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Hip Pain in Teens and Children – Q & A

Dr. Ernest Sink, Adolescent and Child Hip Specialist and Chief of the Hip Preservation Service, Answers Questions about Hip Pain in Teens and Children

Describe the typical patient who comes to see you at the Center for Hip Preservation.

So the typical patient who comes to see me is somebody in adolescence or young adulthood, or even a child under age 10 that complains of pain in the hip or groin pain that limits their sports or activities that they do on a day to day basis.  That is one large group of patients that come to see me.  The other group is the baby hips, and the infants, that had screening after birth by their pediatricians and found a hip that was dislocated or their risk factors for hip dysplasia, which is an abnormality of the ball and socket that may lead to later arthritis in an older age, or an adolescent age.  So the most patients that see me, the reason they come is for hip pain.

What kind of surgery do you specialize in and when is it needed?

Two main surgeries is why I came to hospital for special surgery. One is called the periacetabular osteotomy, which was developed in Bern, Switzerland. That is a procedure that allows us to redirect the acetabulum and place it into a better position so the hip functions better. In hip dysplasia, the problem is often that the acetabulum is not, or the socket is not covering the ball, the thermal head, and the periacetabular osteotomy allows us to effectively reorient the hip socket to a better position and try to preserve the hip. Another surgery that I do that my expertise was wished to be here is what's called the surgical dislocation of the hip. The hip joint is very deep inside the hip, and many of the problems haven't been recognized until we are able to really look completely at the hip socket and the ball, and that can be done through surgical hip dislocation, which is a safe approach, again, developed in Switzerland, that allows us to disarticulate or take the two pieces of the hip apart and fix the abnormalities that have led to pain or improve them to try to improve the patient's pain and function through their life. There's arthroscopic approaches, which are good for a majority of patients, but then there -- some patients need the open procedure because of the limited exposure you can get from an arthroscopic approach. And I was asked to join the faculty as those two things are my area of expertise.

How does a parent or referring physician know that a child or teen needs your expertise?

I think anybody with chronic hip pain that is limiting their activities on a day to day basis or their sports should be evaluated by a physician or a surgeon that sees hip problems on a day to day basis. Hip pain is just not one of those normal-- unlike back pain or other knee pain, it's just not one of those normal things that people suffer from on a day to day basis. And so, if anybody has any pain on a day to day basis that limits them or with sports, I think they need a good evaluation of the hip, including radiographs and exam, as many of the problems that can lead to eventual arthritis can be subtle. And the thing about hip specialty is seeing hip problems on a day to day basis you can realize that some of these subtleties early on can lead to major problems later.

When should a child or adolescent come to see you?

Different ages have different criteria to come to see me. So if the pediatrician examines a hip and feels that it's unstable after birth, then they should come and see us. The other time is if a family has a risk factor for hip dysplasia or problems in a newborn, then we should evaluate that child, specifically if the exam and/or ultrasound testing is abnormal. As far as older children, those with problems specific to pediatric orthopedics such as Perthes disease or slipcapothermalpithesis [phonetic], which are deformities of the upper femur, should be evaluated by a pediatric orthopedist or a hip specialist. And any adult or adolescent with chronic hip problems or hip pain that is more than just one or two days, that last for a specific time where it affects their quality of life, they should come and see me.

How do you work with referring physicians?

When a referring physician sends a patient to me, the first thing I will guarantee is that the family gets a complete assessment of what's going on and good education. So, when they go back to the referring physician, they don't ask the referring physician a lot of questions because our visit was two seconds and they don't know what, why they came here. So, I make sure education is a key component of it. And then, I will make sure the referring physician understands completely what my assessment was on that day. And either by phone calls, notes, or conversations, assure the referring physicians that their patient was taken care of.

Does hip dysplasia always need surgery?

Children with dysplasia don't always need surgery and our hope is that they won't have surgery. If hip dysplasia is found early on, either in-- after birth or in the perinatal period, then we can treat it effectively with bracing in the majority of cases. And, if it's mild, it might just need to be observed to make sure that it improves.

What's the difference between dysplasia and developmental dysplasia?

Developmental dysplasia of the hip is where it describes a pathology where the hip socket doesn't completely support the ball or femoral head, and there is a large variety of hip dysplasia. It can either be so bad that the hip is dislocated at birth to the hip slightly moves out of the joint to where it's dysplastic, but there's no abnormal exam findings. And oftentimes, a patient like that won't present until older age. So hip dysplasia is a large spectrum of disease from, as I mentioned, dislocation to subluxation, meaning the hip moves within the socket, to something that is nearly impossible to pick up until painful at an older age.

Is hip pain in an adolescent normal? How does a parent know it's not growing pains?

So, growing pains in, is more common in the under age ten group. And those are pains where the child runs and plays and at night they hurt. Both legs hurt. Knees hurt. Hips hurt. The next day, they get up and they run and they do everything they want to do. They don't have any other associated findings such as fever or weakness, loss of appetite, etcetera. So, what hip pain is that is specific that needs to be evaluated is one or both hips that's in the groin area or even around the side and it stays. It doesn't get better. So, hip pain in adolescence is different than growing pains. Growing pains is, as I said, more common in the younger child. After they run and play, they get up the next morning and they run and play and they don't seem to be limited by it, at all.

How do you identify a hip problem in a newborn?

There are certain risk factors for hip dysplasia in newborns, such as a family history of hip problems, a breech child, or any abnormal exam or other findings, such as foot deformity, et cetera. And I think now children with risk factors are usually recommended that we do an ultrasound at 4 to 6 weeks of age to make sure that the hip is normal, or doesn't have dysplasia. And so they should be evaluated by their pediatrician or us here to ensure the families and the children with risk factors get appropriate evaluation and treatment.

What is the most common condition that you see?

The condition I see most frequently is the adolescent with hip pain. It's most commonly females, but can be males, with a history of doing sports or activities that require major hip flexion. What happens is, because they spend a lot of their time doing activities where the hip moves beyond its normal constraints, it can lead to some pain and even some injury to the hip, and they eventually present to myself or somebody else at the Hip Center here with discomfort. And then we evaluate them for any abnormality that would require treatment.

What's the long-term impact of current developments in diagnosis and preservation for those with chronic hip pain?

I think our goal is to preserve the hip joint.  And the diagnostic ability to detect hip disease is getting better and better.  The radiologists here at a hospital for special surgery are experts at picking up subtleties.  And we provide constant feedback.  We work together on a day-to-day basis to make sure that we are diagnosing the problem correctly.  And over time, and with research and feedback and discussions with a radiologist, I think we can have even better diagnostic ability to pick up some of the subtle problems that cause hip pain.

What can be done nonsurgically for patients experiencing chronic pain?

I've been very pleased since I've been here at the Hip Center that our therapists work very closely with us. And I think the therapy protocols that we're developing and that are already developed at this center for preoperative, postoperative patients and non-operative patients are second to none. We are making sure that physical therapy is a key component on a day-to-day basis in patient care, such that if they undergo big surgery, we want athletes back to sports as quickly as possible. And oftentimes that requires very specific regimens to manage their muscles and their soft tissues after surgery to get them back to their activities that they enjoy as quickly as possible. And so what we hope to do both preoperatively and postoperatively on patients is to maximize their rehabilitation to help them get back to activities, and patients that we don't believe need surgery, we want to make sure -- or that don't want surgery yet or we're trying to prevent surgery -- that our therapy protocols do everything possible to delay or prevent surgery in the first place.

What is your background and how did you decide on this specialty?

Well, I did a pediatric orthopedic fellowship in San Diego, and at that time, when I was a fellow, hip disease and managing hip disease is a big part of the fellowship there as they have experts in pediatric and young adult hip disease in San Diego. And so I, that initiated a groundwork of fascination with the hip joint. And then when I was at Denver Children's, after a few years, I realized that whenever a patient with a hip problem was shown in the conference or that I was managing, I really had passion about this part of the practice. And so I decided to follow my passion and to do extra training going to Boston and then to Switzerland with Professor Ganz, learning more about complex hip pathology and how to manage it. And from there, it just took off. It became part of my practice at my prior job, and I committed to understand and to take care of hips and mostly hips for the rest of my career, and over time, it has just become a self-fulfilling prophecy that I just follow my bliss, and every day I enjoy looking and  evaluating and seeing the patients and problems with hips.

What made you decide to come to Hospital for Special Surgery?

I think the thing that brought me here was the ability to work with Brian Kelly and the other surgeons in the hip center to make the best hip center in the world, where people could come and feel like they receive world-class evaluation and care.  And teaming up with the other surgeons here at Hospital for Special Surgery gave me a form or a platform to create something that is the best hip center in the world, from birth to young adulthood, where we could really try to make an impact on preserving hip joints and delaying or preventing hip arthritis.

As co-director of the Center for Hip Preservation at Hospital for Special Surgery, what are your goals?

I think the goals of the Center for Hip Pain and Preservation, as co-director working with the other surgeons and non-operative people, is to create a center of excellence where people from all over the world can come and know that they will get an expert evaluation and that we will create a treatment that's best for them. The fact that we have non-operative surgeons here, we have arthroscopic surgeons here, we have open surgeons here, we have total joint surgeons here. We're not limited by only offering treatment that we know how to do. We offer what's best for the hip. And then make sure they are appropriately managed by the person here at the Center for Hip Pain and Preservation that is the expert in managing that.

What sort of research is taking place in the Center for Hip Preservation?

Research is important at the Center for Hip Pain and Preservation to make sure we have the most effective treatment for patients specific to their problem. So all patients are placed into a registry so we can get good feedback, almost our own Consumer Reports, so over time we can effectively guarantee the best treatment for every specific problem.

In light of the rapidly developing orthopedic landscape, where do you see the field in 10 years?

In 10 years, it may look completely different than it does now. The wonderful thing since I've been here at the Center for Hip Pain and Preservation is that there's a large diversity and large volume of patients and families to be seen. And the hip preservation has only been around for a short period of time in orthopedics, five to 10 years. So daily we're learning, and being here, I've been just absolutely elated that the amount of patients that come to see us allow us to just be better and better at picking up subtleties and problems. So with the combination of research and seeing a large volume of patients, we think -- we hope in five to 10 years that anybody in the world that really wants a good judgment and an honest judgment of their hip and to have the best opportunity to have their hip pain resolved and preserve their hip, that they think that the Center for Hip Pain and Preservation is some place where they have to go and be evaluated.


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