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Ok. Mhm. Hello everyone. My name is, uh, can you talk? And, uh, I'm gonna share my experience of dealing with patients with, uh, hip dysplasia. So this is the not the hip preservation team. That's where I work. Uh, we've got a very good fellowship program and, uh, has been through our ranks and, uh, the, the beauty is that all of the outcomes are collected and registered in the national, uh, uh, nonarthropod, we measure all our outcomes. Uh, so it's a fairly big team who look after these patients and, uh, indeed, uh, uh, come up with publications and presentations, uh, from the data that we collect. So key learning points, this place is common. Uh, I'll go through how, uh, you arrive at the diagnosis, what my, uh, uh, line of investigations would be and, uh, clearly, uh, the role of various, uh, procedures in managing these patients. So many years ago, Harris came up with, uh, this particular paper which had looked into the etiology of osteoarthritis. What Harris had proposed was that the idiopathic osteoarthritis is extremely rare and, uh, perhaps the cause of early arthritis in young people is because of an abnormality in the orientation of weight bearing zone, which is dysplasia of femoral head is Felicity which we now know is femoral establishment. Now, when we think about dysplasia, clearly, it comes in various sizes and shapes. But this is the first picture that comes to our mind, but this is now a rare occurrence. This perhaps is slightly more common where there is an incongruent hip. But when we are talking about hip preserving surgery, the kind of dysplasia that we want to see is what is in the last picture where there is clear shallowness of the component. And also, uh there is no arthritis and of course, you can reorient theta part or the femoral head to be able to correct the dysplasia. So that's what we are interested in when we talk about hip reserving surgery. How frequent is hip dysplasia? There have been various papers on it. Uh Well, population studies have shown that depending on the radiological parameter that we use, it can be anywhere between 5 to 10% and, uh, is dysplasia related to osteoarthritis against. Prevalent studies have shown that although 5 to 10% of people may have hip dysplasia, it's not related to self reported hip pain. However, there is a link between hip dysplasia and osteoarthritis. Now, if you look at um, a room full of, uh, people eagerly listening to a le lecture, almost 10% would have uh some degree of dysplasia. So, clearly, these pathologies are very common, both from rest impairment and hip dysplasia, but not all have pain and not all need any form of treatment. So, what are the reasons for it? There'll be genetic factors. So some people genetically will be predisposed to developing pain secondary to fa or dysplasia. There will be some environmental factors, not everyone's uh hips can cope with the demands that we put on them. So if uh someone who has got subtle dysplasia suddenly starts to run every day, clearly, the hip will not cope with it and they'll end up with pain. The third reason may be spinal pelvic alignment. A lot of where the hip is positioned relies on the balance between the spine and pelvis, which again is reliant on the muscles in the front and the back. And of course, the hamstring and the so and labral involvement, unless the labrum is torn, these patients will probably not develop any pain. So, coming back to spinopelvic alignment, the balance between the pelvis and the spine relies on the core muscles, the back muscles, the so tendon and the hamstring. And if there's any imbalance, the position of the pelvis will change. And then if the pelvis is forward tilted, it will be technically uh retroversion type issue or impingement type issue. When the pelvis is backward tilted, the front of the femoral head will become exposed. And these patients despite not having clear dysplasia will present with instability in the hip. So in simple terms, uh think about a shallow socket, which is compensated by a thick labrum. The femoral head actually articulating with the labrum and the stab. And there's a lot of sheer forces. And ultimately, the chondro lump lab junction will tell. And ultimately, these patients will develop pain depending on what the hip is going through. In terms of uh its function. It has been shown that if you remove the labrum, that the contact stress between the femoral head and the tab will increase by almost 90%. And it has also been shown that uh this particular event, the labral detachment is uh perhaps the key occurrence uh in uh patients developing pain. So they may be able to function very well. But once the labral tear happens, they will have pain and they will rapidly titrate. And uh what you can see on this particular image is uh what we call is it simply is calcification of the later. So be on the lookout for it. If you see it, then it's typically uh suggestive of a dysplastic hip with uh a lot of pressure going through the labrum and ultimately labrum calcifying. So this particular paper from the Mayo clinic looked at uh the natural history of osteoarthritis in patients with hip dysplasia and impingement. And it's one of the seminal papers uh that uh I would always quote to people. So, uh one of the measures of hip dysplasia is the lateral center angle. And I will show you how to exactly measure it. The normal is between 30 to 35 degrees. But if the angle is less than 25 then the proportion of patients progressing from to is zero to either to is three arthritis or a hip replacement actually increases. Similarly establish index which measures the angle of the roof of the stab is also uh uh uh quite indicative or quite predictive of what uh is going to happen in the future. So the normal angle is anywhere between 0 to 10. But if the angle increases beyond 10, the chance of progression from 0 to to 3 arthritis or hip replacement increases exponentially. So for every degree, decrease in central angle, the chance of developing arthritis increases by 10%. So quite significant uh uh figures. So the key learning point from the first part is that te dysplasia is common. Labral tear is perhaps the key event which leads to patients developing pain dysplasia is related to osteoarthritis and therefore, early detection is important. So how do we go about diagnosing dysplasia? Clearly, no one comes at the lab of uh hip dysplasia. No one comes and tells you that I've got hip dysplasia, but these patients typically will have pain, will typically have abduct fatigue because the joint reaction force is high and therefore, the abductors will be uh working extra hard and ultimately, they will develop pain. Some uh of these young females present with clicking and snapping, not just of the it band, but also of the ili. So sometimes they may complain of instability type feeling examination is key. The key thing that you would like to note is the range of movement. If the range of movement is stiff, typically, it's uh becoming arthritic. Typically, the role of hip preserving surgery becomes low apprehension test, which has been shown in this particular picture that you can see is uh basically done with the hip in extension, with the one trying to externally rotate the hip so that the femoral head comes and lies under the labrum. And patients may feel as if the hip is going to sublux, rotational profile of the femur is extremely important. So you have to measure it in prone to, you have to look at the tibial torsion along with the femoral version assessment, which can be done by clinical examination. So this is uh my quick examination, you make the patient walk, look at uh how their toes are pointing. If they are walking with indo, typically they have an increased femoral version, then you do a quick tender and test uh some of them. If their abductors are getting, we will have a positive test, then you ask them to straight like this and uh and uh most will be able to. But of course, if uh they are struggling to either the muscles are too weak or uh there may be some other problem clearly, this is a young person and uh you would uh uh check all the muscle strength, all the range of movements, do a proper examination, then do examine the patients in the on the side, ask them to lift the um the leg up to check the doctor's strength. And then uh then you can also do instability test here, which is what is going to be demonstrated. So you basically um at the moment, I'm just checking the doctor's strength, but uh then you can lift the leg up externally, rotate the leg and then uh extend. And if you are complaining of pain, then they typically have an unstable hip, similarly examination and prune.