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Luitjens J, Gassert FG, Patwardhan V, Bhattacharjee R, Joseph GB, Zhang AL, Souza RB, Majumdar S, Link TM. Is hip capsule morphology associated with hip pain in patients without another structural correlate? Eur Radiol 2024; 34:4321-4330. [PMID: 38170264 PMCID: PMC11213662 DOI: 10.1007/s00330-023-10307-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE The goals of this study were (i) to assess the association between hip capsule morphology and pain in patients without any other MRI abnormalities that would correlate with pain and (ii) to investigate whether hip capsule morphology in hip pain patients is different from that of controls. METHODS In this study, 76 adults with hip pain who did not show any structural abnormalities on MRI and 46 asymptomatic volunteers were included. Manual segmentation of the anterior and posterior hip capsules was performed. Total and mean anterior hip capsule area, posterior capsule area, anterior-to-posterior capsule area ratio, and medial-to-lateral area ratio in the anterior capsule were quantified. Differences between the pain and control groups were evaluated using logistic regression models. RESULTS Patients with hip pain showed a significantly lower anterior-to-posterior area ratio as compared with the control group (p = 0.002). The pain group's posterior hip capsule area was significantly larger than that of controls (p = 0.001). Additionally, the ratio between the medial and lateral sections of the anterior capsule was significantly lower in the pain group (p = 0.004). CONCLUSIONS Patients with hip pain are more likely to have thicker posterior capsules and a lower ratio of the anterior-to-posterior capsule area and thinner medial anterior capsules with a lower ratio of the medial-to-lateral anterior hip capsule compartment, compared with controls. CLINICAL RELEVANCE STATEMENT During MRI evaluations of patients with hip pain, morphology of the hip capsule should be assessed. This study aims to be a foundation for future analyses to identify thresholds distinguishing normal from abnormal hip capsule measurements. KEY POINTS • Even with modern image modalities such as MRI, one of the biggest challenges in handling hip pain patients is finding a structural link for their pain. • Hip capsule morphologies that correlated with hip pain showed a larger posterior hip capsule area and a lower anterior-to-posterior capsule area ratio, as well as a smaller medial anterior capsule area with a lower medial-to-lateral anterior hip capsule ratio. • The hip capsule morphology is correlated with hip pain in patients who do not show other morphology abnormalities in MRI and should get more attention in clinical practice.
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Affiliation(s)
- Johanna Luitjens
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, USA.
- Department of Radiology, University Hospital, LMU, Munich, Germany.
| | - Felix G Gassert
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, USA
- Department of Diagnostic and Interventional Radiology, School of Medicine & Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Vasant Patwardhan
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, USA
| | - Rupsa Bhattacharjee
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, USA
| | - Gabby B Joseph
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, USA
| | - Alan L Zhang
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, USA
| | - Richard B Souza
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, USA
| | - Sharmila Majumdar
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, USA
| | - Thomas M Link
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, USA
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The diagnosis of hip microinstability is correlated with ease of intra-operative hip distraction. Knee Surg Sports Traumatol Arthrosc 2023; 31:33-39. [PMID: 35727318 DOI: 10.1007/s00167-022-06998-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 05/04/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Hip microinstability has emerged as a contributor to young adult, non-arthritic hip pain. There is a paucity of objective clinical data to identify patients with hip microinstability and guide surgical treatment. The purpose of this study was to identify the degree of distractibility in patients with and without microinstability undergoing hip arthroscopy. METHODS A single-surgeon series of hip arthroscopies were retrospectively reviewed from 2014-2020. All procedures were performed with paralysis on a fracture table with a perineal post where 1 turn of fine traction equates to 4 mm of axial traction. Diagnosis was recorded as isolated instability, instability plus femoroacetabular impingement (FAI), and isolated FAI. Operative reports were reviewed to collect patient demographic data, number of turns of traction required for adequate distraction of the femoral head relative to the acetabulum (10 mm), and the presence of residual subluxation after initial traction was released. RESULTS A total of 464 patients were identified, 26 (5.6%) with isolated microinstability, 183 (39.4%) with microinstability with FAI anatomy, and 255 (55.0%) with FAI. The concurrent diagnosis of microinstability was associated with decreased turns required to adequately distract the hip. Isolated microinstability patients required 6.9 turns (IQR 4.6-8.8) while those with instability plus FAI required 8.8 turns (IQR 6.5-11) and isolated FAI required 19.1 turns (IQR 15-22). Residual subluxation after removal of negative intra-articular pressure but before performing the hip arthroscopy was more commonly associated with instability, occurring in 84.6% of isolated instability and 86.9% of instability plus FAI as compared with 29.8% in the isolated FAI cohort. CONCLUSION A diagnosis of hip microinstability, with or without features of FAI, is associated with decreased axial traction required to distract the hip. These data support the use of intra-operative ease of distraction as a method of identifying patients with hip microinstability. LEVEL OF EVIDENCE Level III.
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Khanduja V, Darby N, O’Donnell J, Bonin N, Safran MR, Krych A, Malviya A, Stubbs AJ, Takla A, Papavasiliou A, Lund B, McBryde C, Nawabi D, Kohlrieser D, Belzile EL, Witt J, Sunil Kumar KH, Enseki KR, Diamond L, Ejnisman L, Bankes M, Wilson M, Mohtadi N, Marin-Pena O, Ayeni O, Christofilopoulos P, Singh P, Field R, Uchida S, Løken S. Diagnosing Hip Microinstability: an international consensus study using the Delphi methodology. Knee Surg Sports Traumatol Arthrosc 2023; 31:40-49. [PMID: 35499620 PMCID: PMC9859907 DOI: 10.1007/s00167-022-06933-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/04/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Hip microinstability is a relatively new diagnosis which is increasingly being discussed in the literature and yet there are no clear guidelines for making a diagnosis. Microinstability has generally been defined as persistent excessive hip motion that has become symptomatic especially with pain. This aim of this Delphi study was to seek expert opinion to formulate a diagnostic criteria for hip microinstability. METHODS A Delphi methodology was used for this consensus study. A literature search was conducted on PubMed up to March 2019 using the keywords ((hip) and (microinstability)) to identify relevant articles on this topic. All relevant criteria used for diagnosing hip microinstability were collated to create a questionnaire and further criterion suggested by the experts were included as well. Four rounds of questionnaires were delivered via an online survey platform. Between each round the authors acted as administrating intermediaries, providing the experts with a summary of results and synthesising the next questionnaire. The expert panel was comprised of 27 members: 24 (89%) orthopaedic surgeons and 3 (11%) physiotherapists from around the world. RESULTS Expert panel participation in rounds 1-4 was: 27 (100%), 20 (74%), 21 (78%) and 26 (96%) respectively. A literature review by the authors identified 32 diagnostic criteria to populate the first questionnaire. Experts suggested amending three criteria and creating five new criteria. The panel converged on ranking 3 (8%) of criteria as "Not important", 20 (54%) as "Minor Factors" and 14 (38%) as "Major Factors". No criteria was ranked as "Essential". Criteria were subcategorised into patient history, examination and imaging. Experts voted for a minimum requirement of four criteria in each subcategory, including at least six "Major factors". The final diagnostic tool was approved by 20 (77%) of the final round panel. CONCLUSION This study describes the first known expert consensus on diagnosing hip microinstability. The relative complexity of the final diagnostic tool is illustrative of the difficulty clinicians' face when making this diagnosis. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Vikas Khanduja
- Young Adult Hip Service, Addenbrooke's, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK.
| | - Nicholas Darby
- grid.24029.3d0000 0004 0383 8386Young Adult Hip Service, Addenbrooke’s, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - John O’Donnell
- St Vincent’s Private Hospital East Melbourne, East Melbourne, Australia
| | | | - Marc R. Safran
- grid.168010.e0000000419368956Division of Sports Medicine, Department of Orthopaedic Surgery, Team Physician, Stanford University, Redwood City, CA USA
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Gebhardt S, Lerch S, Sobau C, Miehlke W, Wassilew GI, Zimmerer A. Prone Apprehension Relocation Test significantly correlates with radiological instability scores of the hip. J Hip Preserv Surg 2022; 9:78-83. [PMID: 35854807 PMCID: PMC9291363 DOI: 10.1093/jhps/hnac022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 02/26/2022] [Accepted: 03/27/2022] [Indexed: 11/12/2022] Open
Abstract
Recently, there was a debate about whether borderline dysplastic hips should be treated surgically with hip arthroscopy or periacetabular osteotomy (PAO). Current studies recommend a classification into stable and unstable hips. Therefore, radiological scores have been described in recent years. Likewise, a new clinical stability test with the Prone Apprehension Relocation Test (PART) has been described. However, there has been no correlation between the modern radiological scores and the PART. We prospectively studied a consecutive group of patients who presented to our clinic. The PART and radiological scores were assessed in these patients. We divided the patients into a PART-positive and a PART-negative group and analyzed the associated clinical and radiological findings. Out of 126 patients (126 hips) included, 36 hips (29%) were evaluated as PART positive. There were significantly more females in the PART positive group (P = 0.005). Comparing the PART groups, significant differences (P < 0.0001) were found for the lateral center edge angle (LCEA), Femoro-Epiphyseal Acetabular Roof (FEAR) index, Gothic arch angle (GAA), anterior wall index (AWI), the occurrence of the upsloping lateral sourcil (ULS) and signs of acetabular retroversion. The correlation analysis showed an association between LCEA, FEAR index, GAA, AWI, ULS and the PART. A chi-square automatic interaction detection algorithm revealed that the strongest predictor of positive PART was the GAA. In conclusion, a high correlation between the PART and known radiological instability parameters was found. Consequently, a combination of clinical instability testing and radiological instability parameters should be applied to detect unstable hips.
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Affiliation(s)
- Sebastian Gebhardt
- Department of Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald, Germany
- ARCUS Sportklinik Pforzheim, Pforzheim, Germany
| | - Solveig Lerch
- Department of Orthopaedic Surgery, Klinikum Agnes Karll Laatzen, Laatzen, Germany
| | | | | | - Georgi I Wassilew
- Department of Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Alexander Zimmerer
- Department of Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald, Germany
- ARCUS Sportklinik Pforzheim, Pforzheim, Germany
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Öhlin A, Senorski EH, Sansone M, Leff G, Desai N, Lindman I, Ayeni OR, Safran MR. Protocol for a multicenter prospective cohort study evaluating arthroscopic and non-surgical treatment for microinstability of the hip joint. BMC Musculoskelet Disord 2022; 23:309. [PMID: 35361185 PMCID: PMC8973629 DOI: 10.1186/s12891-022-05269-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Microinstability of the hip joint is a proposed cause of hip pain and reduced function in young individuals. The underlying mechanism is thought to be extraphysiological hip motion due to bony deficiency and/or soft tissue deficiency or decreased soft tissue function. Recently, the condition has gained increased attention, and despite the fact that treatment today includes both non-surgical and surgical approaches, there is limited evidence on diagnostic specificity and treatment effects. The aim of this study is to evaluate clinical outcomes of both non-surgical and surgical treatment for microinstability of the hip joint. METHODS A multicenter prospective cohort study is planned to evaluating the outcome of physical therapy aimed at stabilizing the hip joint, as well as arthroscopic plication of the hip joint capsule, if the physical therapy fails. Outcomes will be evaluated using hip-specific patient-reported outcome measures: the short version of the International Hip Outcome Tool and the Copenhagen Hip and Groin Outcome Score, strength and function tests, health-related quality of life as determined using the European Quality of Life-5 Dimensions and the European Quality of Life-Visual Analog Scale, sports activity levels according to the Hip Sport Activity Scale, and reported complications. Patients will be evaluated at 6, 12 and 24 months after each treatment. DISCUSSION It is important to evaluate the clinical outcomes of both non-surgical and surgical treatment for suspected microinstability of the hip joint, and the planned prospective evaluation will contribute to the understanding of non-surgical as well as surgical treatment outcomes, including complications. TRIAL REGISTRATION Clinicaltrials.gov: NCT04934462 . Registered June 22 2021.
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Affiliation(s)
- Axel Öhlin
- Department of Orthopaedics, University of Gothenburg, Gothenburg, Sweden.
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Sansone
- Department of Orthopaedics, University of Gothenburg, Gothenburg, Sweden
| | - Gretchen Leff
- Department of Physical Therapy, Stanford University, Redwood City, CA, USA
| | - Neel Desai
- Department of Orthopaedics, University of Gothenburg, Gothenburg, Sweden
| | - Ida Lindman
- Department of Orthopaedics, University of Gothenburg, Gothenburg, Sweden
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Marc R Safran
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
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