Original Article|Articles in Press

Relationships among hip instability, iliofemoral ligament, and pain in patients with developmental dysplasia of the hip

Published:March 15, 2023DOI:



      To evaluate the relationships among hip instability, pain, and morphology of the iliofemoral ligament (ILFL) in patients with developmental dysplasia of the hip (DDH) using ultrasonography (US).


      We reviewed 86 patients (109 hips) with DDH (Group D), 40 patients (46 hips) with borderline hip dysplasia (BDDH) (Group B) and 20 patients (23 hips) without hip pain and bony abnormality (control group). Group D was classified into three subgroups—the severe (group SP), moderate (group MP), and none/mild (group NMP) hip pain groups—using the visual analogue scale (VAS). For evaluating hip instability and ILFL morphology, the distance between the anterior edge of the anterior inferior iliac spine (AIIS) and the horizontal line to the femoral head, and ILFL thickness were measured using US. The difference between the distance in the neutral position and Patrick position was calculated and defined as the femoral head translation distance (FTD).


      FTD and ILFL thickness in group D were significantly larger than those in the control group and group B (P < 0.05). There was a significant positive correlation between FTD and ILFL thickness in three groups (r = 0.57, P < 0.05; r = 0.55, P < 0.05; r = 0.62, P < 0.05, respectively). FTD and ILFL thickness in group SP were significantly larger than those in group NMP (P < 0.05). FTD and ILFL thickness in group D had significantly negative correlations with the lateral center edge (r = −0.54, P < 0.05; r = −0.40, P < 0.05, respectively) and vertical-center-anterior angle (r = −0.51, P < 0.05; r = −0.43, P < 0.05, respectively).


      Acetabular bony deficiency, especially in the anterior and lateral region can result in antero-posterior hip instability, leading to thickened ILFL and hip pain, even in patients with BDDH. These findings may facilitate our understanding and treatment of patients with DDH. When hip instability is suspected, hip US examination may help confirm the diagnosis and assist in providing objective clinical diagnostic evidence.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Orthopaedic Science
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Reijman M.
        • Hazes J.M.W.
        • Pols H.A.P.
        • Koes B.W.
        • Bierma-Zeinstra S.M.A.
        Acetabular dysplasia predicts incident osteoarthritis of the hip: the Rotterdam study.
        Arthritis Rheum. 2005 Mar; 52: 787-793
        • Bolia I.
        • Chahla J.
        • Locks R.
        • Briggs K.
        • Philippon M.J.
        Micro-instability of the hip: a previously unrecognized pathology.
        Muscles Ligaments Tendons J. 2016 Jul-Sep; 6: 354-360
        • Morvan J.
        • Bouttier R.
        • Mazieres B.
        • Verrouil E.
        • Pouchot J.
        • Rat A.C.
        • et al.
        Relationship between hip dysplasia, pain, and osteoarthritis in a cohort of patients with hip symptoms.
        J Rheumatol. 2013 Sep; 40: 1583-1589
        • Tang H.C.
        • Dienst M.
        Surgical outcomes in the treatment of concomitant mild acetabular dysplasia and femoroacetabular impingement: a systematic review.
        Arthroscopy. 2020 April; 36: 1176-1184
        • McWilliams D.F.
        • Doherty S.A.
        • Jenkins W.D.
        • Maciewicz R.A.
        • Muir K.R.
        • Zhang W.
        • et al.
        Mild acetabulardysplasia and risk of osteoarthritis of the hip: a case-control study.
        Ann Rheum Dis. 2010 Oct; 69: 1774-1778
        • Swarup I.
        • Zaltz I.
        • Robustelli S.
        • Sink E.
        Outcomes of periacetabular osteotomy for borderline hip dysplasia in adolescent patients.
        J Hip Preserv Surg. 2020 July; 7: 249-255
        • Hu B.
        • Safran M.R.
        Hip instability: anatomic and clinical considerations of traumatic and atraumatic instability.
        Clin Sports Med. 2011 April; 30: 349-367
        • DombBG PhilipponMJ.
        • GiordanoBD
        Arthroscopic capsulotomy, capsular repair, and capsular plication of the hip: relation to atraumatic instability.
        Arthrosc J Arthrosc Relat Surg. 2013 Jan; 29: 162-173
        • Jackson T.J.
        • Peterson A.B.
        • Akeda M.
        • Estesss A.
        • McGarry M.H.
        • Adamson G.J.
        • et al.
        Biomechanical effects of capsular shift in the treatment of hip microinstability: creation and testing of a novel hip instability model.
        Am J Sports Med. 2016 Mar; 44: 689-695
        • Kalisvaart M.M.
        • Safran M.R.
        Microinstability of the hip-it does exist: etiology, diagnosis and treatment.
        J Hip Preserv Surg. 2015 Jul; 2: 123-135
        • Klaue K.
        • Durnin C.W.
        • Ganz R.
        The acetabular rim syndrome. A clinical presentation of dysplasia of the hip.
        J Bone Joint Surg Br. 1991 May; 73: 423-429
        • Safran M.R.
        • Lopomo N.
        • Zaffagnini S.
        • Signorelli C.
        • Vaughn Z.D.
        • Lindsey D.P.
        • et al.
        In vitro analysis of peri-articular soft tissues constraining effect on hip kinematics and joint stability.
        Knee Surg Sports Traumatol Arthrosc. 2013 Jul; 21: 1655-1663
        • Martin H.D.
        • Savage A.
        • Braly B.A.
        • Palmer I.J.
        • Beall D.P.
        • Kelly B.
        The function of the hip capsular ligaments: a quantitative report.
        Arthroscopy. 2008 Feb; 24: 188-195
        • Ito H.
        • Song Y.
        • Lindsey D.P.
        • Safran M.R.
        • Giori N.J.
        The proximal hip joint capsule and the zona orbicularis contribute to hip joint stability in distraction.
        J Orthop Res. 2009 Aug; 27: 989-995
        • Van Arkel R.J.
        • Amis A.A.
        • Cobb J.P.
        • Jeffers J.R.T.
        The capsular ligaments provide more hip rotational restraint than the acetabular labrum and the ligamentum teres: an experimental study.
        Bone Joint Lett J. 2015 Apr; 97-B: 484-491
        • Myers C.A.
        • Register B.C.
        • Lertwanich P.
        • Ejnisman L.
        • Pennington W.
        • Giphart E.
        • et al.
        Role of the acetabular labrum and the iliofemoral ligament in hip stability: an in vitro biplane fluoroscopy study.
        Am J Sports Med. 2011 Jul; 39
        • Cheng S.C.
        • Hulse D.
        • Fairbairn K.J.
        • Clarke M.
        • Wallace W.A.
        Comparison of dynamic ultrasound and stress radiology for assessment of inferior glenohumeral laxity in asymptomatic shoulders.
        Skeletal Radiol. 2008 Feb; 37: 161-168
        • Yeap J.S.M.A.
        • Humphries L.
        • Wallace A.L.
        Ultrasonic evaluation of anterior shoulder translation in normal shoulders.
        J Musculoskelet Res. 2003 Apr; 2: 125-134
        • A d'Hemecourt P.
        • Sugimoto D.
        • McKee-Proctor M.
        • Zwicker R.L.
        • Jackson S.J.
        • Novais E.N.
        • et al.
        Can dynamic ultrasonography of the hip reliably assess anterior femoral head translation?.
        Clin Orthop Relat Res. 2019 May; 477: 1086-1098
        • Lequesne M.
        • de Seze S.
        False profile of the pelvis. A new radiographic incidence for the study of the hip. Its use in dysplasias and different coxopathies.
        Rev Rhum Mal Osteoartic. 1961 Dec; 28: 643-652
        • Wiberg G.
        Studies on dysplastic acetabula and congenital subluxation of the hip joint: with special reference to the complication of osteoarthritis.
        Acta Chir Scand. 1940 July; 115: 81
        • Lequesne M.
        • de Seze S.
        Le faux profil du bassin: nouvelle incidenceradiographique pour l etude de la hanche. Son utilit e dans les dyspla-sies et les differentes coxopathies.
        Rev Rhum. 1961; 28: 643-652
        • Fredensborg N.
        The CE angle of normal hips.
        Acta Orthop Scand. 1976; 47: 403-405
        • Mc Auliffe S.
        • McCreesh K.
        • Purtill H.
        • O'Sullivan K.
        A systematic review of the reliability of diagnostic ultrasound imaging in measuring tendon size: is the error clinically acceptable?.
        Phys Ther Sport. 2017 Jul; : 52-63
        • Safran M.R.
        Microinstability of the hip—gaining acceptance.
        J Am Acad Orthop Surg. 2019 Jan; 27: 12-22
        • Gilles B.
        • Christophe F.K.
        • Magnenat Thalmann N.
        • Becker C.D.
        • Duck S.R.
        • Menetrey J.
        • et al.
        MRI-based assessment of hip joint translations.
        J Biomech. 2009 Jun; 42: 1201-1205
        • Wilkin G.P.
        • Ibrahim M.M.
        • Smit K.M.
        • Beaulé P.E.
        A contemporary definition of hip dysplasia and structural instability: toward a comprehensive classification for acetabular dysplasia.
        J Arthroplasty. 2017 Sep; 32: S20-S27
        • Chung C.Y.
        • Park M.S.
        • Lee K.M.
        • Lee S.H.
        • Kim T.K.
        • Kim K.W.
        • et al.
        Hip osteoarthritis and risk factors in elderly Korean population.
        Osteoarthritis Cartilage. 2010 March; 18: 312-316
        • Hewitt J.D.
        • Glisson R.R.
        • Guilak F.
        • Vail T.P.
        The mechanical properties of the human hip capsule ligaments.
        J Arthroplasty. 2002 Jan; 17: 82-89
        • Tateuchi H.
        • Akiyama H.
        • Goto K.
        • So K.
        • Kuroda Y.
        • Ichihashi N.
        Gait- and posture-related factors associated with changes in hip pain and physical function in patients with secondary hip osteoarthritis: a prospective cohort study.
        Arch Phys Med Rehabil. 2019 Nov; 100: 2053-2062
        • Kato Y.
        • Shoji T.
        • Inoue T.
        • Fujiwara Y.
        • Junichi S.
        • Mori R.
        • et al.
        Evaluation of antero-posterior instability of the hip using modified Lequesne's false profile view.
        J Orthop Sci. 2022 Feb; 5 (S0949-2658(22)00021-5.