Hypermobility Spectrum Disorder (HSD or hEDS) is attributed to a collagen abnormality associated with excessive joint flexibility. Approximately 90% of females with hip dysplasia have hypermobility. Manifestations of hypermobility in various body systems are unique to every patient, affecting different tissues of the body with varying degrees of severity. Our purposes were to identify the manifestations of hypermobility across multiple body systems and to study the recognition of hypermobility in the medical literature of multiple specialties over multiple decades. A literature search of the major medical disciplines for key words associated with HSD was performed. These specialties included gastroenterology, gynecology, neurology, psychiatry, oral-maxillofacial surgery, cardiology, and orthopaedic surgery. A specialty-specific impact factor (IF) score was calculated as the percentage of research articles that referenced hypermobility as a comorbidity over all articles within that specialty. Statistical differences were identified using single factor ANOVA with significance determined at p<0.05. We reviewed many published, specialty-specific manifestations of hypermobility, and describe them. All six non-orthopaedic specialties demonstrated a continually increasing relative IF ratio throughout the study period with a peak impact average of 0.22 (p<0.05 compared with other time ranges). There was a 93.3% overall increase in IF scores from the 1992–1998 period to the most recent period examined (p<0.05). Hypermobility is increasingly recognized as a significant health issue in multiple disciplines. Since dysplasia is associated with approximately 40% of all primary total hip arthroplasty cases, understanding the multi-system manifestations, and broad impact of hypermobility on patients, is relevant for every hip surgeon. We are expanding our research into other medical disciplines, including urology, ophthalmology, dermatology, clinical psychology, and others

To quantify the prevalence of Generalized Joint Hypermobility (GJH), aka Hypermobility Spectrum Disorder, in adult patients presenting with hip pain to a sub-specialty hip practice, this 4-year, prospective, observational study evaluated correlations with clinical, demographic, and baseline outcomes. 1,004 consecutive new hip patients (390 males, 614 females) were evaluated for GJH using the Beighton 9-point physical exam criteria and the Hakim-Grahame 5-item history questionnaire. Diagnosis, age, sex and race were tested as predictors of GJH. Patient reported outcomes from iHOT-12 and a modified Harris Hip Score (mHHS) were also assessed. There were 333 patients presenting with hip dysplasia over this period. Hip dysplasia (DDH) patients without osteoarthritis (OA) had a significantly elevated prevalence of GJH (77.9%) compared to non-dysplastic hip patients (32.8%, p<0.0001) or to patients with DDH+OA (35.7%, p<0.0001). The prevalence of GJH was significantly higher in females (OR=4.2, 95% CI: 3.2 to 5.5, p<0.0001) and inversely proportional to age. Hispanic patients presented with significantly lower prevalence of GJH compared with other races (p<0.05). GJH was not a predictor of patient-reported outcomes scores (p=0.51 for iHOT-12 and p=0.44 for mHHS). During the course of this study, we successfully performed our first PAO procedure on an outpatient basis (February 2019). That is currently our standard practice. With a strong correlation observed between hypermobility and developmental dysplasia of the hip (DDH), further research is warranted to explore the genetic basis and significance of this association

Greater trochanteric pain syndrome (GTPS) is a common and disabling hip condition. Hypermobility has been suggested as a possible cause of GTPS. The purpose of this study was to report the prevalence of hypermobility and to investigate its impact on hip-related function and awareness in patients with GTPS. This cross-sectional study was based on a cohort of patients diagnosed with GTPS in the 2013–2015 period. Hypermobility was investigated with the Beighton Score and defined by a cut-off score ≥5. Data on patients' current hip function and awareness were collected with the questionnaires the Copenhagen Hip and Groin Outcome Score and the Forgotten Joint Score. A total of 612 patients with GTPS were identified based on the diagnosis system; out of those, 390 patients were assessed for eligibility, and 145 (37%) were included. The prevalence of hypermobility within this cohort was estimated to be 11% (95% confidence interval (CI): 3–26%) for males and 25% (95% CI: 17–34%) for females. No significant association was found between hypermobility and self- reported hip function and awareness. We recommend that future studies of GTPS will include hypermobility and investigate the consequences of hypermobility among patients with GTPS

We have studied patients with Joint Hypermobility Syndrome (JHS) admitted to the Royal National Orthopaedic Hospital (RNOH) for a three-week in-patient rehabilitation programme. Ten patients were investigated at the start and end of this programme, and so far eight patients have been followed up at three months review. Postural stability was measured using a force plate, and the path of the centre of force (CoF) was tracked while patients were asked to attempt a series of more challenging tasks: double leg stance with eyes open and then with eyes closed, followed by single leg stance with eyes open and closed. Patients also completed a number of questionnaires at the same time points. We found the results of the double stance eyes closed test of postural stability to be the most informative. The ellipse area (EA) containing 95% of the points of the path of the CoF decreased from 21.5 + 14.8 cm2 to 9.0 + 11.5 cm2 over the course of the in-patient programme. In the eight patients followed up at three months, EA has remained the same (9.6 + 14.6 cm2). We conclude that the effects of the exercise programme and advice on subsequent exercise can be maintained over three months

Introduction: Hypermobility is a common finding, however, it lacks diagnostic parameters and is poorly understood, especially in the foot. Aim: To quantify medial column/first ray mobility in patients with midfoot arthritis and planovalgus feet. Methods: We compared first ray mobility in patients with radiologically defined midfoot tarsometatarsal osteoarthritis, a radiologically normal first ray and planovalgus feet, with control subjects who had normal feet and first rays. An all female group of 20 patients (mean age of 70) and 20 controls (mean age of 53) met the criteria. Analysis of patients’ x-rays identified the site of their arthritis and allowed angular measurements of their flat foot deformity. Patient and control subjects underwent identical examinations, recording hindfoot correctability, medial longitudinal arch appearance, hindfoot prontion and supination, forefoot supination and degrees of flexion/extension and abduction/adduction with an electronic goniometer. Each subject was graded by the AOFAS and SF-36 outcome scores. Results: There was a significant difference in first ray mobility between the patient and control subjects for all positions adopted (P=< 0.001), except when dorsiflexed and weight bearing (P=0.052). Patients with a neutral non-weight bearing ankle exhibited greatest mobility of 16.8 +/− 4.7 degrees compared to 9.4 +/− 2.6 degrees in controls. This was a significant difference, P=< 0.001, as was the difference between patients adopting the NWB plantarflexed, dorsiflexed and WB neutral positions. P=0.002, P=0.014, P=0.001 respectively. Patients’ median score for 5 out of 8 SF36 domains were considerably less than controls, as were patients’ AOFAS. Reduced physical and social functioning were shown to be linked to poor foot scores. Conclusion: Patients with planovalgus feet and tarsometatarsal OA have greater first ray mobility than controls with normal feet. Recognising this may help plan orthotic or surgical treatment

Background. Hyperlaxity is associated with a high incidence of shoulder dislocations. Collagen V regulates the diameter of fibrils of the abundant collagen type I. Decorin and biglycan are members of the small leucine rich proteoglycans(SLRP's)family and play important roles in the regulation of collagen fibrillogenesis. The aim of this study was to identify if there was a link in hyperlaxity, capsule strength, collagen V and SLRP's expression. Methods. Data was collected for 10 patients undergoing open shoulder stabilization for recurrent instability. Beighton score was used to assess hyperlaxity. Localization of Collagen V and SLRP's was studied by immunohistochemical staining of paraffin embedded sections of shoulder capsule. Grading of the stain was done on a 0-4 scale(0=no staining and 4=strong staining>50% of the slide)by three observers. Shoulder capsules were mounted on a material testing system and vertical load was applied to reach yield. Results. The mean force required for yield in 15 shoulder capsules was 45N(17-78). Data was analysed for Group A(weak group) with yield<45N(8 specimens) and Group B(strong group)with yield>45N(7 specimens). The mean age was 26 years and all were male. The mean force for group A was 31N(17-41) and group B was 59N(45-78). The mean Beighton score for group A was 1.9(0-4) and Group B was 2. 2 specimens in Group A had Beighton score>4 as compared to 0 in Group B, indicating hyperlaxity. The mean grading of collagen V expression in synovial surface was 2.6,Blood vessels(BV)1.6 and extracellular matrix(ECM)1.9 in Group A and 4,3.1 and 2.6 respectively in group B. The mean grading of decorin expression for shoulder capsule was 2.7 in Group A and 3.3 in group B. The mean grading of Biglycan expression in synovial surface was 2,BV 2 and ECM 2.9 in Group A and 2,2.5 and 4 respectively in group B. Conclusions. We found that weaker capsule specimen(group A)had higher incidence of hyperlaxity. Decorin and biglycan expression in ECM and Collagen V expression in synovial surface, BV and ECM of shoulder capsule was higher in group B(strong group). This study shows a link between hyperlaxity, strength, Collagen V and SLRP's expression in shoulder capsule

Background. Hyperlaxity is associated with a high incidence of sporting injuries. Collagen V regulates the diameter of fibrils of the abundant collagen type I. Decorin and biglycan are members of the small leucine rich proteoglycans(SLRP's)family and play important roles in the regulation of collagen fibrillogenesis. The aim of this study was to identify if there was a link in hyperlaxity, tissue strength, collagen V and SLRP's expression. Patients and methods. Data was collected for 25 patients. 12 had open shoulder stabilization and 13 had primary ACL reconstruction. Beighton score was used to assess hyperlaxity. Localization of Collagen V and SLRP's was studied by immunohistochemical staining of the paraffin embedded sections of the skin. Grading of the stain was done on a 0-4 scale(0=no staining and 4=strong staining>50% of the slide)by three observers. Tissue specimens were mounted on a material testing system and vertical load was applied to reach yield. Results. The mean force required for yield in 43 tissue specimens was 70N(12-171). Data was analysed for Group A(weak group)with yield<70N(21 tissue specimens)and Group B(strong group)with yield>70N(22 specimens). The mean age was 27 years. The mean force for group A was 41N(12-67)and group B was 98N(70-171). The mean Beighton score for group A was 3.4(0-9)and Group B was 1.9(0-5). 9 specimens in Group A and 4 in Group B had Beighton score>4 indicating hyperlaxity. The mean grading of collagen V expression in skin dermal papilla was 2.4, appendages 2.2 and extracellular matrix(ECM)1.8 in group A and 1.3,1.8 and 1.7 respectively in Group B. The mean grading of decorin expression in skin was 3.2 in group A and 3.1 in Group B. The mean grading of biglycan expression in skin epidermis was 1.5, appendages 2.2, ECM in superficial dermis 1.5 and deep dermis 0.75 in group A and 1.75,2.1,1.5 and 0.5 respectively in Group B. Conclusion. We found that weaker tissue specimen had high incidence of hyperlaxity and increased grading of expression for Collagen V in the skin dermal papillae. No difference was found in SLRP's expression in skin in both groups. The study shows a link between hyperlaxity, tissue strength and Collagen V expression in skin dermal papillae

Hypermobility is an acknowledged risk factor for patellar instability. In this case control study the influence of hypermobility on clinical outcome following medial patellofemoral ligament (MPFL) reconstruction for patellar instability was studied. A total of 25 patients with hypermobility as determined by the Beighton criteria were assessed and compared with a control group of 50 patients who were matched for age, gender, indication for surgery and degree of trochlear dysplasia. The patients with hypermobility had a Beighton Score of ≥ 6; the control patients had a score of < 4. All patients underwent MPFL reconstruction performed using semitendinosus autograft and a standardised arthroscopically controlled technique. The mean age of the patients was 25 years (17 to 49) and the mean follow-up was 15 months (6 to 30). Patients with hypermobility had a significant improvement in function following surgery, with reasonable rates of satisfaction, perceived improvement, willingness to repeat and likelihood of recommendation. Functional improvements were significantly less than in control patients (p < 0.01). Joint hypermobility is not a contraindication to MPFL reconstruction although caution is recommended in managing the expectations of patients with hypermobility before consideration of surgery

This study was performed to assess the incidence of generalised ligament laxity in patients presented with recurrent shoulder dislocations.

Prospective data was collected for 38 patients with recurrent shoulder dislocations and 43 patients with clavicle fractures as a control group between May 2007 and July 2009, including demographic details, mechanism of injury, number of dislocations and hyperlaxity. Clinical examination was used to assess the ligament laxity using the Beighton score.

The mean age was 29 years with a range from 14-40 years. There were 36 males and 2 females. The left shoulder was involved in 21 patients; right in 13 patients and 4 patients had bilateral shoulder dislocations. The average number of dislocations was 3 with a range from 2-17, while the average number of subluxations was 4.5 with a range from 0-35. The average Beighton score for the patients with recurrent shoulder dislocations was 2.8 with a range from 0-8. 17 patients (45%) in this group had a Beighton score of 4 or more as compared to the control group that had only 12 patients (27%) There was a statistically significant difference between the 2 groups with a P value of < 0.05. 8 patients (21%) fulfilled the Brighton criteria for BJHS. The most common cause of recurrent shoulder dislocation was sports related injuries in 26 patients (68%). The most common sport was football in 14 patients (37%) followed by rugby in 10 (26%) patients.

We looked at the incidence of generalised ligament laxity in patients with recurrent shoulder dislocations and found a statistically significant difference as compared with the control group. 21% of the patients fulfilled the Brighton criteria for BJHS but 45% had a Beighton score of 4 or more. Appropriate advice should be given to these patients with hyperlaxity and the timing of shoulder stabilisation should be carefully decided.

Understanding spinopelvic mechanics is important for the success of total hip arthroplasty (THA). Despite significant advancements in appreciating spinopelvic balance, numerous challenges remain. It is crucial to recognize the individual variability and postoperative changes in spinopelvic parameters and their consequential impact on prosthetic component positioning to mitigate the risk of dislocation and enhance postoperative outcomes. This review describes the integration of advanced diagnostic approaches, enhanced technology, implant considerations, and surgical planning, all tailored to the unique anatomy and biomechanics of each patient. It underscores the importance of accurately predicting postoperative spinopelvic mechanics, selecting suitable imaging techniques, establishing a consistent nomenclature for spinopelvic stiffness, and considering implant-specific strategies. Furthermore, it highlights the potential of artificial intelligence to personalize care.

Cite this article: Bone Joint J 2024;106-B(11):1206–1215.

Introduction: Growing pains are a common complaint in school age children, but no definite organic causes have been identified. An association between musculoskeletal pain and joint laxity has been proposed. This study therefore investigates the relationship between growing pains and joint hypermobility in children.

Materials and Methods: Thirty three children with growing pains and thirty one controls of similar age and sex were recruited from outpatient clinics of a specialist paediatric hospital. Joint hypermobility was assessed in each group using the Beighton score. A Beighton score of greater than or equal to 4 out of 9 was considered hypermobile.

Results: The median Beighton scores were 6 for the study group and 0 for the control group. 93.3% of the study group had a Beighton score of equal to or greater than 4, compared to 22.6% of the control group. There was a highly significant difference in Beighton score between the two groups (P< 0.0001), with an estimated difference of 4 points 95% CI 4–6.

Discussion and Conclusion: A link between joint hyper-mobility and musculoskeletal symptoms has been demonstrated in adults. There is also some evidence that hypermobile children are more likely to experience musculoskeletal pain, particularly articular, but the extent to which joint hypermobility is related to growing pains specifically has been poorly defined. We have investigated a selective population of children with growing pains and have shown them to be significantly more hypermobile than the control children. The aetiology of growing pains remains unclear. While the growing pains will get better, in view of the possible association of joint hypermobility and other musculoskeletal complains, these children should be carefully assessed for joint laxity.

Introduction

The mechanisms of how spinal arthrodesis (SA) affects patient function after total hip replacement (THA) remain unclear. The objectives of this study were to a) Determine how outcome post-THA compares between patients with- and without-SA, b) Characterize sagittal pelvic changes that occur when moving between different functional positions, and test for differences between patients with- and without-SA, and c) Assess whether differences in sagittal pelvic dynamics are associated with outcome post-THA.

Two individuals with generalised articular hypermobility are described. There are many affected members in both kindreds, and the pedigrees indicate that the disorder is transmitted as an autosomal dominant trait. Orthopaedic complications and deformities are common in one family but absent in the other. It is suggested therefore that the two disorders are distinct and separate genetic entities.

Background: Generalised joint hypermobility (GJH) has a prevalence of approximately 5% in the general population. There might be an association between GHJ and some low back pain. The Beighton Criteria are 9 tests that are widely used to diagnose GJH but it is time-consuming to perform all nine tests.

Purpose: To evaluate which of the nine Beighton tests is the most accurate as a screening test for GHJ. To investigate the relationship between hypermobility and age, gender, and ethnicity.

Methods: From the last 10 years archives at the Back Centre Funen 17,117 patient records were examined. All nine Beighton tests had been performed in 4,062 patients. Data on the nine Beighton tests and age, gender, and ethnicity were extracted.

Results: There was a selection bias in this clinical sample, as the prevalence of GJH was 14.6%. All tests showed an overall accuracy of > 85.2 % as single-item screening tests for GJH in low back pain patients. Extension of the dominant elbow > 10o was the most accurate screening test with an overall accuracy of 93.9 %, sensitivity 76.6 % specificity 96.9 %. There was a higher prevalence of GJH in women (22.8%) than men (3.8%) and in young patients (28.0%) than in older patients (2.5%). No difference in the prevalence of GJH was observed between the patients with Danish ethnicity and non-Danish ethnicity.

Conclusion: Extension of the dominant elbow > 10o was the single most accurate of the nine Beighton tests as a screening test for GJH in patients with low back pain.

Unidirectional instability with or without hyperlaxity can be adressed as such; mostly traumatic changes like Bankart or capsule lesions are seen and they can be treated with the standard arthroscopic suture techniques.

Multidirectional instability (MDI) with or without hyperlaxity is quite rare. In the literature MDI is often mentioned, but most of the time it refers to multidirectional laxity with unidirectional instability. During arthroscopy often capsular redundancy is seen without obvious pathological changes. Several series have been described where arthroscopic capsulorraphy has shown to be reasonably succesfull Since the introduction of thermal shrinkage several series have been published, with poorer results compared to capsular shift: failure rates vary between 11 to 36%. The possible reason of this high failure rate is that 1) many patients with multi-directional laxity are included, 2) as well as the fact that after time the effect of the shrinkage disappears due to regeneration of the capsule. Posterior instability. In posterior subluxation, often posttraumatic, with hyperlaxity frequently as accompanying phenomenon, arthroscopic capsulorraphy has been rather successful. My personal series of 10 patients showed a failure rate of 50%. Shrinkage has been applied for this indication as well, with varying results. Since 1998 13 patients with posterior subluxations were treated in our hospital with shrinkage after the failure of extensive physical therapy. After 1 yr follow-up most of them were stable; after 18–24 months follow-up all showed recurrence of the posterior instability. The pain, often accompanying the subluxation, was however still absent at the latest follow-up.

Multidirectional instability with or without hyperlaxity is a not well defined clinical entity; for this reason the results of several treatment modalities are often not comparable. Posterior instability, especially subluxations are often posttraumatic, with some accompanying hyperlaxity. In both pathological conditions arthroscopic capsulorraphy seems to be more effective than shrinkage

Aims

Spinopelvic mobility plays an important role in functional acetabular component position following total hip arthroplasty (THA). The primary aim of this study was to determine if spinopelvic hypermobility persists or resolves following THA. Our second aim was to identify patient demographic or radiological factors associated with hypermobility and resolution of hypermobility after THA.

Purpose: In 1996, we reported the results of 65 coracoid blocks for chronic anterior instability. We found 6% true recurrence and 34% persistent apprhension. In order to improve these results, we modified our operative technique, associating capsuloplasty in the event of hyperlaxity. The purpose of the present work was to assess mid-term results.

Material and methods: Eighty-eight coracoid blocks were performed between 1995 and 2000 by the same operator. In 41 cases, the classical technique was used. In 47 cases we associated capsuloplasty. The indication for surgery was documented recurrent instability in all cases, with radiographic, MRI or endoscopic confirmation of an anteroinferior capusloligament lesion. Capsuloplasty was associated if signs suggested hyperlaxity: self-reducing dislocation, absence of notch, external rotation arm to body (RE1) greater than 80°, presence of a significant groove, laxity of the inferior flap of a T capsulotomy. Mean patient age was 24 years (14–42) and mean follow-up was 40 months (24–60). Clinical results were assessed with the Duplay criteria and three x-rays were obtained (standard AP, Lamy lateral view and glenoid lateral view).

Results: Eighty-five percent of the patients achieved a good or very good result according to the Duplay criteria. Eighty-eight percent of the blocks held without modification and 12% developed osteolysis. There were no cases of degeneration. One patient experienced recurrent dislocaion. The rate of persistent apprehension declined (12%) compared with our earlier experience. This improvement was achieved at the cost of greater loss of RE1 in the group with capsuloplasty (−20° versus −8°), but without impact on sports activity (82£% returned to their sports activities including 72% at the same level without significant difference between the groups with and without capsulotomy).

Discussion: These results demonstrate that capsuloplasty is warranted if there are signs of hyperlaxity. This technique allowed us to improve results concerning recurrence and persistent apprehension at the cost of less mobility but without effect on sports activities. We detail the objective criteria used to define hyperlaxity and describe the usual clinical expression of radiographic, arthroscopic, and arthroscopic findings.

As it remains unproven that hypermobility of the first tarsometatarsal joint (TMTJ-1) is a significant factor in hallux valgus deformity, the necessity for including arthrodesis of TMTJ-1 as part of a surgical correction of a hallux valgus is questionable. In order to evaluate the role of this arthrodesis on the long-term outcome of hallux valgus surgery, a prospective, blinded, randomised study with long-term follow-up was performed, comparing the Lapidus procedure (which includes such an arthrodesis) with a simple Hohmann distal closing wedge metatarsal osteotomy. The study cohort comprised 101 feet in 87 patients: 50 feet were treated with a Hohmann procedure and 51 with a Lapidus procedure. Hypermobility of TMTJ-1 was assessed pre-operatively by clinical examination. After a mean of 9.25 years (7.25 to 11.42), 91 feet in 77 patients were available for follow-up. There was no difference in clinical or radiological outcome between the two procedures. Also, there was no difference in outcome between the two procedures in the subgroup clinically assessed as hypermobile. This study does not support the theory that a hallux valgus deformity in a patient with a clinically assessed hypermobile TMTJ-1 joint requires fusion of the first tarso-metatarsal joint.

Cite this article: Bone Joint J 2013;95-B:1222–6.

Introduction: The increasing use of Arthroscopic surgery for recurrent anterior shoulder dislocations (RASD) has questioned the indications and contraindications for this procedure. The ideal candidate for this kind of surgery is an overhead athlete, who participates in a noncontact sport, with traumatic unidirectional anterior instability with a well-defined Bankart lesion. Purpose of the paper: To demonstrate that complementing the Arthroscopic Bankart Repair (ABR) with an Arthroscopic Rotator Interval Closure (ARIC) the indication for Arthroscopic management of Anterior shoulder instability can be broaden for patients who has a less defined Bankart lesion and has additional multidirectional hyperlaxity. Patients and Methods: Between January 1, 1999 and December 31, 2002, 166 patients (175 shoulders) suffering from recurrent anterior dislocations were treated by ABR. In the first two years, only patients who had unidirectional instability with no Hyperlaxity or grade 1 Hyperlaxity were selected for this specific method of treatment. Encouraged by the results, beginning of October 2001, in addition to the first group of patients we started to operate patients suffering of recurrent dislocations having grade 2 or grade 3 Hyperlaxity. In this second group of patients we added to the ABR an ARIC procedure. In the first group 130 shoulders whereas in the second group 45 shoulders were operated on. We used Panalok-Panacryl Smith and Nephew 3.5mm x2 Ethibond sutures (OBL) suture anchors or Bioknotless (Mitek) anchors. 157 cases had one side operated whereas in 9 cases both sides were operated on. There were 150 male patients and 16 females in these two groups, 91 patients had the left shoulder, 66 patients had the right shoulder and nine patients had both shoulders operated on. The mean follow-up was 3 years ranging between 4.5 to 1.7 years. Results: In spite of the relatively short follow-up for the second group of patients we encountered very good preliminary results. At revision of all the cases we found 9 recurrences for the ABR group (representing 6.9%) in comparation of the one reoccurrence in the ABR supplemented by ARIC procedure (2.2%). Conclusions: The ARIC is a new technique that broadens the indications for Arthroscopic shoulder surgery as a solution for recurrent dislocations associated with joint Hyperlaxity