Research Advances in Pediatric Hip Preservation Surgery at UPMC Children’s

Standardizing and Improving Diagnostic Accuracy for Nonarthritic Hip Pain: Leading the Way Toward Optimal Presurgical Planning and Quality Long-Term Outcomes

Nonarthritic hip pain in young, active pediatric orthopaedic patients presents a number of diagnostic and treatment challenges to obtain optimal long-term outcomes in hip preservation. Foremost in this clinical situation is a profound lack of consensus among pediatric orthopaedic surgeons on optimal treatment approaches, particularly in cases of mild or borderline hip dysplasia. Diagnostic criteria used to determine the degree of severity of dysplasia – the current gold standard being lateral center edge angle – remain a somewhat suboptimal guide because of the inherent gray area of mild or borderline cases. Treatment approaches for mild hip dysplasia – periacetabular osteotomy and hip arthroscopy – both have benefits and downsides, but again, there is a lack of consensus on how best to apply these surgical approaches to the spectrum of cases in the mild to borderline range.

“What it comes down to is as a field we do not have a unified approach to how we diagnose these cases, nor is there uniformity or consensus on which treatment approaches are best for specific clinical scenarios. Surgeons tend to offer or recommend the procedure type they are most comfortable and experienced at performing, but I believe that approach is not optimal for our patients,” says Michael P. McClincy, MD, pediatric orthopaedic surgeon and hip specialist at UPMC Children’s Hospital of Pittsburgh.

To begin to grapple with these dilemmas in the field of pediatric hip preservation surgery, Dr. McClincy and collaborators from Boston Children’s Hospital led a multicenter study to lay the groundwork for developing a standardized approach to the diagnostic evaluation of patients with nonarthritic hip pain. Results from the study are currently in press and will be published in a forthcoming edition of the Orthopaedic Journal of Sports Medicine.

The study, “Standardizing the Diagnostic Evaluation of Non-Arthritic Hip Pain Through the Delphi Method,” pooled the resources of a panel of 18 orthopaedic surgeons (both adult and pediatric specialists) who have considerable expertise and surgical experience in nonarthritic hip pain and concomitant disorders (femoroacetabular impingement and acetabular dysplasia.)

Panelists were recruited to undergo a series of three iterative rounds of surveys based on four clinical patient scenarios chosen to cover as wide a spectrum as possible of hip pain attributed to a nonarthritic pathology or morphology. The research team used the Delphi method to sequentially hone and obtain consensus on various aspects and criteria of the presurgical diagnostic evaluation.

"There is very little in the literature that has been done with this patient population to establish best practices for diagnosing and ultimately treating non-arthritic hip pain, the vast majority of which is due to impingement or dysplasia. Our study is a good first salvo across the field to bring about consensus in how we talk about these patients – how we diagnose them. If we are not all working from the same set of standards and criteria, it is essentially impossible to make comparisons to determine the reliability or repeatability of diagnosis, how that translates to or informs treatment decisions, or how we conduct further research to expand the evidence base," says Dr. McClincy.

Highlights from the Findings 

Surgeons participating in the survey process all reviewed the same four clinical scenarios, which included a short patient history and description of the pain along with an accompanying anterior/posterior x-ray of the pelvis. Each surgeon was then asked a series of six questions to elicit their responses in how they would proceed with diagnosing the patient. These questions included what historical patient information would be queried, the nature of physical examinations to perform, imaging to obtain, or other diagnostic tasks that would inform the surgeon's ultimate diagnosis.

At the conclusion of the survey and Delphi process, clinical consensus (defined as greater than 75%) on various aspects of the four clinical cases was obtained, albeit not 100% across all four cases and all establishing criteria.

One aspect of the diagnostic evaluation that did achieve consensus across all four cases was a standardized sequence of radiographs to obtain in these cases consisting of a standing AP pelvis, 45° Dunn view, and false-positive views.

Also finding consensus across cases was the use of magnetic resonance (MR) arthrogram and computed tomography (CT) scan.

"We did realize clinical consensus across a rather broad range of the relevant patient history, x-ray sequences to obtain and their clinical interpretation, and other diagnostics. This work puts on the path to grounding our approach to nonarthritic hip pain in the same language using the same tools at our disposal in order to more uniformly, and perhaps in the end better diagnosis these cases," says Dr. McClincy. "However, this is only the start of what will be a long process of research and development to refine and further expand our uniformity and efficacy in the diagnosis and treatment of these cases."

References

1. McClincy MP, et al. Standardizing the Diagnostic Evaluation of Non-Arthritic Hip Pain Through the Delphi Method. Orthop J Sports Med. 2020. In Press.

More About Dr. McClincy

Michael P. McClincy, MD, is an assistant professor of orthopedic surgery. Dr. McClincy earned his medical degree and completed his residency training at the University of Pittsburgh School of Medicine. He then completed fellowships in pediatric sports medicine and pediatric and adolescent hip preservation, both at Boston Children’s Hospital, before returning to Pittsburgh to join UPMC Children's in 2018. Prior to medical school, Dr. McClincy graduated from Dartmouth College with a degree in mathematics. While at Dartmouth, he also was a member of the football team, playing four years as a defensive lineman.

Dr. McClincy’s clinical areas of focus are hip preservation surgery, arthroscopic knee and shoulder surgery, and sports medicine. Fellowship training allowed Dr. McClincy to study
and practice sophisticated hip preservation techniques, such as hip arthroscopy and osteotomies of the acetabulum and proximal femur. His research is focused mainly on the study of hip pathology and improving interventional capabilities for patients with a variety of hip morphologies, from dysplasia to impingement. His interests extend to exploring the biomechanics of the hip in young athletes, especially those that fall between the spectrums of impingement and instability. Dr. McClincy has active research interests in femoroacetabular impingement and hip dysplasia surgery in adolescents and young adults.