American Journal of Medical Genetics Part C (Seminars in Medical Genetics) 175C:188–194 (2017) ARTICLE

Orthopaedic Management of the Ehlers–Danlos Syndromes

WILLIAM B. ERICSON JR.* AND ROGER WOLMAN

The role of orthopedic surgery in Ehlers–Danlos syndrome is inherently controversial, opaque to most patients and many medical providers, and difficult to discern from available medical literature. Non-operative treatment is preferable, but for carefully selected patients, specific joint stabilization and nerve decompression procedures can provide symptomatic relief when conservative measures fail. © 2017 Wiley Periodicals, Inc.

KEY WORDS: orthopedic surgery; Ehlers–Danlos syndrome; joint stabilization; nerve decompression; musculoskeletal treatment How to cite this article: Ericson Jr. WB, Wolman R. 2017. Orthopaedic management of the Ehlers–Danlos syndromes. Am J Med Genet Part C Semin Med Genet 175C:188–194.

INTRODUCTION to help determine the cause of the medicine specialist, patient’s complaints, and recommend Ehlers–Danlos Syndrome (EDS) is a treatment, based on the specific muscu- rheumatologist) in the care connective disorder that in the ortho- loskeletal diagnosis or diagnoses. It is pedic realm involves joint hypermobility of EDS patients is to help extremely important for the physician to (JH). JH is not always painful, but if so, understand the context in which the determine the cause of the (1) is difficult to diagnose without highly joint problem occurs, and that the ’ specialized training, (2) does not show patient s complaints, and physician understands the individual on standard diagnostic tests, (3) does not recommend treatment, based patient’s specific needs and expecta- respond to standard treatment protocols, tions. This requires a thorough under- on the specific musculoskeletal (4) lowers the threshold for associated standing of the bodily manifestations of joint injuries, (5) causes premature diagnosis or diagnoses. EDS as well as extensive knowledge of wearing of joints, and (6) results in a the pathophysiology other painful con- higher failure rate for treatment, both ditions that cause similar, overlapping medical and surgical. symptoms, and appreciating how these The authors have extensive experi- EDS is often either not diagnosed problems are affecting the individual ence with patients with JH issues, and or misdiagnosed, and the situation can person being treated. the following is a brief summary, be extremely frustrating for the patient describing a general approach to patients as well as the physician and other with EDS and JH. The authors do not caregivers. In spite of this, there is specifically endorse, approve, recom- much that can be done for EDS patients. The role of the mend, or certify any specific procedure The role of the musculoskeletal specialist musculoskeletal specialist or technique, and provide these opin- (e.g., orthopedic surgeon, physiatrist, ions for general information only. Such rehabilitation medicine specialist, rheu- (e.g., orthopedic surgeon, information should not be considered matologist) in the care of EDS patients is physiatrist, rehabilitation medical advice and is not intended to

William B. Ericson Jr., M.D., F.A.A.O.S., F.A.C.S., F.A.E.N.S., is a board certified orthopedic hand surgeon, and a graduate of MIT and Harvard Medical School. He has a special interest in painful conditions that do not show on standard diagnostic tests, which include small joint instability and peripheral nerve disorders. He has a large experience with Ehlers–Danlos syndrome patients. Roger Wolman, M.D., F.R.C.P., F.F.S.E.M., trained in Rheumatology and Sport and Exercise Medicine. He has written on Exercise following Brain injury and Exercise and Arthritis. He practices holistic medicine and has a strong belief in the health benefits of exercise. In the NHS, he runs an Exercise Prescription clinic with the aim of replacing medication with Exercise as the most effective way of managing many chronic diseases. His practice at Spire Bushey incorporates these areas into his general Rheumatology and Sports Medicine clinics. *Correspondence to: William B. Ericson Jr., M.D., F.A.A.O.S., F.A.C.S., F.A.E.N.S., Ericson Hand Center—Research, 6100 219th Street SW Suite 540, Mountlake Terrace, WA 98043. E-mail: [email protected]; [email protected] DOI 10.1002/ajmg.c.31551 Article first published online 13 February 2017 in Wiley Online Library (wileyonlinelibrary.com).

ß 2017 Wiley Periodicals, Inc. ARTICLE AMERICAN JOURNAL OF MEDICAL GENETICS PART C (SEMINARS IN MEDICAL GENETICS) 189 replace consultation with a qualified not something that can be learned from normal radiographs tend to physician. Complex musculoskeletal medical literature or online courses; one mislead the physician(s). The problems may best be served by a must be educated by a hands-on Multi-Disciplinary Team (MDT) ap- approach, with direct physical contact. first clue that there is a JH proach including physicians (surgeons, Not all JH is related to EDS, and problem would be a painful rheumatologists, pain consultants), there is controversy regarding labeling physiotherapists, occupational thera- EDS patients with their specific pheno- joint with normal radiographs. pists, psychologists, and nurses. A coor- type. It would be helpful in terms of dinated team can help to plan tracking patients and further determin- management more effectively and can ing likely patterns of associated clinical In a sense, EDS causes premature include a comprehensive inpatient (or problems to know their exact genetic aging of the musculoskeletal system. outpatient) pain management program. group, but, in a practical sense, one must Many of the musculoskeletal problems still deal with the involved painful joints, that can afflict anyone, if they live long whether or not the group or subgroup is enough, occur simultaneously in EDS MEDICAL LITERATURE known. Labeling patients can increase patients, at an earlier age, and unfortu- There is sparse information in the their fear and anxiety, particularly when nately also tend to cause overlapping medical literature regarding the role of unfiltered information is freely available symptoms. It can be particularly chal- “ orthopedic surgery in patients with on the internet, and once labeled, the lenging for a physician to disambigu- ” ’ EDS, particularly successful surgery. resulting bias can cause misinterpreta- ate the root cause(s) of the patient s For example, a recent review article tion of subsequent symptoms by treating symptoms. on EDS in the Journal of Hand Surgery physicians for other conditions that may EDS patients often have nerve discusses the presentation of patients not be related to EDS. pain, presumed to be related to with EDS and reviews the phenotypes, traction and/or compression of the but does not discuss any surgical peripheral nerves. This type of procedures that might be appropriate BASICS nerve problem does not typically for patients with EDS [Christophersen damage the nerves, but causes pain The medical term for partial dislocation where the nerves end, not where they and Adams, 2014]. Many journal articles “ ” of a joint is subluxation, and EDS are compressed, and unfortunately refer obliquely to the higher rate of patients have frequent subluxation and complications, treatment failure, and does not show on electrodiagnostic occasional dislocation of large and small tests, and can be refractory to treat- patient/provider dissatisfaction with joints. The asymmetric loading of the surgical intervention [Freeman et al., ment. Referred pain from nerve joint surfaces as the joint subluxes problems can mimic joint pain from 1996] but often lack detailed analysis or contributes to the early wear of the joint explanation of why surgery did not go instability, and this feature of EDS/JH surface, and it takes very little injury to seriously complicates the lives of EDS well [Weinberg et al., 1999]. Under the “ ” “ ” make a loose joint loose and painful. patients and their physicians. best of circumstances, it would be At least some of the pain is from stretch difficult to form discrete, reliable gen- receptors near the joints, and/or from eralizations about the role of orthopedic swelling of the lining of the joints. This CLINICAL PRESENTATION surgery in EDS patients from the source of pain is not reflected by available medical literature. Determin- diagnostic studies, at least in the early EDS patients tend to present with ing the correct and complete diagnoses stages, and physical examination for joint multiple complaints, specifically vague, in an EDS patient can be a difficult task, instability is not routinely taught outside intermittent pain involving the limbs or and the risks of all of the known hazards of orthopedics, and is not taught consis- spine. Doctors have a tendency to seek a of surgical intervention are distinctly tently for all joints within orthopedics. simple, single diagnosis or unifying ’ higher in EDS patients. With JH and EDS, the joints are approach (the invocation of Occam s The multiple forms of EDS also often painful long before there are Razor), such as a attributing joint pain to “ ” have widely varying clinical manifesta- radiographic changes; normal radiographs a sprain, even when there has been no tions [Shirely et al., 2012], and there is tend to mislead the physician(s). The first injury per se, or invoking the label “ ” inherent genetic heterogeneity that clue that there is a JH problem would be a fibromyalgia when there is widespread further complicates any attempt at painful joint with normal radiographs. pain. As the treatment fails, and diagnos- abstraction of published data. There is tic testing become more exhaustive also considerable unfamiliarity among but remains negative, patients often medical professionals regarding the clin- drift between different specialists— ical history, physical exam, diagnostic With JH and EDS, the joints rheumatology, neurology, orthopedics, testing, treatment, or long-term impli- pain management—without a firm cations of joint instability. And, unfor- are often painful long before diagnosis or successful treatment plan. tunately, diagnosing joint instability is there are radiographic changes; Patients with EDS have increased rates of 190 AMERICAN JOURNAL OF MEDICAL GENETICS PART C (SEMINARS IN MEDICAL GENETICS) ARTICLE clinical depression [Berglund et al., simultaneously, and a medication that 2015], which can seriously complicate reduced pain in all sore joints would be physician and patient interpretation of beneficial and desirable. Unfortunately, strictly subjective complaints. Patients Managing patients prior to oral medication for EDS patients is with EDS are often labeled as the considering surgical problematic: Medications do not change problem, rather than their arm or leg. the underlying cause of the pain, and Physician burnout (emotional exhaus- intervention is best performed often have side effects that negate their tion, depersonalization, and low job by a comprehensive, efficacy. satisfaction) in orthopedic surgeons is multifaceted approach to care EDS patients often have a high endemic in the United States [Daniels incidence of gastroesophageal reflux et al., 2016], and is likely to have more of delivered by knowledgeable [Castori, 2012], and often cannot take an impact on EDS patients, with their EDS providers. non-steroidal anti-inflammatory drugs numerous, unexplained symptoms, and (NSAIDs), or require a second medica- seemingly unsolvable problems. tion (e.g., acid blocking, acid reducing, Successful surgery in general or antihistamine) to protect the stomach. depends on the correct diagnosis (or NON-SURGICAL Acetaminophen does not irritate the in the case of EDS patients, diagno- TREATMENT OPTIONS FOR stomach, but is often insufficient for ses), establishing realistic expecta- EDS PATIENTS pain relief, and large doses can be toxic to tions, and superlative technical Generally speaking, non-surgical op- the liver [Fontana, 2008]. Chronic use of expertise. In EDS patients, it tends tions for treatment of joint pain should opioid medications tends to result in to be much harder to determine the be exhausted prior to recommending tolerance and patients are at risk ’ exact cause or causes of the patients surgery. The following is a partial list of for dependence. Opioids are also pain, expectations of the patient treatments that may help avoid the risks central depressants, and tend to make and/or physician may be unrealistic, of surgery. postural issues worse, and can result in and technical difficulties can have “central sensitization,” where normal much more serious consequences. In physical stimulus becomes interpreted spite of this, for patients with painful Acute Pain as painful. There is also a growing instability of joints or peripheral legislative trend to restrict or suppress nerve compression, surgery may be Pain may be from an acute event, or a doctors from prescribing narcotics, ow- the only treatment that reliably results chronic pattern. In the acute setting, the ing to the recent rapid increase in fatal “ ” in persistent pain relief. standard orthopedic R-I-C-E (Rest, overdoses. Gabapentin and Pregabelin Ice, Compression, Elevation) treatment are similar and also anxiolytic, but is safe and can be effective. It is not associated with weight gain. Naltrexone PAIN RELIEF particularly effective or practical in the has been used off-label for chronic pain Pain relief is a clear goal of every EDS chronic setting. Associated joint injuries with some success [Younger et al., 2014]. patient. Surgery is often the last resort such as anterior cruciate ligament and “Splints” can be quite helpful for for EDS patients, and may be the only meniscal tears in the knee, labral and specific types of joint instability. Several reasonable option for some conditions, rotator cuff tears in the shoulder, wrist splint manufacturers make braces for such as wrist or thumb instability, but instability, thumb joint subluxation, most large joints, including the spine, also may not be an option at all. For labral tears in the hip, and lateral ankle which can be extremely helpful as part example, the tissues around an unstable ligament tears are much more common of a coordinated treatment program. joint may be so lax that NO surgical in the EDS patient population; the usual Splints limit joint motion, and can procedure will ever be successful. EDS treatment options for any patient with therefore limit pain, but may or may patients have a higher incidence of an acute musculoskeletal injury are not result in increased stability, and if bleeding complications, and wider appropriate for most EDS patients. used consistently can make muscles scars, and less predictable healing. weaker through disuse. Special purpose This does not mean they should not finger splints are particularly effective for Chronic Pain have surgery, but optimal treatment “Swan Neck” hyperextension deformi- would include involvement of a sur- In the chronic setting, there are multiple ties of the finger proximal interphalan- geon with knowledge and experience options that may be effective. Patients geal (PIP) joints, and can also be specifically with EDS patients. Manag- and physicians would both appreciate an effective in many patients for the ing patients prior to considering surgi- “oral medication” that results in effective thumb metacarpal–phalangeal (MP) and cal intervention is best performed by a pain relief, especially when diagnostic carpal–metacarpal (CMC) joints. comprehensive, multifaceted approach testing is normal but patients are obvi- “Physical therapy” and “exercise” to care delivered by knowledgeable ously suffering. EDS patients often programs are essential components to EDS providers. have multiple joints that are sore successful pain relief in patients with ARTICLE AMERICAN JOURNAL OF MEDICAL GENETICS PART C (SEMINARS IN MEDICAL GENETICS) 191

EDS (See also “The Evidence-Based “Dietary considerations” are be- incisions are advisable. Joint stabilization Rationale for Physical Therapy Treat- coming more important and the so- procedures in EDS patients have a ment of Children, Adolescents and called “anti-inflammatory” diets are in higher rate of recurrence of instability, Adults Diagnosed With Joint Hyper- vogue these days. There may be clearer but it is lower for non-weight bearing moblity Syndrome/Hypermobilie Eh- indications for specific dietary recom- joints such as the wrist and thumb. The lers–Danlos Syndrome” by Engelbert mendations in the future. “Weight lower extremity is less forgiving. Nor- et al., this issue). Exercises that empha- control” is a major imperative for any mal diagnostic tests and a higher failure size low-impact, isometric and eccentric patient with EDS. “Bone health,” with rate should not preclude surgical inter- strengthening, proprioception, and im- adequate calcium intake and appropriate vention in the EDS population, but proved posture can be extremely help- vitamin D levels, is very important. serious prudence is advised. ful. Physical therapy can be used Exercise is also an important component effectively to increase core muscle of bone health, but is problematic as Cervical Spine strength, and to stabilize specific joints physical activities can easily exacerbate such as the spine, shoulder, and knee. pain related to instability. Craniocervical instability and Arnold– Exercise programs, often self-directed, Chiari malformation may absolutely that do not take into account that EDS require surgical intervention. Upright SURGICAL TREATMENT patients have loose joints but tight MRIs are advisable when evaluating the OPTIONS FOR EDS muscles are doomed to failure. Exercise cervical spine. Cervical spondylosis is PATIENTS programs that emphasize “range of common, and discectomy and fusion motion” exercises or repetitive, forceful EDS patients are at increased risk from may be necessary. However, making one actions such as “work hardening” are any form of surgery, and the outcomes segment of the spine rigid tends to inappropriate and can make patients’ are less predictable. The decision to increase the load at each end of the joint symptoms worse. recommend an orthopedic operation fusion site, and “next-segment” disease needs to be carefully considered, ideally has a much higher incidence in patients through close collaboration between the with JH. Minimally invasive techniques, patient, the musculoskeletal physician, when appropriate, are preferred. JH is a Exercises that emphasize the orthopedic surgeon, and the multi- relative contraindication for artificial disciplinary team. disks. low-impact, isometric and Surgery is an option for a select number of specific conditions in EDS eccentric strengthening, Thoracic Outlet proprioception, and improved patients, but there remains very little in the surgical literature to support this Thoracic outlet “symptoms” are com- posture can be extremely approach. The rate of failure of surgical mon in EDS patients, and are often helpful. Physical therapy can intervention is clearly higher in EDS related to Thoracic Outlet Syndrome patients, particularly for conditions (TOS). The thoracic outlet is the space be used effectively to increase where ligaments are repaired, but an- where nerves and blood vessels to the core muscle strength, and to other cause of failure is the fundamental arm pass from the neck/chest area into assumption errors that are made during the arm. The nerves in this area are stabilize specific joints such as the diagnostic process. That is to say, the subject to compression from the anterior the spine, shoulder, and knee. cause of the patient’s pain was some- scalene and pectoralis minor muscles, thing other than what was operated on. and the 1st rib. They are also subject to In the opinion of one author (Ericson), tension from inferior shoulder subluxa- “Local anesthesia” injections can be this is particularly true in the upper tion in patients with JH (causing helpful in determining the source of extremity. This type of error is more thoracic outlet “symptoms” related to pain. It should be noted that the most likely to occur when the patient and posture and joint laxity). Compression common forms of local anesthesia, his/her concerns are not the complete and/or tension on the nerves in this area xylocaine, and bupivacaine, are now focus of the medical appointment. cause symptoms where the nerves end, known to be specifically and highly In spite of this, EDS patients have not where they are pinched or pulled. cytotoxic to chondrocytes [Chu et al., multiple problems for which surgery The result is vague hand/arm pain that 2010], and ropivacaine should be used may be the only reasonable option, if the unfortunately overlaps with the other preferentially for intra-articular injec- diagnosis can be made correctly. With areas that tend to be painful in patients tions. EDS patients are often resistant to upper extremity surgery, at least in one with loose joints. Physical therapy is lidocaine and bupivacaine [Hakim et al., author’s experience (Ericson), most essential for this condition. Botox 2005], a fact underappreciated by most EDS patients do not have significant injections into the anterior scalene or physicians. Anecdotally, carbocaine problems with wound healing or bleed- pectoralis minor muscles can give tends to work better in EDS patients. ing. Scars tend to be wider, so smaller tremendous relief if the patient has 192 AMERICAN JOURNAL OF MEDICAL GENETICS PART C (SEMINARS IN MEDICAL GENETICS) ARTICLE

TOS. Surgery may be indicated in Wrist occur in anyone [Adams and Habbu, recalcitrant cases, but detaching stabiliz- 2015] can also be present in EDS Wrist pain is a common complaint in ing muscles in loose-jointed patients can patients, and respond well to surgery, if EDS patients. EDS patients tend to have definitely make patients worse. TOS is necessary and the diagnosis is correct. unstable ankles, knees, and hips, and an inherently complex and controversial frequently fall on their outstretched topic in the medical community hands. This wrist trauma can convert [Moore, 1986; Parker and Parker, Lumbar Spine loose wrist joints into painful loose wrist 2002; Wehbe, 2004; Illig et al., joints. Physical therapy and hand exer- Lumbar spondylosis is common, and 2013] and seriously complicates the cise often make this type of wrist pain spine surgery in terms of laminectomy lives of many patients with EDS. worse. Surgical stabilization of the wrist or fusion is not uncommon. Cauda works reasonably well for radiocarpal, Equina Syndrome is a concern for any Shoulder midcarpal, and distal radioulnar joint patient with EDS or JH who presents instability [Buchler,€ 1996]. Intercarpal with severe back pain and radicular Shoulder instability is a very common fusions have a role, but can create load symptoms, particularly with leg weak- problem in EDS patients, but fortu- imbalance and loss of motion that can ness or perineal numbness, incontinence nately responds well to physical therapy also be painful. Painful instability of the or sudden onset of sexual dysfunction. in most patients. The goal of therapy is pisiform is common, and responds well This can require emergency surgery to to increase the resting tone of the rotator to surgery. Proximal median nerve prevent permanent paralysis and loss of cuff muscles, without overpowering the entrapment causes intermittent severe bladder/bowel control. deltoid, which can cause bursitis and/or wrist pain with pronation, and can be impingement. Radiographs and MRI treated successfully with surgery if the are typically normal. Surgery in the diagnosis can be made. Hip form of a Neer Inferior Capsular Shift can be extremely helpful in stabilizing Hip pain is common in EDS patients. the shoulder [Neer and Foster, 1980; Thumb Lateral hip pain is common and may Pollock et al., 2000]. Possible compli- occur as a result of the iliotibial band cations include recurrent instability, and Thumb problems are almost universal in subluxing over the greater trochanter. joint stiffness. In patients with very, very EDS patients. A painful unstable non- This often produces a painful, loud loose shoulders this procedure has a high arthritic thumb CMC joint can be clunking sensation (which the patient failure rate and should be approached stabilized surgically, with a good prog- often interprets as the hip dislocating). cautiously. nosis [Eaton and Littler, 1973]. Unfor- This can lead to trochanteric bursitis Rotator cuff and labral tears are not tunately, radiographs do not correlate which makes if difficult for patients to uncommon and are more likely in with symptoms [Hoffler et al., 2015], sleep on their sides. This may show patients with excess joint motion. and patients must be examined carefully edema in the bursa on MRI, and usually Surgery is indicated for full thickness by specialists with extensive subspecialty responds to physical therapy and steroid tears that remain painful. Possible com- training. Thumb MP joint hyperexten- injections (which should be avoided if plications include recurrent tears and sion instability can be treated with soft possible). In recalcitrant cases, endo- joint stiffness. tissue stabilization and/or extensor pol- scopic surgery can give tremendous licus brevis tenodesis, or more reliably relief, if the diagnosis is correct [Red- with arthrodesis. Painful clicking at the mond et al., 2016]. Labral tears are much Elbow thumb interphalangeal joint is caused more common in EDS patients, and hip Both lateral and medial humeral epi- by sesamoiditis, and is treated with arthroscopy to remove or repair this type condylitis are more common in EDS sesamoidectomy. of tear can give tremendous relief of patients. Radial tunnel syndrome is also pain, although long term evidence for very common in EDS patients. These this procedure is lacking. Sacroiliac (SI) Fingers problems often resolve spontaneously or joint instability is very common in EDS with physical therapy or other modali- Hyperextension of the proximal inter- patients, and presents as vague low back/ ties, such as Platelet Rich Plasma phalangeal joints of the fingers is pelvic pain. This often responds well to (PRP) injections [Rabago et al., 2009; common in EDS patients. This may be physical therapy, if the diagnosis is made. Glanzmann and Audige, 2015], but entirely asymptomatic. If painful, or if Prolotherapy for isolated SI joint insta- when persistent and refractory to other the fingers catch or lock because of this, bility can be helpful but remains treatment modalities, surgery can be a digital Figure-of-eight splints are ex- controversial. Braces to stabilize the SI reasonable option. Literature support is tremely helpful. Surgery is an option if joint can be helpful for episodic pain. lacking. Posterolateral rotatory instabil- the splints fail, but this type of surgery is Surgery for SI joint instability is rarely ity of the elbow may also be an issue in technically challenging and has a higher necessary but can give immediate and patients with JH and EDS. failure rate. Tendinopathies that can permanent relief of pain. Hip pain may ARTICLE AMERICAN JOURNAL OF MEDICAL GENETICS PART C (SEMINARS IN MEDICAL GENETICS) 193 also be radicular pain from disk failure at give out on uneven ground, and often if the correct diagnosis can be made and L4–L5. If the radiographs and/or MRI causes falling. The ankle may also be the right patient population is selected. of the hip are normal, the pain is likely injured by the fall, and can become more Peripheral nerve compression also re- referred pain from the lumbar spine. In unstable. Ankle braces and orthotics sponds well to surgical decompression, if this setting, if the lumbar spine is work reasonably well in many patients, the correct diagnosis can be made. With normal, the patient could also have but are cumbersome. Soft tissue proce- multiple overlapping complaints that are Piriformis syndrome, which usually dures around the ankle have a high linked anatomically, it is no wonder that responds to physical therapy or chiro- failure rate, and wound problems are patients and providers struggle to provide practic are if the diagnosis is made. common. Malalignment of the hindfoot answers and solutions. Successful treat- can result in imbalance that exacerbates ment of EDS patients requires the care- any underlying knee, hip or back givers to have extensive knowledge of instability or malalignment. Physical anatomy and physiology, as well as Hip pain is common in EDS therapy and orthotics are the mainstay treatment options, including surgery, patients. Lateral hip pain is of treatment, but talotarsal stabilization and extensive resources in terms of surgery can be helpful [Graham, 2015]. diagnostic testing, physical therapy, and common and may occur as a consultation/coordination of treatment with knowledgeable providers. result of the iliotibial band Foot subluxing over the greater Bunions are common in EDS patients. If trochanter. This often the bunion is not painful it should best be REFERENCES left alone. Metatarsalgia is also common. produces a painful, loud Adams JE, Habbu R. 2015. Tendinopathies of the Steroid injections may seem like a good hand and wrist. J Am Acad Orthop Surg clunking sensation (which the idea for metatarsalgia, but will often 23:741–750. weaken the soft tissues and make this Berglund B, Pettersson C, Pigg M, Kristiansson P. patient often interprets as the 2015. Self-reported quality of life, anxiety hip dislocating). This can lead problem worse. 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