenital acetabular dysplasia: one in six is retroverted. Clin Orthop Relat Res. 2003;416:245–53.PubMedCrossRefGoogle Scholar
  5. 5.
    Mast JW, Brunner RL, Zebrack J. Recognizing acetabular version in the radiographic presentation of hip dysplasia. Clin Orthop Relat Res. 2004;418:48–53.PubMedCrossRefGoogle Scholar
  6. 6.
    MacKenzie JR, Kelley SS, Johnston RC. Total hip replacement for coxarthrosis secondary to congenital dysplasia and dislocation of the hip. Long-term results. J Bone Joint Surg Am. 1996;78(1):55–61.PubMedGoogle Scholar
  7. 7.
    Murphy SB, Ganz R, Muller ME. The prognosis in untreated dysplasia of the hip. A study of radiographic factors that predict the outcome. J Bone Joint Surg Am. 1995;77(7):985–9.PubMedGoogle Scholar
  8. 8.
    Jessel RH, Zurakowski D, Zilkens C, Burstein D, Gray ML, Kim YJ. Radiographic and patient factors associated with pre-radiographic osteoarthritis in hip dysplasia. J Bone Joint Surg Am. 2009;91(5):1120–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Ganz R, Leunig M, Leunig-Ganz K, Harris WH. The etiology of osteoarthritis of the hip: an integrated mechanical concept. Clin Orthop Relat Res. 2008;466(2):264–72.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Klaue K, Durnin CW, Ganz R. The acetabular rim syndrome. A clinical presentation of dysplasia of the hip. J Bone Joint Surg Br. 1991;73(3):423–9.PubMedGoogle Scholar
  11. 11.
    Hashimoto S, Rai MF, Gill CS, Zhang Z, Sandell LJ, Clohisy JC. Molecular characterization of articular cartilage from young adults with femoroacetabular impingement. J Bone Joint Surg Am. 2013;95(16):1457–64.PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Troelsen A. Assessment of adult hip dysplasia and the outcome of surgical treatment. Dan Med J. 2012;59(6):B4450.PubMedGoogle Scholar
  13. 13.
    Peled E, Eidelman M, Katzman A, Bialik V. Neonatal incidence of hip dysplasia: ten years of experience. Clin Orthop Relat Res. 2008;466(4):771–5.PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Howorth B. “Congenital dislocation” of the hip … its early diagnosis and treatment. Arch Pediatr. 1962;79:1–17.PubMedGoogle Scholar
  15. 15.
    Lee CB, Mata-Fink A, Millis MB, Kim YJ. Demographic differences in adolescent-diagnosed and adult-diagnosed acetabular dysplasia compared with infantile developmental dysplasia of the hip. J Pediatr Orthop. 2013;33(2):107–11.PubMedCrossRefGoogle Scholar
  16. 16.
    Gosvig KK, Jacobsen S, Sonne-Holm S, Palm H, Troelsen A. Prevalence of malformations of the hip joint and their relationship to sex, groin pain, and risk of osteoarthritis: a population-based survey. J Bone Joint Surg Am. 2010;92(5):1162–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Sankar WN, Nevitt M, Parvizi J, Felson DT, Agricola R, Leunig M. Femoroacetabular impingement: defining the condition and its role in the pathophysiology of osteoarthritis. J Am Acad Orthop Surg. 2013;21 Suppl 1:S7–15.PubMedCrossRefGoogle Scholar
  18. 18.
    Nunley RM, Prather H, Hunt D, Schoenecker PL, Clohisy JC. Clinical presentation of symptomatic acetabular dysplasia in skeletally mature patients. J Bone Joint Surg Am. 2011;93 Suppl 2:17–21.PubMedCrossRefGoogle Scholar
  19. 19.
    Wall PD, Fernandez M, Griffin DR, Foster NE. Nonoperative treatment for femoroacetabular impingement: a systematic review of the literature. PM & R J Inj Funct Rehabil. 2013;5(5):418–26.CrossRefGoogle Scholar
  20. 20.
    Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H. Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res. 2009;467(3):638–44.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Shu B, Safran MR. Hip instability: anatomic and clinical considerations of traumatic and atraumatic instability. Clin Sports Med. 2011;30(2):349–67.PubMedCrossRefGoogle Scholar
  22. 22.
    Troelsen A, Mechlenburg I, Gelineck J, Bolvig L, Jacobsen S, Soballe K. What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics? Acta Orthop. 2009;80(3):314–8.PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Clohisy JC, Carlisle JC, Beaule PE, Kim YJ, Trousdale RT, Sierra RJ, et al. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am. 2008;90 Suppl 4:47–66.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Tannast M, Zheng G, Anderegg C, Burckhardt K, Langlotz F, Ganz R, et al. Tilt and rotation correction of acetabular version on pelvic radiographs. Clin Orthop Relat Res. 2005;438:182–90.PubMedCrossRefGoogle Scholar
  25. 25.
    Siebenrock KA, Kalbermatten DF, Ganz R. Effect of pelvic tilt on acetabular retroversion: a study of pelvis from cadavers. Clin Orthop Relat Res. 2003;407:241–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Troelsen A, Jacobsen S, Romer L, Soballe K. Weightbearing anteroposterior pelvic radiographs are recommended in DDH assessment. Clin Orthop Relat Res. 2008;466(4):813–9.PubMedCentralPubMedCrossRefGoogle Scholar
  27. 27.
    Nepple JJ, Prather H, Trousdale RT, Clohisy JC, Beaule PE, Glyn-Jones S, et al. Clinical diagnosis of femoroacetabular impingement. J Am Acad Orthop Surg. 2013;21 Suppl 1:S16–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Troelsen A, Romer L, Kring S, Elmengaard B, Soballe K. Assessment of hip dysplasia and osteoarthritis: variability of different methods. Acta Radiol. 2010;51(2):187–93.PubMedCrossRefGoogle Scholar
  29. 29.
    Troelsen A, Elmengaard B, Soballe K. Medium-term outcome of periacetabular osteotomy and predictors of conversion to total hip replacement. J Bone Joint Surg Am. 2009;91(9):2169–79.PubMedCrossRefGoogle Scholar
  30. 30.
    Hartig-Andreasen C, Troelsen A, Thillemann TM, Soballe K. What factors predict failure 4 to 12 years after periacetabular osteotomy? Clin Orthop Relat Res. 2012;470(11):2978–87.PubMedCentralPubMedCrossRefGoogle Scholar
  31. 31.
    Clohisy JC, Barrett SE, Gordon JE, Delgado ED, Schoenecker PL. Medial translation of the hip joint center associated with the Bernese periacetabular osteotomy. Iowa Orthop J. 2004;24:43–8.PubMedCentralPubMedGoogle Scholar
  32. 32.
    Fujii M, Nakashima Y, Yamamoto T, Mawatari T, Motomura G, Matsushita A, et al. Acetabular retroversion in developmental dysplasia of the hip. J Bone Joint Surg Am. 2010;92(4):895–903.PubMedCrossRefGoogle Scholar
  33. 33.
    Reynolds D, Lucas J, Klaue K. Retroversion of the acetabulum. A cause of hip pain. J Bone Joint Surg Br. 1999;81(2):281–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Kalberer F, Sierra RJ, Madan SS, Ganz R, Leunig M. Ischial spine projection into the pelvis: a new sign for acetabular retroversion. Clin Orthop Relat Res. 2008;466(3):677–83.PubMedCentralPubMedCrossRefGoogle Scholar
  35. 35.
    Peters CL, Erickson JA, Hines JL. Early results of the Bernese periacetabular osteotomy: the learning curve at an academic medical center. J Bone Joint Surg Am. 2006;88(9):1920–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Meyer DC, Beck M, Ellis T, Ganz R, Leunig M. Comparison of six radiographic projections to assess femoral head/neck asphericity. Clin Orthop Relat Res. 2006;445:181–5.PubMedGoogle Scholar
  37. 37.
    Lequesne M, Djian A. New radiographic angles for the study of the hip. The “false profile” of the pelvis. Vie Med. 1961;42:1629–41.PubMedGoogle Scholar
  38. 38.
    Sakai T, Nishii T, Sugamoto K, Yoshikawa H, Sugano N. Is vertical-center-anterior angle equivalent to anterior coverage of the hip? Clin Orthop Relat Res. 2009;467(11):2865–71.PubMedCentralPubMedCrossRefGoogle Scholar
  39. 39.
    Troelsen A, Romer L, Jacobsen S, Ladelund S, Soballe K. Cranial acetabular retroversion is common in developmental dysplasia of the hip as assessed by the weight bearing position. Acta Orthop. 2010;81(4):436–41.PubMedCentralPubMedCrossRefGoogle Scholar
  40. 40.
    Leunig M, Podeszwa D, Beck M, Werlen S, Ganz R. Magnetic resonance arthrography of labral disorders in hips with dysplasia and impingement. Clin Orthop Relat Res. 2004;418:74–80.PubMedCrossRefGoogle Scholar
  41. 41.
    Toomayan GA, Holman WR, Major NM, Kozlowicz SM, Vail TP. Sensitivity of MR arthrography in the evaluation of acetabular labral tears. AJR Am J Roentgenol. 2006;186(2):449–53.PubMedCrossRefGoogle Scholar
  42. 42.
    Freedman BA, Potter BK, Dinauer PA, Giuliani JR, Kuklo TR, Murphy KP. Prognostic value of magnetic resonance arthrography for Czerny stage II and III acetabular labral tears. Arthroscopy. 2006;22(7):742–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Keeney JA, Peelle MW, Jackson J, Rubin D, Maloney WJ, Clohisy JC. Magnetic resonance arthrography versus arthroscopy in the evaluation of articular hip pathology. Clin Orthop Relat Res. 2004;429:163–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Cunningham T, Jessel R, Zurakowski D, Millis MB, Kim YJ. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage to predict early failure of Bernese periacetabular osteotomy for hip dysplasia. J Bone Joint Surg Am. 2006;88(7):1540–8.PubMedCrossRefGoogle Scholar
  45. 45.
    Babst D, Steppacher SD, Ganz R, Siebenrock KA, Tannast M. The iliocapsularis muscle: an important stabilizer in the dysplastic hip. Clin Orthop Relat Res. 2011;469(6):1728–34.PubMedCentralPubMedCrossRefGoogle Scholar
  46. 46.
    Troelsen A, Jacobsen S, Bolvig L, Gelineck J, Romer L, Soballe K. Ultrasound versus magnetic resonance arthrography in acetabular labral tear diagnostics: a prospective comparison in 20 dysplastic hips. Acta Radiol. 2007;48(9):1004–10.PubMedCrossRefGoogle Scholar
  47. 47.
    Hunt D, Prather H, Harris Hayes M, Clohisy JC. Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders. PM & R J Inj Funct Rehabil. 2012;4(7):479–87.CrossRefGoogle Scholar
  48. 48.
    Lewis CL, Sahrmann SA. Acetabular labral tears. Phys Ther. 2006;86(1):110–21.PubMedGoogle Scholar
  49. 49.
    Byrd JW, Jones KS. Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients. Am J Sports Med. 2004;32(7):1668–74.PubMedCrossRefGoogle Scholar
  50. 50.
    Pateder DB, Hungerford MW. Use of fluoroscopically guided intra-articular hip injection in differentiating the pain source in concomitant hip and lumbar spine arthritis. Am J Orthop (Belle Mead NJ). 2007;36(11):591–3.Google Scholar
  51. 51.
    Bogunovic L, Gottlieb M, Pashos G, Baca G, Clohisy JC. Why do hip arthroscopy procedures fail? Clin Orthop Relat Res. 2013;471(8):2523–9.PubMedCentralPubMedCrossRefGoogle Scholar
  52. 52.
    Clohisy JC, Beaule PE, O’Malley A, Safran MR, Schoenecker P. AOA symposium. Hip disease in the young adult: current concepts of etiology and surgical treatment. J Bone Joint Surg Am. 2008;90(10):2267–81.PubMedCrossRefGoogle Scholar
  53. 53.
    Schoenecker PL, Clohisy JC, Millis MB, Wenger DR. Surgical management of the problematic hip in adolescent and young adult patients. J Am Acad Orthop Surg. 2011;19(5):275–86.PubMedGoogle Scholar
  54. 54.
    Numair J, Joshi AB, Murphy JC, Porter ML, Hardinge K. Total hip arthroplasty for congenital dysplasia or dislocation of the hip. Survivorship analysis and long-term results. J Bone Joint Surg Am. 1997;79(9):1352–60.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Anay Patel
    • 1
  • John P. Manalo
    • 1
  • Michael D. Stover
    • 1
  1. 1.Department of Orthopaedic SurgeryFeinberg School of Medicine, Northwestern UniversityChicagoUSA

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