Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version

Current advances and research in ultrasound imaging to the assessment and management of musculoskeletal disorders

Currently evidence-based practice has given scientific weight to the physical therapist profession; it is essential that all medical professional and physical therapists know the usefulness of new tools that optimize the effectiveness of their interventions and allow the growing of the scientific knowledge base. The use of ultrasound imaging (USI) by physiotherapists has evolved in recent years, consolidating as an increasingly standardized technique, low cost compared to other imaging techniques, quickly of execution, feasible and reliable tool. USI offers a wide range of opportunities in clinical practice as well as in different research areas. Therefore, ultrasound has been currently used as a diagnostic tool by physicians and in recent years there has been an expansion of the use of ultrasound equipment by non-physicians professionals such as physical therapist or physical trainers, who incorporates USI as a means of assessing musculoskeletal system architecture and composition, musculoskeletal changes in dysfunction, pain or injury conditions, as an interventional technique assisting echo-guided procedures or using the visual real-time information as a biofeedback in control motor approaches, as guiding tool in clinical decisions as well as to improve the understanding of tissue adaptations to exercise or movement. The purpose of this article is to review and provide an overview about the currently research of the USI applications and their benefits for the diagnosis and management in individuals with musculoskeletal conditions.

A Contemporary Look at the Evaluation and Treatment of Adult Borderline and Frank Hip Dysplasia

BACKGROUND

Adult hip dysplasia is often diagnosed according to the lateral center-edge angle (LCEA). Patients with frank hip dysplasia (LCEA <20°) traditionally require treatment with bony realignment through a periacetabular osteotomy (PAO) and/or derotational femoral osteotomy, while patients with borderline hip dysplasia (BHD) present a challenging treatment dilemma, as it remains unknown when they should be treated with hip arthroscopy and/or a PAO.

PURPOSE

To perform a narrative review to report the differences in hip morphology and clinical outcomes between adult patients with frank hip dysplasia and BHD.

STUDY DESIGN

Narrative review.

METHODS

A systematic search of the literature was conducted through the Medline, EMBASE, and Cochrane databases with the search phrase borderline hip dysplasia.

RESULTS

The search identified 305 articles, of which 48 were considered relevant to this study after screening of titles and abstracts. Four articles discussed new radiographic means of evaluating adult hip dysplasia, 16 articles analyzed morphology of dysplastic hips, and 28 articles described the clinical outcomes of patients with frank hip dysplasia or BHD treated with hip arthroscopy and/or PAO. Because the level of evidence obtained from this search was not adequate for systematic review or meta-analysis, a current concepts review on the diagnosis, hip morphology, and clinical outcomes of patients with frank hip dysplasia or BHD is presented.

CONCLUSION

Adult hip dysplasia is most commonly diagnosed based on the LCEA; however, the LCEA is an unreliable sole marker for dysplasia, and additional radiographic parameters should be utilized. Furthermore, specific pathology identified on imaging and/or during hip arthroscopy can provide clues to a surgeon when the diagnosis is inconclusive according to history and physical examination alone. While the data support that patients with frank dysplasia are best treated with PAO, there is no such preferred treatment for patients with BHD, who have a wide spectrum of instability. Selective use of arthroscopic labral and capsular treatment alone may provide good results in carefully chosen patients with BHD, while some may end up requiring a bony realignment procedure.

Editorial Commentary: Treating Hip Impingement Without a Computed Tomography Scan? You Might as Well Operate With a Blindfold

Hip impingement is defined as a bony conflict between the femur and acetabulum occurring throughout normal or supraphysiological range of motion. Traditionally, the cause was attributed to reduced femoral head-neck offset and/or excessive acetabular coverage, giving rise to cam, pincer, and mixed impingement. However, recent outcome studies showing less favorable results of hip arthroscopy in patients with femoral and acetabular version abnormalities have sparked renewed interest in the pathomechanics of hip impingement. We now have a greater appreciation for the 3-dimensional scope of the problem through specialized computed tomography sequencing allowing assessment of the entire limb and pelvis. Consequently, we have learned that rotational hip range of motion is more strongly correlated with combined femoral and acetabular version than with the sphericity of the femoral head, allowing us to counsel patients accordingly. We also recognize that impingement can occur with little to no femoral asphericity if the combined femoral and acetabular version does not permit adequate clearance for unimpeded motion. This improved understanding can be applied to diagnose subtle and uncommon cases of impingement and will ultimately enable a more complete bony resection.

The Bipolar Hip: How Acetabular and Femoral Pathomorphology Affects Hip Motion in Femoral Acetabular Impingement Syndrome

PURPOSE

To investigate the individual and combined contributions of acetabular and femoral morphology to hip range of motion (ROM) in patients with femoroacetabular impingement syndrome (FAIS) by use of computed tomography measurements and hip ROM evaluated on physical examination.

METHODS

A retrospective chart and radiographic analysis of patients presenting with hip pain suggestive of FAIS was performed. The femoral neck-shaft angle, femoral version, magnitude and clock-face location of the alpha angle, midcoronal center-edge angle (CEA), midsagittal CEA, acetabular version, and McKibbin index were measured on computed tomography scans. Univariate and multivariate linear regression analyses determined which measurements correlated with hip ROM, including hip flexion as well as hip internal and external rotation with the hip in 90° of flexion.

RESULTS

Two hundred hips that met the inclusion and exclusion criteria during the eligibility period were included in the analysis. The mean age was 31.9 ±10.0 years, there were 145 female patients (72%), and the mean body mass index was 25.2 ± 5.0. Multivariate linear regression analysis showed that the midsagittal CEA was the only measurement correlating with flexion (q = .031) whereas the femoral neck-shaft angle and McKibbin index were the only significant variables that correlated with external rotation (q = .031 and q < .001, respectively). Finally, the McKibbin index and maximum alpha angle were the only variables that correlated with internal rotation (q < .001 and q = .034, respectively).

CONCLUSIONS

Multivariate analysis showed that combined acetabular and femoral version significantly correlated with internal and external rotation whereas femoral version in isolation did not. Increased cam morphology remained a significant contributor to reduced internal rotation but did not affect hip flexion. These data suggest that hip ROM is affected by both femoral pathomorphology and acetabular pathomorphology and that careful evaluation of both should be conducted prior to corrective osteoplasty or osteotomy.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The Effect of Modality and Landmark Selection on MRI and CT Femoral Torsion Angles

Background Assessment of femoral torsion at preoperative hip imaging is commonly recommended. However, it is unclear whether MRI is as accurate as CT and how different methods affect femoral torsion measurements. Purpose To compare MRI- and CT-based assessment of femoral torsion by using four commonly used measurement methods in terms of agreement, reproducibility, and reliability and to compare femoral torsion angles between the four different measurement methods. Materials and Methods This retrospective study evaluated patients with hip pain who underwent CT and 3-T MRI of the hip including sequences of the pelvis and distal condyles between May 2017 and June 2018. The four measurement methods differed regarding the landmark levels for the proximal femoral reference axis and included measurements at the level of the greater trochanter, femoral neck, base of the femoral neck, and level of the lesser trochanter. Intraclass correlation coefficients (ICCs) were calculated, and Bland-Altman analysis was performed. Results Forty-five patients (mean age ± standard deviation, 19 years ± 5; 27 female) and 57 hips were evaluated. Inter- and intrarater reliability were excellent for each of the four CT- and MRI-based measurement methods (ICC range, 0.97-0.99). Mean difference between CT- and MRI-based measurement ranged from 0.3° ± 3.4 (P = .58) to 2.1° ± 4.1 (P < .001). Differences between CT and MRI were within the corresponding ICC variation for all four measurement methods. Mean torsion angles were greater by 17.6° for CT and 18.7° for MRI (all P < .001) between the most proximal to the most distal measurement methods. Conclusion MRI- and CT-based femoral torsion measurements showed high agreement and comparable reliability and reproducibility but were dependent on the level of selected landmarks used to define the proximal reference axis. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Zoga in this issue.

[Diagnostic algorithm "FAI and sports hernia" : Results of the consensus meeting for groin pain in athletes]

As a result of the complexity and diversity of diseases in the region of the groin, differentiation of the various soft-tissue and bone pathologies remains a challenge for differential diagnosis in routine clinical practice. In the case of athletes with pain localized in the area of the groin, femoroacetabular impingement (FAI) and athlete's groin must be considered as important causes of the groin pain, whereby the common occurrence of double pathologies further complicates diagnosis. Despite the importance of groin pain and its differential diagnoses in everyday clinical practice, there has been a lack of recognized recommendations for diagnostic procedure to date. To this end, a consensus meeting was held in February 2017, in which a group composed equally of groin and hip surgeons took part. With the formulation of recommendations and the establishment of a practicable diagnostic path, colleagues that are involved in treating such patients should be sensitized to this issue and the quality of the diagnosis of groin pain improved in routine clinical practice.

Location of Intra- and Extra-articular Hip Impingement Is Different in Patients With Pincer-Type and Mixed-Type Femoroacetabular Impingement Due to Acetabular Retroversion or Protrusio Acetabuli on 3D CT-Based Impingement Simulation

BACKGROUND

Diagnosis and surgical treatment of hips with different types of pincer femoroacetabular impingement (FAI), such as protrusio acetabuli and acetabular retroversion, remain controversial because actual 3-dimensional (3D) acetabular coverage and location of impingement cannot be studied via standard 2-dimensional imaging. It remains unclear whether pincer hips exhibit intra- or extra-articular FAI.

PURPOSE

(1) To determine the 3D femoral head coverage in these subgroups of pincer FAI, (2) determine the impingement-free range of motion (ROM) through use of osseous models based on 3D-computed tomography (CT) scans, and (3) determine the osseous intra-and extra-articular 3D impingement zones by use of 3D impingement simulation.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

This is a retrospective, comparative, controlled study involving 70 hips in 50 patients. There were 24 patients (44 hips) with symptomatic pincer-type or mixed-type FAI and 26 patients (26 hips) with normal hips. Surface models based on 3D-CT scans were reconstructed and compared for hips with acetabular retroversion (30 hips), hips with protrusio acetabuli (14 hips), and normal asymptomatic hips (26 hips). Impingement-free ROM and location of impingement were determined for all hips through use of validated 3D collision detection software based on CT-based 3D models. No abnormal morphologic features of the anterior iliac inferior spine were detected.

RESULTS

(1) Mean total femoral head coverage was significantly (P < .001) increased in hips with protrusio acetabuli (92% ± 7%) and acetabular retroversion (71% ± 5%) compared with normal hips (66% ± 6%). (2) Mean flexion was significantly (P < .001) decreased in hips with protrusio acetabuli (104°± 9°) and acetabular retroversion (116°± 6°) compared with normal hips (125°± 13°). Mean internal rotation in 90° of flexion was significantly (P < .001) decreased in hips with protrusio acetabuli (16°± 12°) compared with normal hips (35°± 13°). (3) The prevalence of extra-articular subspine impingement was significantly (P < .001) higher in hips with acetabular retroversion (87%) compared with hips with protrusio acetabuli (14%) and normal hips (0%) and was combined with intra-articular impingement. The location of anterior impingement differed significantly (P < .001) between hips with protrusio acetabuli and normal hips.

CONCLUSION

Using CT-based 3D hip models, we found that hips with pincer-type and mixed-type FAI have significantly larger femoral head coverage and different osseous ROM and location of impingement compared with normal hips. Additionally, intra- and extra-articular subspine impingement was detected predominantly in hips with acetabular retroversion. Acetabular rim trimming during hip arthroscopy or open surgical hip dislocation should be performed with caution for these hips. Patient-specific analysis of location of impingement using 3D-CT could theoretically improve diagnosis and planning of surgical treatment.

Hip morphology and its relationship with hip strength, mobility and lower limb biomechanics: a systematic review in adults

Abstract This systematic review (PROSPERO registration n.43640) aimed to summarise and determine the quality of evidence relating hip bone morphology to (i) hip strength, (ii) mobility and (iii) lower limb biomechanics during functional activities. A standardized search on MEDLINE/PubMed, Web of Science, ScienceDirect and Scopus resulted in 17 papers that met inclusion criteria: i) original investigations with a minimal sample of n=10, ii) studies on humans and iii) presence of at least one quantitative hip morphological parameter and one hip functional (i.e. strength and mobility) and/or one lower limb biomechanical parameter. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool with adaptations. Sixteen out of the 17 included studies showed high risk of bias. We observed that primary evidence pointed to the influence of hip morphology on hip mobility in the transverse plane. Specifically, positive correlations between femoral anteversion angle and range of internal hip rotation in physical examination were observed. Regarding biomechanical parameters, no clear evidence of association between hip morphology, and kinematic and kinetic parameters were found. Our results point to a field that is currently under explored and future studies with low risk of bias addressing these relationships are required.

The Influence of Hip Structure on Functional Valgus Collapse During a Single-Leg Forward Landing in Females

Clinical femoral anteversion (Craig test) and hip range of motion (ROM) have been associated with valgus collapse, but their clinical usefulness in predicting biomechanics is unknown. Our purpose was to determine the individual and combined predictive power of femoral anteversion and passive hip ROM on 3-dimensional valgus collapse (hip internal rotation and adduction, knee rotation, and abduction) during a single-leg forward landing in females. Femoral anteversion and passive hip ROM were measured on 20 females (24.9 [4.1] y, 168.7 [8.0] cm, 63.8 [11.6] kg). Three-dimensional kinematics and kinetics were collected over 5 trials of the task. Each variable was averaged across trials. Backward, stepwise regressions determined the extent to which our independent variables were associated with valgus collapse. The combination of greater hip internal and external rotation ROM (partial r = .52 and .56) predicted greater peak knee internal rotation moment (R2 = .38, P = .02). Less hip internal rotation ROM (partial r = −.44) predicted greater peak knee abduction moments (R2 = .20, P = .05). Greater total hip ROM (internal and external rotation ROM) was not consistently associated with combined motions of valgus collapse but was indicative of isolated knee moments. Passive hip ROM is more associated with knee moments than is femoral anteversion as measured with Craig test.

Femoroacetabular Impingement Patients With Decreased Femoral Version Have Different Impingement Locations and Intra- and Extraarticular Anterior Subspine FAI on 3D-CT-Based Impingement Simulation: Implications for Hip Arthroscopy

BACKGROUND

It remains unclear whether decreased femoral version (FV) causes anterior intra- or extra-articular femoroacetabular impingement (FAI). Therefore, we evaluated symptomatic hips with decreased FV, with and without cam and pincer FAI, by using computed tomography (CT)-based virtual 3-dimensional (3D) impingement simulation and compared this group with patients with normal FV and with asymptomatic hips.

PURPOSE

To investigate (1) the osseous range of motion, (2) the osseous femoral and acetabular impingement zones, and (3) whether hip impingement is extra- or intra-articular in symptomatic hips with FAI.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

An institutional review board-approved, retrospective comparative analysis was performed on a total of 84 hips in 68 participants. Of these, 37 hips in 24 symptomatic patients with FAI had decreased FV. These hips were compared with 21 hips of 18 symptomatic patients with anterior FAI with normal FV (10°-25°) and 26 asymptomatic hips with no FAI and normal FV. All patients with FAI were symptomatic and had anterior hip pain and a positive anterior impingement test. They underwent pelvic CT scans to measure FV. Decreased FV was defined as FV less than 5°. The 37 hips with decreased FV presented both with and without cam and pincer FAI. All 84 hips were evaluated by use of CT-based 3D models and a validated 3D range of motion and impingement simulation. Asymptomatic hips were contralateral normal hips imaged in patients undergoing total hip arthroplasty.

RESULTS

Hips with FAI combined with decreased FV had a significantly (P < .001) lower mean flexion (114°± 8° vs 125°± 13°) and internal rotation (IR) at 90° of flexion (18°± 6° vs 32°± 9°, P < .001) compared with the asymptomatic control group. Symptomatic patients with FAI and normal FV had flexion of 120°± 16° and IR at 90° of flexion of 23°± 15°. In a subgroup analysis, we found a significantly (P < .001) lower IR in 90° of flexion in hips with FV less than 5° combined with mixed-type FAI compared with hips with FV less than 5° without a cam- or pincer-type deformity. The maximal acetabular impingement zone for hips with decreased FV was located at the 2-o'clock position and ranged from 1 to 3 o'clock. In hips with decreased FV, most of the impingement locations were intra-articular but 32% of hips had combined intra- and extra-articular FAI in internal rotation in 90° of flexion. During the flexion-adduction-IR test performed in 10° and 20° of adduction, extra-articular subspine FAI had significantly (P < .001) higher prevalence (68% and 84%) in hips with decreased FV compared with normal hips.

CONCLUSION

Hips with FAI and decreased FV had less flexion and internal rotation in 90° of flexion compared with the asymptomatic control group. The majority of hip impingement due to low FV was intra-articular, but one-third of samples had combined intra- and extra-articular subspine FAI. Anterior extra- and intra-articular hip impingement can be present in patients who have FAI with decreased FV. This could be important for patients undergoing hip arthroscopy.

Retrograde Intramedullary Nail Fixation for Derotational Femoral Osteotomy for Recurrent Femoropatellar Instability

Axial alignment of the femur and tibia is often misdiagnosed in patients with patellofemoral stability problems. Femoral torsion is critical for patellofemoral biomechanics, so it must be evaluated in every patient before the plan of surgery is decided. This case describes a femoral derotational osteotomy due to excessive internal torsion of the femur fixed with a retrograde femoral nail. This type of fixation provides a biomechanical advantage compared to plates. At the two-year follow-up, the patient achieved excellent results, reaching a functional score of 91 points on the Lysholm scale. Derotational femoral osteotomy should be considered in patellofemoral pathology, and a retrograde femoral nail is a valid fixation method for this surgery.

Prevalence and diagnostic accuracy of in-toeing and out-toeing of the foot for patients with abnormal femoral torsion and femoroacetabular impingement: implications for hip arthroscopy and femoral derotation osteotomy

AIMS

Abnormal femoral torsion (FT) is increasingly recognized as an additional cause for femoroacetabular impingement (FAI). It is unknown if in-toeing of the foot is a specific diagnostic sign for increased FT in patients with symptomatic FAI. The aims of this study were to determine: 1) the prevalence and diagnostic accuracy of in-toeing to detect increased FT; 2) if foot progression angle (FPA) and tibial torsion (TT) are different among patients with abnormal FT; and 3) if FPA correlates with FT.

PATIENTS AND METHODS

A retrospective, institutional review board (IRB)-approved, controlled study of 85 symptomatic patients (148 hips) with FAI or hip dysplasia was performed in the gait laboratory. All patients had a measurement of FT (pelvic CT scan), TT (CT scan), and FPA (optical motion capture system). We allocated all patients to three groups with decreased FT (< 10°, 37 hips), increased FT (> 25°, 61 hips), and normal FT (10° to 25°, 50 hips). Cluster analysis was performed.

RESULTS

We found a specificity of 99%, positive predictive value (PPV) of 93%, and sensitivity of 23% for in-toeing (FPA < 0°) to detect increased FT > 25°. Most of the hips with normal or decreased FT had no in-toeing (false-positive rate of 1%). Patients with increased FT had significantly (p < 0.001) more in-toeing than patients with decreased FT. The majority of the patients (77%) with increased FT walk with a normal foot position. The correlation between FPA and FT was significant (r = 0.404, p < 0.001). Five cluster groups were identified.

CONCLUSION

In-toeing has a high specificity and high PPV to detect increased FT, but increased FT can be missed because of the low sensitivity and high false-negative rate. These results can be used for diagnosis of abnormal FT in patients with FAI or hip dysplasia undergoing hip arthroscopy or femoral derotation osteotomy. However, most of the patients with increased FT walk with a normal foot position. This can lead to underestimation or misdiagnosis of abnormal FT. We recommend measuring FT with CT/MRI scans in all patients with FAI. Cite this article: Bone Joint J 2019;101-B:1218-1229.

The CU PAO: A Minimally Invasive, 2-Incision, Interlocking Periacetabular Osteotomy: Technique and Early Results

BACKGROUND

The aims of this study were to describe a novel minimally invasive, interlocking periacetabular osteotomy (PAO) for the treatment of hip dysplasia that was developed at our institution and to report on its safety, complications, and early clinical outcomes.

METHODS

This was a prospective longitudinal study of the first 200 consecutive hips that underwent the CU (University of Colorado) PAO, an interlocking osteotomy combining the benefits of the Birmingham interlocking pelvic osteotomy (BIPO) and the Ganz PAO. The technique provides direct visualization of the sciatic nerve during the ischial osteotomy and allows for immediate weight-bearing postoperatively. Demographic characteristics, intraoperative and perioperative parameters, and functional outcomes were documented. All patients underwent hip arthroscopy 3 to 10 days prior to the PAO to address concomitant intra-articular pathology. Mechanical deep venous thrombosis (DVT) prophylaxis was used for 2 weeks postoperatively. Results were stratified to compare the first 100 and the second 100 cases.

RESULTS

A total of 161 patients (200 hips) underwent primary PAO; mean follow-up was 20 months (range, 3 to 33 months). The mean patient age at the time of surgery was 29.4 years (range, 13 to 55 years). Females accounted for 89% of the patients included in this study. The average length of stay was 4 days. A concomitant proximal femoral derotational osteotomy was performed in 19 hips. The lateral center-edge angle (LCEA) improved from a mean of 18.8° preoperatively to 31.5° postoperatively (p < 0.001). The mean Non-Arthritic Hip Score (NAHS) improved from 56.0 preoperatively to 89.4 at the 24-month follow-up (p < 0.0001). Paresthesias in the distribution of the lateral femoral cutaneous nerve were common (65% at 2 weeks postoperatively) but resolved in 85% of the patients within the first 6 months. There were no sciatic nerve-related complications, deep infections, or DVTs.

CONCLUSIONS

The CU PAO enables corrective realignment of symptomatic acetabular dysplasia with direct visualization of the sciatic nerve, early weight-bearing, cosmetic incisions, and good short-term outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ultrasonographic Assessment of Femoral Torsion Angle Based on Tilting Angles of Femoral Neck and Condylar Axis

Femoral anteversion has been assessed with ultrasound using femoral neck tilting angle (FN-TA); however, femoral torsion angle (FTA), which is defined using FN-TA and condylar axis tilting angle, has not been assessed with ultrasound. This study aimed to establish the ultrasonographic assessment of FTA (US-FTA) by comparing data obtained through US-FTA and computed tomography (CT). Twenty-one patients (age range, 38-82 y) with 21 intact hips were included. In the US-FTA, the femoral head and anterior tubercle of the greater trochanter were used as bony landmarks. The intra-rater and inter-rater reliabilities and standard error of measurement (SEM) of US-FTA were 0.994 (SEM 0.93) and 0.994 (SEM 0.94), respectively. A strong agreement was found between FTA variables obtained with ultrasound and CT (R = 0.939, p < 0.001). Ultrasound is useful and can be a valid alternative to CT for the evaluation of the femoral torsion angle without radiation exposure.

Is there an association between hip range of motion and nonspecific low back pain? A systematic review

OBJECTIVE

To systematically review whether there is an association between hip range of motion (ROM) and nonspecific low back pain (NSLBP).

DATA SOURCES

MEDLINE, EMBASE, Cochrane library, PsychINFO, CINAHL and AMED databases were searched from year of inception until October 31st, 2018, using a combination of LBP and hip joint search terms. Commonly cited journals were also hand searched within the previous two years.

STUDY SELECTION

Two reviewers independently screened identified articles, by title and abstract and then by full-text. After first round screening of 2908 identified records, 248 progressed to full-text screening. Due to the heterogeneity of studies identified, post hoc inclusion criteria of English language, studies comparing subjects with NSLBP and healthy controls, cross-sectional design, and clinical measures of hip ROM were applied. Twenty-four records were finally included.

DATA EXTRACTION

Extracted data included population characteristics, duration and severity of NSLBP, hip movement direction, testing position, measurement tool and between-group difference. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess for study bias.

DATA SYNTHESIS

Hip flexion ROM was measured in seven studies, extension in 13, internal rotation (IR) in 14, external rotation (ER) in 13, abduction in six, and adduction in only two studies. Among all directions tested, IR ROM was reported in more studies as significantly reduced in NSLBP subjects compared to healthy individuals. Overall the quality of evidence was very low. Common sources of study bias included lack of sample size justification, blinding of outcome assessors, adjusting for key confounders, and poor reporting.

CONCLUSION

There is very low-quality evidence to support an association between limited hip ROM and NSLBP. Limited hip IR ROM was the only movement impairment found to be significantly associated with NSLBP, however this should be viewed with caution due to the low-quality supportive evidence. Further studies are needed.

Differences in Femoral Torsion Among Various Measurement Methods Increase in Hips With Excessive Femoral Torsion

BACKGROUND

Correct quantification of femoral torsion is crucial to diagnose torsional deformities, make an indication for surgical treatment, or plan the amount of correction. However, no clear evaluation of different femoral torsion measurement methods for hips with excessive torsion has been performed to date.

QUESTIONS/PURPOSES

(1) How does CT-based measurement of femoral torsion differ among five commonly used measurement methods? (2) Do differences in femoral torsion among measurement methods increase in hips with excessive femoral torsion? (3) What is the reliability and reproducibility of each of the five torsion measurement methods?

METHODS

Between March and August 2016, we saw 86 new patients (95 hips) with hip pain and physical findings suggestive for femoroacetabular impingement at our outpatient tertiary clinic. Of those, 56 patients (62 hips) had a pelvic CT scan including the distal femur for measurement of femoral torsion. We excluded seven patients (seven hips) with previous hip surgery, two patients (two hips) with sequelae of Legg-Calvé-Perthes disease, and one patient (one hip) with a posttraumatic deformity. This resulted in 46 patients (52 hips) in the final study group with a mean age of 28 ± 9 years (range, 17-51 years) and 27 female patients (59%). Torsion was compared among five commonly used assessment measures, those of Lee et al., Reikerås et al., Jarrett et al., Tomczak et al., and Murphy et al. They differed regarding the level of the anatomic landmark for the proximal femoral neck axis; the method of Lee had the most proximal definition followed by the methods of Reikerås, Jarrett, and Tomczak at the base of the femoral neck and the method of Murphy with the most distal definition at the level of the lesser trochanter. The definition of the femoral head center and of the distal reference was consistent for all five measurement methods. We used the method described by Murphy et al. as our baseline measurement method for femoral torsion because it reportedly most closely reflects true anatomic femoral torsion. With this method we found a mean femoral torsion of 28 ± 13°. Mean values of femoral torsion were compared among the five methods using multivariate analysis of variance. All differences between two of the measurement methods were plotted over the entire range of femoral torsion to evaluate a possible increase in hips with excessive femoral torsion. All measurements were performed by two blinded orthopaedic residents (FS, TDL) at two different occasions to measure intraobserver reproducibility and interobserver reliability using intraclass correlation coefficients (ICCs).

RESULTS

We found increasing values for femoral torsion using measurement methods with a more distal definition of the proximal femoral neck axis: Lee et al. (most proximal definition: 11° ± 11°), Reikerås et al. (15° ± 11°), Jarrett et al. (19° ± 11°), Tomczak et al. (25° ± 12°), and Murphy et al. (most distal definition: 28° ± 13°). The most pronounced difference was found for the comparison between the methods of Lee et al. and Murphy et al. with a mean difference of 17° ± 5° (95% confidence interval, 16°-19°; p < 0.001). For six of 10 possible pairwise comparisons, the difference between two methods increased with increasing femoral torsion and decreased with decreasing femoral torsion. We observed a fair-to-strong linear correlation (R range, 0.306-0.622; all p values < 0.05) for any method compared with the Murphy method and for the Reikerås and Jarrett methods when compared with the Tomczak method. For example, a hip with 10° of femoral antetorsion according Murphy had a torsion of 1° according to Reikerås, which corresponds to a difference of 9°. This difference increased to 20° in hips with excessive torsion; for example, a hip with 60° of torsion according to Murphy had 40° of torsion according to Reikerås. All five methods for measuring femoral torsion showed excellent agreement for both intraobserver reproducibility (ICC, 0.905-0.973) and interobserver reliability (ICC, 0.938-0.969).

CONCLUSIONS

Because the quantification of femoral torsion in hips with excessive femoral torsion differs considerably among measurement methods, it is crucial to state the applied methods when reporting femoral torsion and to be consistent regarding the used measurement method. These differences have to be considered for surgical decision-making and planning the degree of correction. Neglecting the differences among measurement methods to quantify femoral torsion can potentially lead to misdiagnosis and surgical planning errors.

LEVEL OF EVIDENCE

Level IV, diagnostic study.

Increased Prevalence of Femoroacetabular Impingement in Patients With Proximal Hamstring Tendon Injuries

PURPOSE

To determine the prevalence of clinically diagnosed femoroacetabular impingement (FAI) in a consecutive series of patients presenting with proximal hamstring tendon injury and to correlate this with pelvic anatomic factors.

METHODS

The prevalence of clinically symptomatic cam-, pincer-, and mixed-type and overall FAI was calculated among a consecutive series of patients presenting to a hip preservation clinic with a confirmed clinical and radiographic diagnosis of proximal hamstring tendon injury between 2012 and 2017. The presence of a cam lesion was determined by an alpha angle > 50° on radiographs and computed tomography radial sequences of the head-neck junction and a femoral head-neck offset ratio < 0.18. Clinical diagnoses of osseous impingement were determined according to accepted pathomorphologic signs and measurements. A diagnosis of FAI was confirmed by imaging findings of acetabular overcoverage for pincer-type FAI and the presence of an anterior or lateral cam lesion for cam-type FAI.

RESULTS

Overall, 120 hips in 97 patients (mean age, 45 years) were included in this study. A clinical diagnosis of FAI was noted in 70.8% of hips (pincer-type 9.2%, cam-type 40.8%, mixed-type 20.8%), an approximate 2- to 7-fold increased prevalence in comparison with the general population from prior studies.

CONCLUSIONS

The prevalence of FAI is high in patients with symptomatic proximal hamstring tendon pathology. Because FAI results in restriction of hip range of motion and altered pelvic tilt, future studies are warranted to investigate whether the presence of FAI acts as a predisposing factor for injury to the hamstring muscle complex.

LEVEL OF EVIDENCE

Level IV, case series.

Can We Discriminate Symptomatic Hip Patients From Asymptomatic Volunteers Based on Anatomic Predictors? A 3-Dimensional Magnetic Resonance Study on Cam, Pincer, and Spinopelvic Parameters

BACKGROUND

Given the high prevalence of patients with hip deformities and no ongoing hip dysfunction, understanding the anatomic factors predicting the symptomatic state is critical. One such variable is how the spinopelvic parameters (SPPs) may interplay with hip anatomic factors.

HYPOTHESIS/PURPOSE

SPPs and femoral- and acetabular-specific parameters may predict which patients will become symptomatic. The purpose was to determine which anatomic characteristics with specific cutoffs were associated with hip symptom development and how these parameters relate to each other.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

548 participants were designated either symptomatic patients (n = 176, scheduled for surgery with hip pain and/or functional limitation) or asymptomatic volunteers (n = 372, no pain) and underwent 3-dimensional magnetic resonance imaging. Multiple femoral (α angle, Ω angle, neck angle, torsion), acetabular (version, coverage), and spinopelvic (pelvic tilt, sacral slope [SS], pelvic incidence) parameters were measured semiautomatically. Normative values, optimal differentiating thresholds, and a logistic regression analysis were computed.

RESULTS

Symptomatic patients had larger cam deformities (defined by increased Ω angle and α angle), smaller acetabular coverage, and larger pelvic incidence and SS angles compared with the asymptomatic volunteers. Discriminant receiver operating characteristic analysis confirmed that radial 2-o'clock α angle (threshold 58°-60°, sensitivity 75%-60%, specificity 80%-84%; area under the curve [AUC] = 0.831), Ω angle (threshold 43°, sensitivity 72%, specificity 70%; AUC = 0.830), acetabular inclination (threshold 6°, sensitivity 65%, specificity 70%; AUC = 0.709), and SS (threshold 44°, sensitivity 72%, specificity 75%; AUC = 0.801) ( P < .005) were the best parameters to classify participants. When parameters were entered into a logistic regression, significant positive predictors for the symptomatic patients were achieved for SS, acetabular inclination, Ω angle, and α angle at 2-o'clock, correctly classifying 85% of cases (model sensitivity 72%, specificity 91%; AUC = 0.919).

CONCLUSION

Complex dynamic interplay exists between the hip and SPPs. A cam deformity, acetabular undercoverage, and increased SPP angles are predictive of a hip symptomatic state. SPPs were significant to discriminate between participants and were important in combination with other hip deformities. Symptomatic patients can be effectively differentiated from asymptomatic volunteers based on predictive anatomic factors.

Unaddressed Cam Deformity Is Associated with Elevated Joint Contact Stress After Periacetabular Osteotomy

BACKGROUND

Femoral cam deformity is frequently present in patients with acetabular dysplasia. Computational modeling can be used to identify how this deformity affects joint mechanics. Our purpose was to identify the relationship between cam deformity and joint contact stress after periacetabular osteotomy (PAO). We hypothesized that cam deformity is associated with an increase in peak joint contact stress after PAO.

METHODS

This was a retrospective review of patients treated for hip dysplasia with PAO without femoral osteochondroplasty. Patient-specific hip models created from preoperative and postoperative computed tomography (CT) scans were evaluated using discrete element analysis to determine maximum joint contact stress after PAO. Twenty hips with a postoperative increase in maximum contact stress were compared with 20 that demonstrated decreased maximum contact stress. Hips were assessed for cam deformity on cross-sectional imaging. Radiographic measures of acetabular dysplasia before and after PAO were assessed and compared with the change in maximum contact stress after PAO.

RESULTS

There was a moderate relationship between the change in maximum contact stress and the α angle (r = 0.31; p = 0.04), and the average α angle in the hips with increased maximum contact stress was significantly different from that in the hips with decreased joint contact stress (51° ± 11.4° versus 42° ± 5.1°; p = 0.04). All 6 hips with an α angle of >60° demonstrated increased joint contact stress.

CONCLUSIONS

Cam deformity is common in patients with hip dysplasia. In our study, α angles of >60° were associated with increased postoperative joint contact stress. The α angle should be assessed preoperatively, and deformity should be addressed for optimal joint mechanics after PAO.

CLINICAL RELEVANCE

A reduction in joint contact stress is a proposed mechanism for the increased joint longevity following periacetabular osteotomy for hip dysplasia. Impingement from abnormal femoral offset negatively impacts clinical outcome, but this finding has not been evaluated from a biomechanical perspective previously and a threshold for performing femoral osteochondroplasty has not been established previously. This study provides biomechanical evidence supporting surgical management of femoral cam deformity for an α angle of >60°.

Pincer-type MRI morphology seen in over a third of asymptomatic healthy volunteers without femoroacetabular impingement

BACKGROUND

In daily routine, pincer femoroacetabular impingement (FAI) findings are often seen without a clinical diagnosis of pincer FAI.

PURPOSE

To assess the presence of pincer FAI MRI findings in asymptomatic volunteers with negative impingement test versus patients with clinically confirmed FAI.

STUDY TYPE

Case-control study.

POPULATION

Sixty-three asymptomatic volunteers and 63 matched patients with FAI were included.

FIELD STRENGTH/ SEQUENCE

A coronal T₁ -weighted turbo spin-echo sequence as well as a 3D oblique transverse water-excitation true fast imaging sequence at 1.5T.

ASSESSMENT

The volunteers underwent standard MRI of the hip, and patients underwent MR arthrography of the symptomatic hip using the same MR sequences. Measurements of cranial acetabular version, acetabular depth, and lateral center-edge angle were performed independently by three fellowship-trained musculoskeletal radiologists.

STATISTICAL TESTS

Descriptive statistics, Mann-Whitney U-test, Unpaired t-test, receiver operating characteristics (ROC), Intraclass correlation coefficient (ICC).

RESULTS

Forty-one percent (26/63, reader 1), 32% and 37% (20 and 23/63, reader 2/3) of asymptomatic volunteers had at least one positive MR finding for pincer-FAI. Patients with pincer or mixed-type FAI had cranial retroversion of the acetabulum of -0.2° ± 7.1 (mean ± standard deviation) for reader 1 and -0.3° ± 5.5/-0.2° ± 4.8 for reader 2 / reader 3, while asymptomatic volunteers had an anteversion of 6.2° ± 6.4 (reader 1) and 3.2° ± 4.9/3.1° ± 6.5 (readers 2/3): This difference was statistically significant (P ≤ 0.002), but there was a large overlap between the groups. Acetabular depth measurements were very similar for patients with either pincer or mixed-type FAI (5.1-5.3 mm ± 3.1) and volunteers (5.2-6.1 mm ± 2.6), without a statistically significant difference (P ≤ 0.50). Lateral center-edge angle was also similar in patients with either pincer or mixed-type FAI (32.1-35.1° ± 9.1) and volunteers (30.7-33.2° ± 6.5), without a statistically significant difference (P ≤ 0.28).

DATA CONCLUSION

There is a large overlap in pincer-type MRI findings between patients with symptomatic FAI and asymptomatic volunteers. More than a third of volunteers exhibited at least one positive pincer-type MRI finding.

LEVEL OF EVIDENCE

1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:1296-1303.

Analysis of Femoral Version in Patients Undergoing Periacetabular Osteotomy for Symptomatic Acetabular Dysplasia

INTRODUCTION

A paucity of information exists on the range of femoral version, its effect on hip stability, clinical examination, and presentation in patients with symptomatic acetabular dysplasia. The purpose of this study was to describe the range of version in symptomatic acetabular dysplasia, the association between femoral version and proximal femoral morphology and degree of dysplasia, and the effect of version on clinically measured hip range of motion and on preoperatively measured hip outcome scores.

METHODS

We reviewed 314 patients prospectively enrolled in a longitudinal clinical study on periacetabular osteotomy between January 2014 and August 2015 and measured femoral version, morphologic characteristics of the upper femur and acetabulum, and preoperative clinical outcome scores.

RESULTS

The average femoral version was 19.7° ± 11.2° (range, -20° to 50°). Femoral version correlated strongly with clinically measured hip range of motion but did not correlate linearly with either radiographic severity of acetabular dysplasia or preoperative symptomatology.

DISCUSSION

Despite concerns that transverse plane femoral anatomy influences the stability of the hip joint after skeletal maturity, we did not find a statistical association between femoral version and severity of dysplasia or presenting symptomatology. This finding suggests that femoral version is not a major influence on the clinical presentation of acetabular dysplasia.

LEVEL OF EVIDENCE

Level IIIb.

Clinical Outcomes According to Femoral and Acetabular Version After Periacetabular Osteotomy

Background:

Patients with acetabular dysplasia often have abnormal femoral and acetabular version. The effect of combined femoral and acetabular version on clinical outcomes after periacetabular osteotomy for the treatment of acetabular dysplasia remains unclear. The purposes of the present study were (1) to evaluate the association of combined femoral and acetabular version with clinical outcome after periacetabular osteotomy and (2) to investigate the association of femoral version independently with clinical outcome after periacetabular osteotomy.

Methods:

We retrospectively reviewed the records for 92 consecutive patients (95 hips) who had undergone periacetabular osteotomy for the treatment of symptomatic acetabular dysplasia. The patient cohort comprised 85 females and 7 males with a mean age of 38.9 years at the time of surgery. The mean duration of follow-up was 4.8 years (range, 2.0 to 7.2 years). Femoral and acetabular version and the alpha angle were measured on postoperative computed tomography scans. Clinical outcomes included range of motion and the modified Harris hip score. Analysis of variance was used to investigate the effect of femoral version on clinical outcomes. Analysis of covariance was used to adjust for potential covariates.

Results:

Combined femoral and acetabular version after periacetabular osteotomy was slightly, but significantly, correlated with postoperative flexion (r = 0.222; p = 0.031) and internal rotation in flexion (r = 0.326; p = 0.001). Patients with mild femoral version (<15°) experienced significantly less postoperative internal rotation in flexion than those with severe femoral version (>35°); however, this difference was lost after adjustment for potential covariates. There were no differences among femoral version groups (mild, moderate, and severe) in terms of improvements in the clinical outcomes of pain, function, and activity.

Conclusions:

Combined femoral and acetabular version after periacetabular osteotomy was significantly correlated with postoperative range of motion. Abnormality of femoral version associated with acetabular dysplasia did not demonstrate any effect on the clinical outcomes of periacetabular osteotomy.

Level of Evidence:

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Advanced Concepts in Hip Morphology, Associated Pathologies, and Specific Rehabilitation for Athletic Hip Injuries

Hip and groin injuries comprise up to 17% of athletic injuries and can pose rehabilitation challenges for many athletes. Injuries involving abnormal femoral acetabular morphology, reduced range of motion, and decreased lumbopelvic strength and endurance also may increase the risk of injury to lower extremities and delay return to play if proper rehabilitation does not take place. The rehabilitation of athletic hip injuries requires a multifaceted interdisciplinary approach that manages the interplay of multiple factors to restore preinjury function and facilitate return to play. Emphasis should be placed on activity modification, preservation of the arcs of range of motion, functional strengthening of the lumbopelvic core, and optimization of proprioceptive and neuromechanical strategies. Communication between providers and the injured athlete also is crucial to ensure that proper therapeutic approaches are being applied.

Femoral Version Abnormalities Significantly Outweigh Effect of Cam Impingement on Hip Internal Rotation

BACKGROUND

The purpose of this study was to investigate the effects of femoral version, cam-type femoroacetabular impingement (FAI), and the combination of the 2 on the passive hip range of motion (ROM).

METHODS

We prospectively analyzed a consecutive cohort of 220 patients (440 hips) who presented with unilateral or bilateral hip pain. The passive hip ROM was measured bilaterally with the patient in prone, supine, and lateral positions. Femoral version was measured and the presence of cam-type deformity was determined on preoperative computed tomography (CT) scans. Diagnostic findings of cam-type FAI included an alpha angle of >50° on CT radial sequences of the head-neck junction and a femoral head-neck offset ratio of <0.18 on both radiographs and CT.

RESULTS

Multivariate linear regression analysis confirmed that femoral version, as compared with the presence of a cam lesion, was a stronger independent predictor of internal rotation ROM. Conversely, the presence of a cam lesion resulted in a significant decrease in the passive hip flexion ROM (p < 0.001) with no additional effects due to the degree of femoral version. The passive hip internal rotation ROM in neutral flexion/extension and with the hip in 90° of flexion were maximized in patients with femoral anteversion and decreased significantly with each incremental decrease in femoral version (p < 0.001).

CONCLUSIONS

Abnormalities in femoral version significantly outweigh the effect of cam-type impingement on the passive hip internal rotation ROM. In contrast, the presence of a cam lesion significantly decreases the hip flexion ROM, irrespective of the degree of femoral version. These findings help to inform surgical decision-making for patients with cam-type FAI or femoral version abnormalities.

CLINICAL RELEVANCE

It is common clinical practice to ascribe loss of hip internal rotation to the presence of a cam lesion and to assume that arthroscopic femoral osteoplasty will substantially improve internal rotation postoperatively. Our study shows that the cam lesion is more intimately tied to hip flexion than to hip internal rotation. This result directly impacts the clinical assessment of a patient presenting with radiographic findings of FAI.

Prevalence of Femoral and Acetabular Version Abnormalities in Patients With Symptomatic Hip Disease: A Controlled Study of 538 Hips

BACKGROUND

Variations in femoral and acetabular version are becoming increasingly recognized as contributing factors to the development of hip pain in patients with femoroacetabular impingement (FAI) and hip dysplasia. It is still unknown what the true prevalence of these rotational abnormalities is in this patient population.

PURPOSE

To determine (1) the prevalence of femoral version abnormalities in symptomatic hips with FAI and hip dysplasia, (2) the prevalence of combined abnormalities of femoral and acetabular version in these patients, and (3) which specific hip morphologies are associated with abnormalities of femoral version.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 462 symptomatic patients (538 hips) were included who had hip pain attributed to FAI or hip dysplasia and who presented to our tertiary referral center for hip preservation surgery between 2011 and 2015. We retrospectively examined femoral and acetabular version among 11 subgroups with predefined hip morphologies and compared findings with a control group. The allocation to each subgroup was based on morphologic reference values for femoral head coverage, lateral center edge angle, alpha angle, and neck-shaft angle calculated on plain radiographs.

RESULTS

Of the 538 hips included, 52% were found to have abnormal femoral version; severe abnormalities were found in 17%. Severely decreased femoral version (<0°) was found in 5%; moderately decreased femoral version (0°-10°), in 17%; moderately increased femoral version (26°-35°), in 18%; and severely increased femoral version (>35°), in 12%. The most frequent abnormal combination was increased femoral version combined with normal acetabular version (22%). We found significantly lower mean femoral version for the cam-type FAI group (15°) and significantly higher mean femoral version for the Perthes hips (32°; ie, Legg-Calvé-Perthes disease) as compared with the control group (22°). The mean femoral version of the study group was 19°; for male patients, 15°; and for female patients, 22°.

CONCLUSION

Abnormalities in femoral version are highly prevalent in patients with hip pain who are eligible for hip preservation surgery, and severe abnormalities are prevalent in 1 of 6 patients (17%). Based on these results, the evaluation of young patients with hip pain should always include an assessment of femoral version and acetabular version to best decide what treatment approach should be undertaken to optimize outcomes.

Accuracy and Reliability of Computed Tomography and Magnetic Resonance Imaging Compared With True Anatomic Femoral Version

BACKGROUND

Abnormal torsion of the femur is correlated to lower extremity pathologies. Although computed tomography (CT) scan is the gold standard torsional measurement, magnetic resonance imaging (MRI) is proposed as a viable alternative. Our aim was to determine the accuracy and consistency of MRI and CT femur rotational studies based on 4 described protocols.

METHODS

Twelve cadaveric femora were stripped of soft tissue before imaging and physical assessment of torsion. Four advanced imaging series were obtained for each specimen: CT with axial cuts of the femoral neck (CT-axial); CT with oblique cuts of the femoral neck (CT-oblique); MRI with axial cuts of the femoral neck (MR-axial); MRI with oblique cuts of the femoral neck (MR-oblique). Anatomic specimens were placed with the posterior femoral condyles flat on a dissection table for assessment of true torsion with digital images. Three independent reviewers performed all measurements, including true torsion, using imaging software. Bland-Altman analysis was repeated with the data from each reviewer.

RESULTS

Interobserver repeatability for all groups was high at 0.95, 0.87, 0.90, 0.97, and 0.92 for CT-axial, CT-oblique, MR-axial, MR-oblique, and true torsion, respectively. CT-axial had the lowest mean difference from clinical imaging for all three observers (all <1 degree) and held the tightest 95% limits of agreement for 2/3 observers. As torsion increases from neutral, MR-oblique linearly overestimates the rotation compared with true torsion. CT-oblique and MR-axial showed slightly greater differences from true torsion compared with CT-axial, but did not reach clinical significance.

CONCLUSIONS

CT-axial was both most accurate and reproducible when compared with true torsion of the femur and should be the gold standard imaging modality; however, both MR-axial and CT-oblique were accurate to a level that is likely less than clinical significance. MR-axial images should be used in clinical situations where radiation exposure needs to be limited. MR-oblique images can overestimate true antetorsion and should not be used.

CLINIC SIGNIFICANCE

CT-axial followed by MRI-axial is the most accurate and consistent in measuring true torsion of the femur.

Is lower hip range of motion a risk factor for groin pain in athletes? A systematic review with clinical applications

BACKGROUND

Whether hip range of motion (ROM) is a risk factor for groin pain in athletes is not known.

OBJECTIVES

To systematically review the relationship between hip ROM and groin pain in athletes in cross-sectional/case-control and prospective studies.

STUDY DESIGN

Systematic review, prospectively registered (PROSPERO) according to PRISMA guidelines.

METHODS

Pubmed, Embase, CINAHL and SPORTDiscus were systematically searched up to December 2015. Two authors performed study selection, data extraction/analysis, quality assessment (Critical Appraisal Skills Programme) and strength of evidence synthesis.

RESULTS

We identified seven prospective and four case-control studies. The total quality score ranged from 29% to 92%. Heterogeneity in groin pain classification, injury definitions and physical assessment precluded data pooling. There was strong evidence that total rotation of both hips below 85° measured at the pre-season screening was a risk factor for groin pain development. Strong evidence suggested that internal rotation, abduction and extension were not associated with the risk or presence of groin pain.

CONCLUSION

Total hip ROM is the factor most consistently related to groin pain in athletes. Screening for hip ROM is unlikely to correctly identify an athlete at risk of developing groin pain because of the small ROM differences found and poor ROM measurement properties.

Therapeutic Effect of Microcurrent Therapy in Children With In-toeing Gait Caused by Increased Femoral Anteversion: A Pilot Study

Objective

To investigate the efficacy of portable microcurrent therapy device (PMTD) of the hip internal rotators in the treatment of in-toeing gait caused by increased femoral anteversion in children over 8 years of age.

Methods

Eleven children (22 legs; 4 boys and 7 girls; mean age, 10.4±1.6 years) with in-toeing gait caused by increased femoral anteversion were included in the present study. All children received 60 minutes of PMTD (intensity, 25 µA; frequency, 8 Hz) applied to the hip internal rotators daily for 4 weeks. Hip internal rotation (IR) angle, external rotation (ER) angle, and midmalleolar-second toe angle (MSTA) measurement during stance phase at transverse plane and Family Satisfaction Questionnaire, frequency of tripping and fatigue like pains about the PMTD were performed before treatment and at 4 weeks after initial PMTD treatment. Paired t-test and Fisher exact test were used for statistical analysis.

Results

Hip IR/ER/MSTA was 70.3°±5.4°/20.1°±5.5°/–11.4°±2.7°, and 55.7°±7.8°/33.6°±8.2°/–2.6°±3.8° before treatment and at 4 weeks after initial PMTD treatment, respectively (p<0.01). Ten of 11 (91%) children's family stated that they were generally satisfied with the PMTD treatment. The frequency of tripping and fatigue like pains was significantly lower at 4 weeks after PMTD treatment (p<0.05). Excellent inter-rater and intra-rater reliability was observed for repeated MSTA measurements between the examiners (k=0.91–0.96 and k=0.93–0.99), respectively.

Conclusion

PMTD of the hip internal rotators can be effective in improving the gait pattern of children with in-toeing gait caused by increased femoral anteversion.

Hip instability: a review of hip dysplasia and other contributing factors

BACKGROUND

Hip instability has classically been associated with developmental dysplasia of the hip (DDH) in newborns and children. However, numerous factors may contribute to hip instability in children, adolescents, and adults.

PURPOSE

This review aims to concisely present the literature on hip instability in patients of all ages in order to guide health care professionals in the appropriate diagnosis and treatment of the various disorders which may contribute to an unstable hip.

METHODS

We reviewed the literature on the diagnosis and surgical management of hip dysplasia and other causes of hip instability.

CONCLUSIONS

Multiple intra- and extra-articular variables may contribute to hip instability, including acetabular bony coverage, femoral torsion, femoroacetabular impingement, and soft tissue laxity. Physical examination and advanced imaging studies are essential to accurately diagnose the pathology contributing to a patient's unstable hip. Conservative management, including activity modification and physical therapy, may be used as a first-line treatment in patients with intra-articular hip pathology. Patients who continue to experience symptoms of pain or instability should proceed with arthroscopic or open surgical treatment aimed at correcting the underlying pathology.

LEVEL OF EVIDENCE

V.