Project 2015-1-RO01-KA202-015230

CASE REPORT
Rehabilitation program in a patient
with congenital dysplasia and
subluxation of the hip

Rodica Traistaru, Diana Kamal, Constantin Kamal

Filantropia Hospital - Craiova
CI, 40 year old woman with
cementless total hip replacement for
congenital dysplasia and subluxation of the hip

1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Personal data

Patient Complaints
Mild pain and stiffness in right hip and groin, moderate disability in gait
Post surgical (cementless total hip arthroplasty for secondary right coxarthrosis, due to congenital dysplasia and
subluxation of right hip) rehabilitation status.

ANAMNESIS (history)
Our 40 year old woman was diagnosed with congenital hip dysplasia 25 years ago. During the past 15 years she has
had numerous weeks with pain and discomfort. In the last year, her functional status significantly disturbed, her pain
was permanent, located in the lower back, right hip and knee, and she was diagnosed with secondary right
coxarthrosis. She had never performed a rehabilitation program. The lower limbs length difference was about 3.5 cm
and most of the hip muscles for stabilization were disabled.
She had no previous history of surgical intervention or other diseases.
She performed daily activities in sitting postures in her professional life.
Because her current status was constant pain and she always walked with a limp, she presented to orthopedic
department for surgical intervention. The surgeon performed a cementless total hip arthroplasty (Multi Cotile revetu
46, insert Biolox 28/27, short ceramic cup and femoral stem dimension 8) and femoral osteotomy with metallic
cerclage. It was performed anticoagulant prophylaxis and treatment with antibiotics. Post operative period was
uneventful. Sutures are removed at 14 days.
The patient was allowed to non weightbearing with the help of crutches after one week after intervention.
SA is coming in our department to perform and to teach the rehabilitation measures for regain her gait and her
independence daily life.
Personal data
Questions (for assessment detailed answers see next page)

1. How can we explain the secondary arthrosis in the right hip in our patient?
a. Due to genetic factors
b. Due to the anatomical features of bones
c. Due to the physical activity of the patient
R=b

2. Is it important to regain the function of lower limb in our patient?

a. No
b. It is indifferent
c. Yes
R=c

3. How can we explain the location of pain in our patient?

a. Valgus force on the knee in a female with postmenopausal osteoporosis
b. History of osteoarthritis
c. Varus force on the knee in a young female
R=a
 Personal data
Questions` answers

1. How can we explain the secondary arthrosis in the right hip in our patient?
Congenital hip dysplasia (CHD) is a medical disorder in which there is abnormal development of the hip joint
especially in the relationship between the head of the femur and the acetabulum. The femoral head and the
acetabulum are present in the wrong position, leading occasionally to the development of a false acetabulum,
particularly in severe conditions. In our patient, this congenital disease was asymptomatic until 20 years old.
Because this disease left untreated can result in arthritis of the hip, after several decades of her life, when CI
performed standing daily activity.

2. Is it important to regain the function of lower limb in our patient?

Yes. Restoration of the functional integrity and strength of the hip in our patient is essential for gait and
performing the daily activities. Correct detection and appropriate treatment of congenital hip dysplasia and
subluxation Incomplete contact between the articular surfaces of the femoral head and acetabulum are very
important for minimizing patient disability, to prevent the left hip and spine posture deterioration.

3. How can we explain the location of pain in our patient?

Congenital hip dysplasia is frequently asymptomatic. When illiopsoas muscle and hip flexor pains happens
because they are essentially taking over the role of the hip socket and holding her hip joint in place. It seems
an explanation for her horrible tendon and muscle pain in the front of patient hip and groin.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Clinical data

CI is 1.63 m height and a weight of 61 kg.

Pulmonary, cardiac, digestive and urogenital systems are normal in clinical exam. Mental status is clear.
Vertebral spine lumbar hyperlordosis and back pain.
Upper limb joints ROM and muscle strength with normal values in accordance with her age.
Lower limb with left hip, knees and ankles joints in normal limits for ROM and MMT (manual muscular testing).
Right hip with cementless total repalcement
pain along the lateral side of hip and thight, skin in right hip region with post intervention scars, without any
pathologic aspects;
flexion AROM 0 to 75 degrees, PROM 0 to 90 degrees, abduction AROM 0 to 25 degrees, PROM 0 to 30
degrees, no pain during passive movement.
manual muscular testing: 4 for great gluteus, -4 for hip stable muscle, -4 for quadriceps and 4 for posterior limb
muscles.

Gait is possible with two crutches (non weightbearing gait on the right lower extremity). The patient complained of
minimal right hip pain when she got up from a chair and walked.
Neurovascular status of lower limbs are intact.
Vital Signs: temperature 36.7C, blood pressure 120/60 mmHg, rhythmic pulse 72 b/min, 16 respirations / min.
Clinical data
Questions (for assessment detailed answers see next page)

1. How can we explain the loss of range of motion in our patients right hip?
a. Because of the bone abnormalities
b. Because our patient is female
c. Because concomitant damage to the soft tissue around bones
R = a, c

2. It is important for gait rehabilitation to examine the proprioception and balance?

a. Yes
b. No
c. It is indifferent
R=a

3. Why is it important to perform MMT (manual muscle testing) for all muscles of the lower limb?
a. For gait are important both extension and flexion kinetic chains of lower limb
b. For control the hip pain
c. For choosing the AINS medication
R=a
 Clinical data
Questions` answers

1. How can we explain the loss of range of motion in our patients right hip ?
Hip dysplasia is often cited as causing secondary osteoarthritis of the hip at a young people. Dislocated load
bearing surfaces lead to increased and unusual wear. An abnormal location for the center of rotation of the hip,
proximal femoral deformity, soft-tissue contracture, abnormal muscle development and poor bone stock may
lead to abnormal joint bearing and cartilage disturbance. The anatomy of the dislocated hip, especially after
several months and years, often includes formation of a ridge - the neolimbus. Closed reduction is often
unsuccessful at a later date, secondary to various obstacles to reduction, like - ligamentous teres, a transverse
acetabular ligament, and pulvinar and capsular constriction, adductor and psoas tendon contraction. With long-
standing dislocations, interposition of the labrum can also interfere with reduction.

2. It is important for gait rehabilitation to examine the proprioception and balance?

Yes. The patient has to regain her optimal gait, only when her lower limb functions are recovered. So, we assess
the patients ability to maintain balance with NWB using an assistive device, the balance on the involved /
uninvolved lower limb as appropriate when hip replacement is consolidated and weight-bearing status is
progressed.

3. Why is it important to perform MMT (manual muscle testing) for all muscles of the lower limb?
All rehabilitation program for gait in patient with total hip replacement take into consideration the global kinetic
exercises, after analytic kinetic program. Muscles hypotrophy after any surgical intervention can make moving
around painful and slow. The kinetic muscle chains of the lower limb for extension and for flexion, for
abduction are very important for independence ambulation, so previous kinetic program must do the MMT.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Imagistic data

X-rays.
Standard radiographic views for congenital hip dysplasia include a standing antero-posterior (AP) view of the pelvis,
with the hips in neutral position, and a false profile view in which the patient is standing angled at 65 from the x-ray
plate. The radiograph is then taken, profiling the anterior aspect of the acetabulum.
If any evidence of hip subluxation is present, an abducted internal rotation view can
help determine if the hip reduces and better determines the true neck-shaft angle
of the proximal femur. After surgery, the X-ray showed the status
post intervention cementless total hip arthroplasty.

Ultrasonography - in children
This type of scan has been of substantial benefit in the assessment and treatment of children with congenital dysplasia
of the hip. Even with ultrasonographic screening, children with hip dysplasia can be diagnosed late, and one concern
with routine ultrasonographic evaluation of newborns is over diagnosis of hip dysplasia.

Computed tomography (CT) scan.

This type of scan can create a cross-section image of the hip. Computed tomography (CT) can also be helpful in
determining femoral anteversion and in determining the extent of posterior acetabular coverage. Three-dimensional
(3D) images are also quite popular and can be beneficial in visualizing the overall shape of the acetabulum.

Magnetic resonance imaging (MRI) scan.

This type of scan provides high resolution images of bones and soft tissues of the hip. MRI scan can be beneficial in
identifying the underlying bony and soft-tissue anatomy.
Imagistic data
Questions (for assessment detailed answers see next page)

1. What is the type of hip surgical procedures performed in our patient?

a. Hip resurfacing
b. Hip replacement
c. Fixation with cannulated screw
R=b

2. The imagistic findings of X-ray pelvis and hips can suggest the degree of malformation and dislocation in our
patient?
a. Yes
b. No
c. It is a MRI image of hip
R=a

3. The total hip replacement can suggest the type of optimal management performed in our patient?
a. No
b. It is indifferent
c. Yes
R=c
 Imagistic data
Questions` answers

1. What is the type of hip surgical procedures performed in our patient?

In our patient a hip replacement was performed. It is not a hip resurfacing that offers a less invasive, bone preserving
option because less bone is removed to perform the surgery. The hip resurfacing is indicated for active and younger
patients with relatively normal anatomy. However, hip resurfacing is not always the best option for patients with hip
dysplasia. For women of child-bearing age there is a theoretical concern that metal-on-metal resurfacing creates
metal ions that could affect a babys development.

2. The imagistic findings of X-ray ankle can suggest the mechanism of injury suffered by our patient?
In 1979 Dr. John F. Crowe et al. proposed a classification to define the degree of malformation and dislocation, that is
very useful for studying treatment results. Grouped from least severe Crowe I dysplasia to most severe Crowe IV. For
surgical planning, hip dysplasia is usually classified in the same mode, from mild to severe with Type 1 being the
least involved and Type 4 the most severe. When the dysplasia is more severe, or the patient is older and is diagnosed
with secondary coxarthrosis, then a traditional total hip replacement is usually performed.

3. The total hip replacement can suggest the type of optimal management performed in our patient?
Yes. The type of hip arthroplasty is an important conditioning factor for the future rehabilitation program. The
cementless hip arthroplasty is in accordance with the anatomy of a dysplastic hip, different from the anatomy of other
types of hip arthritis. Placement of the socket is perhaps the most important part of total hip replacement for patients
with hip dysplasia. Currently, the preferred artificial joint surfaces for young people tend to be ceramics like in our
patient, or metal on modern polyethylens. The kinetic program and rehabilitation period should be performed for
preserving and favor the consolidation of cementless total hip replacement.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Functional data

We assess, in accordance with ICF:

impairments of body functions - pain, stiffness, muscle weakness (special for quadriceps muscle and middle gluteus);
changes in body structures right hip replacement;
activity limitation - limited walking ability and problems with ADLs;
participation restrictions - reduced participation in leisure activities and in household chores.
The primary ICF activities and participation codes associated with hip stability and movement coordination impairments
are d450 walking, d4552 running, d4553 jumping, d4558 moving around, specified as direction changes while walking
or running.

We used:
easily reproducible physical performance measures for activity limitation and participation restriction
VAS = 5 before, 2 after rehabilitation program;
6 Minute Walk, with crutches = 140 meters before; 200 meters after rehabilitation program;
Timed Up and Go, with crutches = 40 seconds before; 32 seconds after rehabilitation program;
scales for condition-specific health status measures
the Harris Hip Score (HHS) (is a tool for the evaluation of how a patient is doing after their hip is replaced; the
questions are further grouped into three categories pain, function and functional activities; the score is reported as 90-
100 for excellent results, 80-90 being good, 70-79 fair, 60-69 poor, and below 60 a failed result) = 74 before
rehabilitation; 92 after rehabilitation program.
SF-36 (the lower the score the more disability - a score of zero is equivalent to maximum disability; the higher the
score the less disability a score of 100 is equivalent to no disability) = 38 before rehabilitation; 46after
rehabilitation program.
Functional data
Questions (for assessment detailed answers see next page)

1. It is important to assess the functional status in our patient ?

a. No
b. Yes
c. Is no important to mention
R=b

2. The changes in body structures that appeared from surgery may explain?
a. A further disturbance in the neuromuscular status
b. Optimal balance and gait
c. Back pain
R=a

3. The final score of the two scales used for our patient The Harris Hip Score (HHS) and SF-36 are in
concordance for disability status ?
a. Yes
b. No
c. It is no possibility to compare the two score scales
R=a

4. How can we explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
a. There are no explanations
b. The functional status is not improved after intervention
c. The rehabilitation program for hip replacement status takes a few weeks after intervention
R=c
Functional data
Questions` answers

1. It is important to assess the functional status in our patient ?

Yes. Many investigators have evaluated both short- and long-term results after surgery, to establish the complete
clinical and functional status of patient. Initially, in the non weightbearing period, functional assessment will be
limited and will focus on activity of daily living modification, transfers and short distance ambulation and stairs.
Once weight-bearing is allowed, the therapist will need to reassess gait, balance activities, and higher-level functional
activities as appropriate.

2. The changes in body structures that appeared from surgery may explain?
Additionally, the changes in body structures that appeared from surgery may explain the picture of a further
disturbance in the neuromuscular status. This aspect has a great impact on the different parameters like lack of
extension, range of movement, instability, walking distance and pain score.

3. The final score of the two scales used for our patient The Harris Hip Score (HHS) and SF-36 are in
concordance for disability status ?
Yes. The both scales contain the items for quality if life and various daily activities in which the lower limb, hip
especially, is responsible for balance and gait. These measurement instruments, based on scoring systems, are applied
so as to assess the benefits achieved by the surgical procedure and rehabilitation measures.

4. How can explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
Patients recovering from cementless total hip replacement reclaim 2 3 months for strength and functional gains.
The outcome measures chosen for our patient study are common clinical measures and their associated impairments
are theoretically addressable by targeted rehabilitation techniques, in accordance with medical literature data.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Complete diagnosis

1. Secondary right hip osteoarthritis resulting from congenital dislocation and subluxation of
the right hip, operated 3 weeks ago with cementless total hip arthroplasty
2. Mechanical back pain
 Complete diagnosis
Questions (for assessment detailed answers see next page)

1. What are the arguments for a late diagnosis of our patient ?

a. Patient is asymptomatic since 20 years old
b. Misdiagnosis
c. Missing of medical consulting
R = a, c

2. The following diagnosis can be taken into consideration for possible complications in our patient?
a. Infection
b. Dislocation
c. Nerve palsy
R = a, b

3. Should the surgical protocol mention if femoral osteotomy or tenotomies are performed ? Why?
a. No, it is not an important aspect
b. Yes, because these aspects have an important conditioning for rehabilitation program (goals and methods)
c. Yes, but not important for rehabilitation program
R=b
 Complete diagnosis
Questions` answers

1. What are the arguments for a late diagnosis of our patient ?

Patients are usually asymptomatic, hence the importance of screening right after birth and in the early developmental
period. The physical exam is of prominent importance for screening newborns. Very late diagnosis may sometimes
necessitate surgical treatment, like in our patient, who said that she was afraid to make a medical visit for her pain
and right hip dysfunction.

2. The following diagnosis can take into consideration for possible complications in our patient?
Our patient was correctly treated after intervention with antibiotics so, the infection risk is minimal but possible. The
nerve palsy is absent, because she could moved active, in bed, her right lower limb. So, the dislocation is the real
critical possible complication. Because in surgical protocol it was mentioned the it made an adequate medialisation of
the centre of the hip that preserves the force of the abductor muscles and may not compromise long-term results, the
dislocation risk is minimal.

3. Should the surgical protocol mention if femoral osteotomy or tenotomies are performed ? Why?
Rehabilitation program typically reclaims kinetic exercises. It is very important to know what happened in the
surgical protocol with bones and muscles around the hip. In our patient, proximal femoral shortening osteotomy and
muscle release were performed, to achieve appropriate lengthening while reducing the risk of neurological
complications.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Rehabilitation program (RP)

1. Objectives of RP that must address both impairments in order to ensure good outcomes in our patient:
painful status control;
to restore function of the involved limb
during the acute rehabilitation care - increasing hip joint ROM, muscle control and balance, and functional
independence, recovery of normal walking;
during outpatient rehabilitation care - keeping the hip in the economy of the limb biomechanics and minimizing
the all impairments (ROM, strength, proprioception, gait, balance);
maintenance of normal daily activities and maximization in quality of life.
2. Methods of RP used in our patient:
pharmacological modalities - analgesics, vitamin D3 and calcium carbonate oral
non-pharmacological modalities:
- educational, diet and hygiene,
- physical (thermotherapy ice-pack to control pain; electrotherapy - TENS, laser, NMES for bilateral calf muscles)
- massage classic and special massage (for vein drainage)
- kinetic
early rehabilitation includes gait training with assistive devices, walking support first, crutches after; ankle
pumps, leg, knee and hip range of motion, flexion, extension, abduction (if indicated), and adduction
active/active assisted/passive ROM of operative hip, isometric contraction of all muscles of lower limbs,
breathing exercises (deep breathing, coughing);
therapeutic exercise/strength training with focus on isometric and functional hip flexor and quadriceps control,
hamstrings, as well as hip abductors, adductors, and gluteal muscles;
for gait training we performed progressive exercise program consisting of strength training, stabilization
exercises and coordination exercises; the gait training progressed increasing the weight, speed and duration.
home-training exercises presented to be performed after inpatient program
Rehabilitation program
Questions (for assessment detailed answers see next page)

1. Why we should respect the kinetic algorithm program in our patient rehabilitation ?
a. Because ROM exercises must preceded the strength exercise
b. Because it is the patient option
c. Because it is performed total hip replacement
R=a

2. What are the components of the recommended home-training in our patient?

a. Initiate functional weight bearing exercises , open kinetic chain AROM and isotonic strengthening exercises
b. Initiate proprioception and gradual gait exercises
c. Closed chain exercises, resistive exercises, gait training on even surfaces, coordination activities
R=c

3. It is important to recover the neuromuscular status in our patient?

a. No
b. Yes
c. It is indifferent
R=b

4. The dysfunction in lower limb is optimally controlled in our patient?

a. Yes
b. No
c. It is no important
R=a
 Rehabilitation program
Questions` answers

1. Why we should respect the kinetic algorithm program in our patient rehabilitation ?
The range of motion, strengthening, and proprioceptive exercises of the involved joint should be initiated and progressed as
indicated and tolerated by the individual.

2. What are the components of the recommended home-training in our patient?

The principle components of home-training in our patient are: closed chain exercises when the patient demonstrates good pain
control, muscle strength, and balance; resistive exercises for the quadriceps and hamstrings are generally not used in the acute
phase of rehabilitation, but are commonly initiated within 2 months post-operatively; gait training on even surfaces, stair
training and, uneven terrain as indicated; balance and coordination activities; body mechanics and postural exercises.

3. It is important to recover the neuromuscular status in our patient?

Yes. Proprioception and balance are significant function for optimal rehabilitation. Hip joint proprioceptive testing may be
indicated depending on where the patient is in their postoperative course, as this may impact balance. Following hip
replacement, it is important to assess and document both static and dynamic balance in the sitting and standing positions.

4. The dysfunction in lower limb is optimally controlled in our patient?

Yes. Everyone heals differently, and everyone's total hip replacement is different, especially for secondary hip osteoarthritis.
After RP performed, our patient had optimal gait training, non weightbearing with crutches for 45 days, then with partial and
total weight bearing. She was help to progress from using an assistive device to walking independently; applied progression
for walking included: using walking support, crutches, cane when our patient went home. We recommended a home-training
program (muscles can gain both the endurance and the strength needed for everyday activities through controlled exercises,
patient should exhibit operative hip strength >=4+/5 MMT within 3 months following total hip replacement), so our patient
will maintain an optimal global function .