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González-de-la-Flor Á, García-Pérez-de-Sevilla G. A criteria-based progressive rehabilitation program for rectus femoris strain in a recreational soccer player: a case report. Front Bioeng Biotechnol 2024; 12:1385786. [PMID: 39175620 PMCID: PMC11338860 DOI: 10.3389/fbioe.2024.1385786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 07/22/2024] [Indexed: 08/24/2024] Open
Abstract
Introduction: The purpose of this study was to describe the criteria-based progressive rehabilitation program implemented on a recreational soccer player diagnosed with a grade 1 rectus femoris strain. Methods: A 33-year-old male injured the rectus femoris muscle. At the first physical examination, the patient showed significant physical impairment due to important limitations to the active range of motion of the knee flexion and the hip flexor strength. The rehabilitation program consisted of specific training of the rectus femoris, lumbopelvic stabilization, mobility exercises, and running technique exercises, for 6 weeks, which was divided into three phases. Each week, the patient performed four rehabilitation sessions, combined with cross-training (swimming), to maintain his cardiorespiratory capacity. Results: The patient improved functionally and returned to play soccer 6 weeks after the injury without pain. Moreover, the patient passed the criteria of each phase at week 2 for phase 1, at week 4 for phase 2 and at week 6 for phase 3. Conclusion: This case study demonstrates that criteria of progression may control the return to sport timetable for recreational soccer players according to the functional and clinical limitations throughout the entire treatment.
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Vidal Leão R, Fernandes Batista Pereira R, Omena Martins R, Sayuri Yamachira V, Tokechi Amaral D, Ejnisman L, de Paula Correa MF, Partezani Helito PV. Imaging evaluation of hip capsule disorders: a comprehensive review. Skeletal Radiol 2024:10.1007/s00256-024-04766-5. [PMID: 39096373 DOI: 10.1007/s00256-024-04766-5] [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: 06/13/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 08/05/2024]
Abstract
The hip capsule and capsular ligaments play crucial roles in providing hip stability and mobility. Their role in hip pathologies is being increasingly recognized, underscoring the need for thorough imaging evaluation, which is better performed through MRI-arthrography. Various diseases affect the hip capsule directly or indirectly. Improper mechanical loading, as seen in conditions such as femoroacetabular impingement or chondrolabral pathology, can induce capsule thickening, whereas thinning and laxity of the capsule are characteristics of microinstability. Inflammatory conditions, including adhesive capsulitis of the hip, crystal deposition disease, polymyalgia rheumatica, and infections, also lead to capsular changes. Traumatic events, particularly posterior hip dislocations, cause capsule ligament disruption and may lead to hip macroinstability. Friction syndromes can lead to capsular edema due to impingement of the adjacent capsule. Hip arthroscopy can result in various postoperative findings ranging from fibrotic adhesions to focal or extensive capsule discontinuation. Although the significance of hip capsule thickness and morphology in the pathogenesis of hip diseases remains unclear, radiologists must recognize capsule alterations on imaging evaluation. These insights can aid clinicians in accurately diagnosing and effectively managing patients with hip conditions.
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Affiliation(s)
- Renata Vidal Leão
- Musculoskeletal Division, University of Iowa Hospitals and Clinics, Iowa, IA, USA.
| | | | - Raul Omena Martins
- Radiology Department, Hospital Sírio-Libanês, R Adma Jafet, São Paulo, 101, Brazil
| | | | | | - Leandro Ejnisman
- Institute of Orthopaedics and Traumatology, Av. Albert Einstein, 627/701, Morumbi, São Paulo, Brazil
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Le HM, d'Hemecourt PA, Jackson SS, Whitney KE, Miller PE, Millis MB, Wuerz TH, Kiapour AM, Lewis CL, Stracciolini A. Protocol and validity testing of femoroacetabular posterior translation with dynamic hip ultrasonography. Skeletal Radiol 2024; 53:1287-1293. [PMID: 38217703 DOI: 10.1007/s00256-024-04560-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/30/2023] [Accepted: 01/01/2024] [Indexed: 01/15/2024]
Abstract
OBJECTIVE To describe femoroacetabular posterior translation (FAPT) using dynamic hip ultrasonography (DHUS), and to determine the inter- and intra-rater reliability of hip ultrasound measurements of FAPT. MATERIALS AND METHODS The study design was a feasibility study of 13 healthy young adults (26 hips) using test-retest analysis. The data was collected prospectively over a 2-week time period. Three DHUS measurements (posterior neutral (PN), flexion, adduction, and internal rotation (PFADIR), and stand and load (PStand) were measured by four independent raters (2 senior who divided the cohort, 1 intermediate, 1 junior) at two time points for bilateral hips of each participant. Reliability was assessed by calculating the intraclass correlation coefficient (ICC) along with 95% confidence intervals (CIs) for each rater and across all raters. RESULTS A total of 468 US scans were completed. The mean age of the cohort was 25.7 years (SD 5.1 years) and 54% were female. The inter-rater reliability was excellent for PFADIR (ICC 0.85 95% CI 0.76-0.91), good for PN (ICC 0.69 95% CI 0.5-0.81), and good for PStand (ICC 0.72 95% CI 0.55-0.83). The intra-rater reliability for all raters was good for PFADIR (ICC 0.60 95% CI 0.44-0.73), fair for PN (ICC 0.42 95% CI 0.21-0.59), and fair for PStand (ICC 0.42 95% CI 0.22-0.59). CONCLUSION This is the first study to present a protocol using dynamic ultrasonography to measure FAPT. DHUS measure for FAPT was shown to be reliable across raters with varying levels of ultrasound experience.
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Affiliation(s)
- Hung M Le
- Department of Orthopedics, Division of Sports Medicine, Boston Children's Hospital, 319 Longwood Ave, Boston, MA, 02115, USA.
- Health Services, Brown University, Providence, RI, USA.
| | - Pierre A d'Hemecourt
- Department of Orthopedics, Division of Sports Medicine, Boston Children's Hospital, 319 Longwood Ave, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Sarah S Jackson
- Department of Orthopedics, Division of Sports Medicine, Boston Children's Hospital, 319 Longwood Ave, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Kristin E Whitney
- Department of Orthopedics, Division of Sports Medicine, Boston Children's Hospital, 319 Longwood Ave, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Patricia E Miller
- Department of Orthopedics, Division of Sports Medicine, Boston Children's Hospital, 319 Longwood Ave, Boston, MA, 02115, USA
| | - Michael B Millis
- Harvard Medical School, Boston, MA, USA
- Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
| | - Thomas H Wuerz
- Department of Orthopedics, Division of Sports Medicine, Boston Children's Hospital, 319 Longwood Ave, Boston, MA, 02115, USA
- Center for Hip Preservation, Division of Sports Medicine, New England Baptist Hospital, Boston, MA, USA
| | - Ata M Kiapour
- Department of Orthopedics, Division of Sports Medicine, Boston Children's Hospital, 319 Longwood Ave, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Cara L Lewis
- Department of Physical Therapy and Athletic Training, Boston University, Boston, MA, USA
| | - Andrea Stracciolini
- Department of Orthopedics, Division of Sports Medicine, Boston Children's Hospital, 319 Longwood Ave, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
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Metz AK, Lewis DC, Froerer DL, Featherall J, Rosenthal RM, Khalil AZ, Aoki SK. Dysplastic Hips Have Decreased Iliofemoral Ligament Thickness on Coronal Sequences in Magnetic Resonance Imaging: A Matched Cohort Analysis. Arthroscopy 2024:S0749-8063(24)00417-1. [PMID: 38944323 DOI: 10.1016/j.arthro.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 05/18/2024] [Accepted: 05/30/2024] [Indexed: 07/01/2024]
Abstract
PURPOSE To characterize hip capsule thickness on advanced imaging in patients with and without hip dysplasia and to also evaluate differences in capsular thickness between patients with borderline and patients with true dysplasia. METHODS Patients evaluated by the senior author for concerns of hip pathology from June 2020 to June 2021 were queried and images reviewed to determine dysplasia status by lateral center-edge angle (LCEA) ≤25°. A group of patients without dysplasia was identified and matched for age, sex, and body mass index. Hip capsular thickness was quantified using magnetic resonance imaging. A subanalysis was conducted to compare patients with true dysplasia (LCEA < 20°) with patients with borderline dysplasia (LCEAs between 20° and 25°). The analysis included independent samples t tests, χ2 tests, and multivariable regression. RESULTS A total of eighty patients were included, with a mean age of 31.8 ± 11.7 years, a mean body mass index of 26.6 ± 6.5 points, and 70% (56) female patients. Patients with dysplasia had a mean LCEA of 19.8 ± 4.3°. Patients with dysplasia had decreased capsular thickness compared with patients without dysplasia (2.75 ± 0.96 mm vs 3.52 ± 1.22 mm, P = .003). Multivariable regression showed decreased capsular thickness associated with decreased LCEAs (β = 2.804, R = 0.432, P < .001) and dysplasia (β = -0.709, R2 = 0.056, P = .004). Results of a subanalysis of the dysplastic group examining differences between accepted definitions of borderline dysplasia and true dysplasia showed no significant differences in capsular thickness between the 2 groups (P = .379). CONCLUSIONS Patients with hip dysplasia were found to have thinner iliofemoral ligaments in the coronal plane on magnetic resonance imaging on magnetic resonance imaging. Further investigation is needed to evaluate any potential implications with hip instability, given the thinner hip capsule demonstrated in this study. LEVEL OF EVIDENCE Level III, retrospective comparative prognostic trial.
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Affiliation(s)
- Allan K Metz
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Daniel C Lewis
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Devin L Froerer
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Joseph Featherall
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Reece M Rosenthal
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Ameen Z Khalil
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Stephen K Aoki
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A..
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Li SJ, Huang HJ, Li CT, Hu GJ, Yu F, Liu YB. Mechanical effect of changed femoral neck ante-version angles on the stability of an intertrochanteric fracture fixed with PFNA: A finite element analysis. Heliyon 2024; 10:e31480. [PMID: 38813167 PMCID: PMC11133928 DOI: 10.1016/j.heliyon.2024.e31480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/16/2024] [Accepted: 05/16/2024] [Indexed: 05/31/2024] Open
Abstract
Objective Change of femoral neck ante-version angle postoperatively due to inadequate reduction could result in unsatisfying treatment outcome of intertrochanteric fracture. However, the influence of increased or decreased femoral neck ante-version on the biomechanical stability of the bone-implant complex has rarely been studied. Methods A finite element model of a complete normal human femur with normal femoral neck ante-version as 13° was established accurately by scanning a 64 year old female femur. The models of 31-A1.1 intertrochanteric fractures with different femoral neck ante-version angles of 3°, 5.5°, 8°, 10.5°, 13°, 15.5°, 18°, 20.5°, 23° were created. They were assembled with a proximal femoral nail anti-rotation (PFNA) device. The biomechanical differences with varying femoral neck ante-version angles were compared using finite element analysis method. Results As the femoral neck ante-version angle gradually increased from 13° to 23°with a gradient of 2.5°, the peak von Mises stress was gradually increased from 137.82 MPa to 276.02 MPa. Similarly, the peak von Mises stress was gradually increased from 137.82 MPa to 360.12 MPa with the femoral neck ante-version angle decreased from 13° to 3°. When decreased ante-version angle of 7.5° and increased ante-version angle of 10° will exceed the yield strength of femoral (240.32 MPa), the risk of femoral fracture will increase significantly. The maximum displacement of the femur was significantly reduced for increased ante-version models than for decreased ante-version models, whether the changes of ante-version angles were 2.5°, 5°, 7.5° or 10°. The maximum stress of PFNA was found in the intersection of main nail and helical blade, and became greater gradually as the ante-version angle increased or decreased with a gradient of 2.5°. The maximum stress of PFNA was presented in the model 5.5° with the maximum stress of 724.42 MPa (near to the yield strength of titanium alloy of 700-1000 MPa), producing the breakage risk of PFNA. The maximum displacement of the PFNA was significantly reduced for increased ante-version models than for decreased ante-version models, whether the changes of ante-version angles were 2.5°, 5°, 7.5° or 10°. Conclusion Based on the results of present study, it was demonstrated that the anatomical reduction of femoral neck ante-version was vital to secure the optimal stability. Abnormal femoral ante-version could increase the potential risk of failure for intertrochanteric fracture after PFNA. The stability of increased femoral ante-version (less than 10°) was superior to the stability of decreased ante-version (less than 5°) for the cases of difficulty to acquire anatomical reduction. The clinical implication of the finding was that increased femoral neck ante-version had an advantage of mechanical stability towards the decreased femoral neck ante-version for the cases of comminuted intertrochanteric fracture and failure of anatomical reduction.
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Affiliation(s)
- Song-Jian Li
- Orthopedics Center, Department of Orthopedics and Traumatology, Zhujiang Hospital, Southern Medical University, China
| | - Hua-Jian Huang
- Orthopedics Center, Department of Orthopedics and Traumatology, Zhujiang Hospital, Southern Medical University, China
| | - Chen-Tian Li
- Orthopedics Center, Department of Orthopedics and Traumatology, Zhujiang Hospital, Southern Medical University, China
| | - Guo-Ju Hu
- Orthopedics Center, Department of Orthopedics and Traumatology, Zhujiang Hospital, Southern Medical University, China
| | - Fei Yu
- College of Management, Guangdong Polytechnic Normal University, China
| | - Yu-Bin Liu
- Orthopedics Center, Department of Orthopedics and Traumatology, Zhujiang Hospital, Southern Medical University, China
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Fujiwara Y, Shoji T, Ota Y, Saka H, Inoue T, Kato Y, Sumii J, Yasunaga Y, Adachi N. Relationships among hip instability, iliofemoral ligament, and pain in patients with developmental dysplasia of the hip. J Orthop Sci 2024; 29:835-840. [PMID: 36931978 DOI: 10.1016/j.jos.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/25/2023] [Accepted: 03/01/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND To evaluate the relationships among hip instability, pain, and morphology of the iliofemoral ligament (ILFL) in patients with developmental dysplasia of the hip (DDH) using ultrasonography (US). METHODS We reviewed 86 patients (109 hips) with DDH (Group D), 40 patients (46 hips) with borderline hip dysplasia (BDDH) (Group B) and 20 patients (23 hips) without hip pain and bony abnormality (control group). Group D was classified into three subgroups-the severe (group SP), moderate (group MP), and none/mild (group NMP) hip pain groups-using the visual analogue scale (VAS). For evaluating hip instability and ILFL morphology, the distance between the anterior edge of the anterior inferior iliac spine (AIIS) and the horizontal line to the femoral head, and ILFL thickness were measured using US. The difference between the distance in the neutral position and Patrick position was calculated and defined as the femoral head translation distance (FTD). RESULTS FTD and ILFL thickness in group D were significantly larger than those in the control group and group B (P < 0.05). There was a significant positive correlation between FTD and ILFL thickness in three groups (r = 0.57, P < 0.05; r = 0.55, P < 0.05; r = 0.62, P < 0.05, respectively). FTD and ILFL thickness in group SP were significantly larger than those in group NMP (P < 0.05). FTD and ILFL thickness in group D had significantly negative correlations with the lateral center edge (r = -0.54, P < 0.05; r = -0.40, P < 0.05, respectively) and vertical-center-anterior angle (r = -0.51, P < 0.05; r = -0.43, P < 0.05, respectively). CONCLUSIONS Acetabular bony deficiency, especially in the anterior and lateral region can result in antero-posterior hip instability, leading to thickened ILFL and hip pain, even in patients with BDDH. These findings may facilitate our understanding and treatment of patients with DDH. When hip instability is suspected, hip US examination may help confirm the diagnosis and assist in providing objective clinical diagnostic evidence.
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Affiliation(s)
- Yusuke Fujiwara
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Takeshi Shoji
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Yuki Ota
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Hideki Saka
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Tadashi Inoue
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Yuichi Kato
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Junichi Sumii
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Yuji Yasunaga
- Department of Orthopaedic Surgery, Hiroshima Prefectural Rehabilitation Center, 295-3 Taguchi, Saijo-town, Higashi-hiroshima, 739-0036, Japan.
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
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Girardi NG, Kraeutler MJ, Jesse MK, Lee JH, Genuario JW, Mei-Dan O. The Windshield Wiper Sign Is an Instability-Related Osteochondral Defect of the Anterolateral Femoral Head. Arthroscopy 2024:S0749-8063(24)00307-4. [PMID: 38697329 DOI: 10.1016/j.arthro.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/25/2024] [Accepted: 04/07/2024] [Indexed: 05/04/2024]
Abstract
PURPOSE To investigate a radiographic sign believed to be indicative of hip instability and acetabular suction seal disruption in the native hip, coined the "windshield wiper" (WSW) sign. METHODS A retrospective review was performed for patients who underwent periacetabular osteotomy (PAO) with the senior author between March 2021 and September 2023. A WSW sign was identified on plain films as a concave or flat osteochondral defect on the anterolateral femoral head extending medial to the head-neck junction with resultant loss of femoral head sphericity in the native hip. Every patient underwent a standardized series of radiographs, as well as computed tomography and magnetic resonance imaging. All patients underwent arthroscopy before PAO to address intra-articular pathology and other indicated procedures. The osteochondral defect and resultant suction seal disruption were verified during arthroscopy. These patients were then compared with a control group of arthroscopically treated hips without hip instability. RESULTS Of 250 patients reviewed, a total of 19 hips in 17 patients (prevalence of 7.6%) demonstrated radiographic evidence of the WSW sign. All patients with a WSW sign presented with symptomatic clinical hip instability requiring a PAO. The mean patient age was 31.2 years, with a mean lateral center-edge angle (LCEA) of 14.3°. There were 13 hips (68.4%) with dysplasia, 4 (21.1%) with borderline dysplasia, and 2 (10.5%) with a normal LCEA. All patients with a WSW sign and LCEA ≥ 20° displayed significant femoral antetorsion abnormalities. All arthroscopic videos and images demonstrated a compromised suction seal. Of the 50 control group hips reviewed, the WSW sign was not identified. CONCLUSIONS The WSW sign is an uncommon radiographic finding in patients with hip instability. When identified, it can be predictive of substantial instability, especially in cases which are otherwise considered borderline dysplasia or normal based on LCEA. LEVEL OF EVIDENCE Level III, retrospective comparative case control study.
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Affiliation(s)
- Nicholas G Girardi
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - Matthew J Kraeutler
- Departments of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A.; Department of Orthopaedics, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Gothenburg, MöIndal, Sweden
| | - Mary K Jesse
- Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - Jessica H Lee
- Departments of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - James W Genuario
- UC Health Steadman Hawkins Clinic-Denver, Englewood, Colorado, U.S.A
| | - Omer Mei-Dan
- Departments of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A..
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Gillinov SM, Siddiq BS, Cherian NJ, Martin SD. Puncture Capsulotomy Technique During Hip Arthroscopy. JBJS Essent Surg Tech 2024; 14:e23.00061. [PMID: 38903605 PMCID: PMC11186812 DOI: 10.2106/jbjs.st.23.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
Background A number of techniques have been described to enter the capsule and gain access to the hip joint during hip arthroscopy1,2. Among these, the interportal and T-capsulotomies are the most commonly utilized; however, these approaches transect the iliofemoral ligament, which normally resists anterior subluxation and stabilizes extension3. Thus, these approaches may introduce capsuloligamentous instability1,4-7 and have been associated with complications such as dislocation, postoperative pain, microinstability, seroma, and heterotopic ossification5,8-12. Although prior literature has demonstrated durable mid-term results for patients undergoing capsulotomies with capsular closure6,13, avoidance of iatrogenic injury to the hip capsule altogether is preferable. Thus, the puncture capsulotomy technique we present is minimally invasive, preserves the biomechanics of the hip joint and capsule without disrupting the iliofemoral ligament, and allows for appropriate visualization of the joint through placement of multiple small portals. Description Following induction of anesthesia and with the patient supine on a hip traction table, the nonoperative leg is positioned at 45° abduction with support of a well-padded perineal post, and the operative hip is placed into valgus against the post14. Intra-articular fluid distention with normal saline solution is utilized to achieve approximately 9 mm of inferior migration of the femoral head and decrease risk of iatrogenic nerve injury15. Then, under fluoroscopic guidance, an anterolateral portal is created 1 cm anterior and 1 cm superior to the greater trochanter at an approximately 15° to 20° angle. Second, via arthroscopic visualization, the anterior portal is created 1 cm distal and 1 cm lateral to the intersection of a vertical line drawn at the anterior superior iliac spine and a horizontal line at the level of the anterolateral portal. Third, equidistant between the anterior and anterolateral portals, the mid-anterior portal is created distally. Finally, at one-third of the distance between the anterior superior iliac spine and the anterolateral portal, the Dienst portal is created. Thus, these 4 portals form a quadrilateral arrangement through which puncture capsulotomy can be performed5. Alternatives Alternative approaches to the hip capsule include interportal and T-capsulotomies, with or without capsular closure1,2,4,6,7,16. Although the most frequently utilized, these approaches transect the iliofemoral ligament and thus may introduce capsuloligamentous instability1,4-7,17. Rationale The puncture capsulotomy technique has the advantage of maintaining the integrity of the capsule through the placement of 4 small portals. The technique does not transect the iliofemoral ligament and thus does not introduce capsuloligamentous instability. Furthermore, although good mid-term outcomes have been reported with capsular closure6,13,18, the present technique avoids creating unnecessary injury to the capsule and complications of an unrepaired capsule or, conversely, of plication. Expected Outcomes Patients who underwent the puncture capsulotomy technique showed significant improvements in multiple functional outcome scores at a mean follow-up of 30.4 months, including the International Hip Outcome Tool (iHOT-33) (39.6 preoperatively to 76.1 postoperatively), Hip Outcome Score-Activities of Daily Living subscale (HOS-ADL) (70.0 to 89.3), HOS Sport-Specific Subscale (HOS-SSS) (41.8 to 75.7), and modified Harris hip score (mHHS) (60.1 to 84.9). At 2 years postoperatively with respect to iHOT-33, 81.0% of patients achieved the minimal clinically important difference, 62.0% achieved the patient acceptable symptom state, and 58.9% achieved substantial clinical benefit. In addition, mean visual analog scale pain scores improved significantly over the follow-up period (6.3 to 2.2; p < 0.001). Finally, there were zero occurrences of infection, osteonecrosis of the femoral head, dislocation or instability, or femoral neck fracture in patients treated with puncture capsulotomy19,20. Important Tips Anterolateral portal placement should be performed using the intra-articular fluid distention technique with fluoroscopy to avoid risk of iatrogenic labral damage and distraction-induced neurapraxia. Subsequent portals must then be placed under direct arthroscopic visualization.On establishment of the anterolateral portal, the scope should be switched to the anterior portal to ensure that the anterolateral portal has not been placed through the labrum and to adjust its placement to better access pathology. This portal, as well as all others, may be subsequently modified by adjusting the angle of the cannula, without making a new skin incision.If a cam lesion is located more anteromedially or posterolaterally, an additional accessory portal may be made distal or proximal to the anterolateral portal, respectively, in order to enhance visualization.Intermittent traction is utilized throughout the surgery. No traction is utilized during preparing and draping, suture tensioning and tie-down, and femoroplasty, with minimal traction during acetabuloplasty; these precautions serve to prevent iatrogenic superficial peroneal nerve injury.There can be a steep learning curve for this technique. In particular, greater surgical experience is required to perform adequate femoral osteoplasty for large cam lesions with this approach21.Instrument maneuverability and visualization can be somewhat constrained with this approach.It is more difficult to perform certain procedures with this technique, including segmental and circumferential labral reconstructions, particularly with remote grafts5. Acronyms and Abbreviations iHOT-33 = International Hip Outcome Tool-33HOS-ADL = Hip Outcome Score-Activities of Daily Living subscaleHOS-SSS = Hip Outcome Score-Sport-Specific SubscaleAP = anteroposteriorMRA = magnetic resonance arthrogramMRI = magnetic resonance imagingCT = computed tomographyASIS = anterior superior iliac spinemHHS = modified Harris hip score.
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Affiliation(s)
- Stephen M. Gillinov
- Department of Orthopaedics, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, Massachusetts
| | - Bilal S. Siddiq
- Department of Orthopaedics, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, Massachusetts
| | - Nathan J. Cherian
- Department of Orthopaedics, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, Massachusetts
- Department of Orthopaedic Surgery, University of Nebraska, Omaha, Nebraska
| | - Scott D. Martin
- Department of Orthopaedics, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, Massachusetts
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Radha S, Hutt J, Lall A, Domb B, Lynch TS, Griffin D, Field RE, Chuck-Cakic J. Best practice guidelines for clinical and radiological assessment of patients with femoroacetabular impingement. Results from the ISHA International Delphi Consensus Project-Phase 2. J Hip Preserv Surg 2024; 11:44-50. [PMID: 38606327 PMCID: PMC11005775 DOI: 10.1093/jhps/hnad028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/11/2023] [Accepted: 08/16/2023] [Indexed: 04/13/2024] Open
Abstract
In 2018, the International Society for Hip Preservation Surgery (ISHA) initiated a series of Delphi consensus studies to identify the global hip preservation community's current opinion on best practices for different facets of hip preservation surgery. Arthroscopic procedures to treat hip pathologies, such as femoroacetabular impingement syndrome (FAIS) are now established in mainstream orthopaedic practice. This study establishes recommendations for the investigation of patients with suspected FAIS. The investigation has focused on the three phases of the diagnostic process-patient history, physical examination and special investigations. Our expert panel consisted of 174 international orthopaedic surgeons with expertise in hip preservation surgery, thereby making recommendations generalisable across the globe. After three rounds of survey and analysis with 174 participants per round, our study achieved consensus at a minimum agreement threshold of 80.0% on 55 statements pertaining to the assessment of patients with FAIS. We encourage our junior and senior hip arthroscopy colleagues internationally to consider these statements both to standardize the clinical and radiological assessment of patients with FAIS and to aid in the design of future research.
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Affiliation(s)
- Sarkhell Radha
- Trauma and Orthopaedics, Croydon University Hospital, 530 London Road, London CR7 7YE, UK
- Al-Kindy University, Mohamed Al-Qasim Expy, Baghdad, Iraq
| | - Jonathan Hutt
- Trauma and Orthopaedics, University College London Hospital, 235 Euston Road, London NW1 2BU, UK
| | - Ajay Lall
- America Hip Institute, 999 E Touhy Ave # 450, Chicago 60018, USA
| | - Benjamin Domb
- America Hip Institute, 999 E Touhy Ave # 450, Chicago 60018, USA
| | - T Sean Lynch
- Northwestern University, 633 Clark Street, Chicago, IL 60208, USA
| | - Damian Griffin
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Richard E Field
- South West London Elective Orthopaedic Centre, Dorking Road, London KT18 7EG, UK
| | - Josip Chuck-Cakic
- Rosebank Centre for Sports Medicine and Orthopaedics and Fourways Life Hospital, 9 Sturdee Avenue, Johannesburg, South Africa
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10
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Enseki KR, Bloom NJ, Harris-Hayes M, Cibulka MT, Disantis A, Di Stasi S, Malloy P, Clohisy JC, Martin RL. Hip Pain and Movement Dysfunction Associated With Nonarthritic Hip Joint Pain: A Revision. J Orthop Sports Phys Ther 2023; 53:CPG1-CPG70. [PMID: 37383013 DOI: 10.2519/jospt.2023.0302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
The Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). This is an update to the 2014 Clinical Practice Guideline (CPG) for Hip Pain and Movement Dysfunction Associated with Nonarthritic Hip Joint Pain. The goals of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. This current CPG covers pathoanatomical features, clinical course, prognosis, diagnosis, examination, and physical therapy interventions in the management of nonarthritic hip joint pain. J Orthop Sports Phys Ther 2023;53(7):CPG1-CPG70. doi:10.2519/jospt.2023.0302.
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11
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Curtis DM, Pullen WM, Hopkins JN, Murray IR, Money A, Segovia NA, Safran MR. Can Hip Passive Range of Motion Predict Hip Microinstability? A Comparative Study. Orthop J Sports Med 2023; 11:23259671231169978. [PMID: 37347027 PMCID: PMC10280519 DOI: 10.1177/23259671231169978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/06/2023] [Indexed: 06/23/2023] Open
Abstract
Background Hip microinstability is an increasingly recognized cause of pain and disability in young adults. It is unknown whether differences in passive hip range of motion (ROM) exist between patients with versus without hip microinstability. Hypothesis Underlying ligamentous and capsular laxity will result in differences in clinically detectable passive ROM between patients with femoroacetabular impingement (FAI), patients with microinstability, and asymptomatic controls. Study Design Cross-sectional study; Level of evidence, 3. Methods A retrospective review of all patients undergoing hip arthroscopy between 2012 and 2018 was conducted. Patients with a diagnosis of isolated microinstability based on intraoperative findings were identified and classified as having isolated FAI, instability, or FAI + instability. Patients without a history of hip injury were included as controls. Range of motion was recorded in the supine position for flexion, internal rotation, and external rotation. Univariate and multivariate analysis was performed on each measurement in isolation as well as combinations of motion to include total rotation arc, flexion + rotation arc, and flexion + 2× rotation arc Models were then created and tested to predict instability status. Results In total, 263 hips were included: 69 with isolated instability, 50 with FAI, 50 with FAI + instability, and 94 control hips. A higher proportion of patients in the instability and FAI + instability groups were female compared with the FAI and control groups (P < .001). On univariate analysis, differences were found in all groups in all planes of motion (P < .001). Multivariable analysis demonstrated differences in all groups in flexion and flexion + rotation arc. In symptomatic patients, the best performing predictive model for hip microinstability was flexion + rotation arc ≥200° (Akaike information criterion, 132.3; P < .001) with a sensitivity of 68.9%, specificity of 80.0%, positive predictive value of 89.1%, and negative predictive value of 51.9%. Conclusion Patients with hip microinstability had significantly greater ROM than symptomatic and asymptomatic cohorts without hip microinstability. Symptomatic patients with hip flexion + rotation arc ≥200° were highly likely to have positive intraoperative findings for hip microinstability, whereas instability status was difficult to predict in patients with a flexion + rotation arc of <200°.
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Affiliation(s)
| | - W. Michael Pullen
- Medical University of South Carolina,
Charleston, South Carolina, USA
| | | | | | - Adam Money
- Rothman Institute, Orlando, Florida,
USA
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12
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Eberlin CT, Kucharik MP, Abraham PF, Nazal MR, Conaway WK, Varady NH, Martin SD. Puncture Capsulotomy Technique for Hip Arthroscopy: Midterm Functional Outcomes. Orthop J Sports Med 2023; 11:23259671221144056. [PMID: 36743736 PMCID: PMC9893367 DOI: 10.1177/23259671221144056] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/13/2022] [Indexed: 01/27/2023] Open
Abstract
Background The most common surgical approaches in hip arthroscopy are interportal and T-capsulotomy. However, these methods may introduce capsular instability. Puncture capsulotomy preserves capsuloligamentous integrity by avoiding iatrogenic transection of the iliofemoral capsular ligament. Purpose To present minimum 2-year functional outcomes for patients who underwent arthroscopic treatment for acetabular labral tears and concomitant femoroacetabular impingement using the puncture capsulotomy technique. Study Design Case series; Level of evidence, 4. Methods The authors conducted a retrospective review of prospectively collected data on patients who underwent arthroscopic acetabular labral tear treatment between December 2013 and May 2019. Included were patients aged ≥18 years who underwent hip arthroscopy by a single surgeon and completed a minimum of 2 years of patient-reported outcome measure (PROM) surveys. Intraoperatively, patients underwent hip arthroscopy via puncture capsulotomy to treat labral tears and any concomitant femoroacetabular impingement. Clinical outcome data consisted of PROMs. Results A total of 163 hips were included; the mean patient follow-up was 30.4 months (range, 24-60 months; 95% CI, 28.5-32.3 months). Patients had a mean age of 37.9 years (range, 36.1-39.6 years), with a mean body mass index of 25.9 (range, 25.2-26.5). There were significant improvements in mean [95% CI] baseline to final follow-up scores for the 33-Item International Hip Outcome Tool (iHOT-33) (39.6 [36.8-42.4] vs 76.1 [72.7-79.6]), Hip Outcome Score-Activities of Daily Living (70.0 [67.0-73.0] vs 89.3 [87.3-91.3]), modified Harris Hip Score (60.1 [57.9-62.4] vs 84.9 [82.5-87.2]), and Hip Outcome Score-Sports Specific Subscale (41.8 [37.9-45.6] vs 75.7 [71.7-79.7]) (P < .001 for all). Additionally, the mean [95% CI] visual analog scale pain scores were noted to significantly improve throughout the duration of the postoperative period (from 6.3 [5.9-6.7] to 2.2 [1.8-2.6]; P < .001). There were no incidences of infection, avascular necrosis of the femoral head, dislocation/instability, or femoral neck fracture. At the 2-year follow-up, 81.0%, 62.0%, and 58.9% of hips achieved previously published clinically meaningful iHOT-33 thresholds for minimally clinically important difference, Patient Acceptable Symptom Score, and substantial clinical benefit, respectively. Conclusion Puncture capsulotomy demonstrated significantly improved functional and clinically meaningful outcomes at a minimum 2-year follow-up, along with a minimal complication rate.
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Affiliation(s)
- Christopher T. Eberlin
- Sports Medicine Center, Department of Orthopaedic Surgery,
Massachusetts General Hospital, Mass General Brigham, Boston, Massachusetts,
USA.,Christopher T. Eberlin, BS, Sports Medicine Center, Department
of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham,
175 Cambridge Street, Suite 400, Boston, MA 02114, USA (
)
| | - Michael P. Kucharik
- Sports Medicine Center, Department of Orthopaedic Surgery,
Massachusetts General Hospital, Mass General Brigham, Boston, Massachusetts,
USA
| | - Paul F. Abraham
- Department of Orthopaedic Surgery, Keck School of Medicine of the
University of Southern California, Los Angeles, California, USA
| | - Mark R. Nazal
- Department of Orthopaedic Surgery, University of Kentucky,
Lexington, Kentucky, USA
| | - William K. Conaway
- Department of Orthopaedic Surgery, Thomas Jefferson University,
Philadelphia, Pennsylvania, USA
| | - Nathan H. Varady
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New
York, New York, USA
| | - Scott D. Martin
- Sports Medicine Center, Department of Orthopaedic Surgery,
Massachusetts General Hospital, Mass General Brigham, Boston, Massachusetts,
USA
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13
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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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14
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Cohen D, Jean PO, Patel M, Aravinthan N, Simunovic N, Duong A, Safran MR, Khanduja V, Ayeni OR. Hip microinstability diagnosis and management: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:16-32. [PMID: 35441843 DOI: 10.1007/s00167-022-06976-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/29/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE The purpose of this systematic review is to present the most common causes, diagnostic features, treatment options and outcomes of patients with hip micro-instability. METHODS Three online databases (MEDLINE, Embase, and PubMed) were searched from database inception March 2022, for literature addressing the diagnosis and management of patients with hip micro-instability. Given the lack of consistent reporting of patient outcomes across studies, the results are presented in a descriptive summary fashion. RESULTS Overall, there were a total of 9 studies including 189 patients (193 hips) included in this review of which 89% were female. All studies were level IV evidence with a mean MINORS score of 12 (range: 10-13). The most commonly used features for diagnosis of micro-instability on history were anterior pain in 146 (78%) patients and a subjective feeling of instability with gait in 143 (81%) patients, while the most common feature on physical examination was the presence of anterior apprehension with combined hip extension and external rotation in 123 (65%) patients. The most common causes of micro-instability were iatrogenic instability secondary to either capsular insufficiency or cam over-resection in 76 (62%) patients and soft tissue laxity in 38 (31%) patients. CONCLUSION The most common symptom of micro-instability on history was anterior hip pain and on physical exam was pain with hip extension and external rotation. There are many treatment options and when managed appropriately based on the precise cause of micro-instability, patients may demonstrate improved outcomes. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Dan Cohen
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, 4E15, Hamilton, ON, L8N 3Z5, Canada
| | - Pierre-Olivier Jean
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, 4E15, Hamilton, ON, L8N 3Z5, Canada
| | - Milin Patel
- Faculty of Science, McMaster University, Hamilton, ON, Canada
| | | | - Nicole Simunovic
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, 4E15, Hamilton, ON, L8N 3Z5, Canada
| | - Andrew Duong
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, 4E15, Hamilton, ON, L8N 3Z5, Canada
| | - Marc R Safran
- Department of Orthopedic Surgery, Stanford University, Redwood City, CA, USA
| | - Vikas Khanduja
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, 4E15, Hamilton, ON, L8N 3Z5, Canada. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, L8N 3Z5, Canada.
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15
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Jean PO, Safran MR, Ayeni OR. Hip microinstability: fact or fiction? Knee Surg Sports Traumatol Arthrosc 2023; 31:1-3. [PMID: 35064288 DOI: 10.1007/s00167-021-06835-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/02/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Pierre-Olivier Jean
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, ON, L8N 3Z5, Canada
| | - Marc R Safran
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway St, Pavillion A, Redwood City, CA, 94063, USA
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, ON, L8N 3Z5, Canada.
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16
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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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17
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Matthewson G, Williams A, Macciacchera M, Shahabinezhad A, Duong A, Ayeni OR. Effective Management Options for Treatment of Microinstability of the Hip: a Scoping Review. Curr Rev Musculoskelet Med 2022; 16:9-18. [PMID: 36472785 PMCID: PMC9839911 DOI: 10.1007/s12178-022-09808-w] [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] [Accepted: 11/01/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To review the recent literature identifying and summarizing the research involving management of microinstability of the hip and highlight new and evolving techniques in its treatment. RECENT FINDINGS Recent updates in the understanding of capsular management hip arthroscopy will likely lead to less revision surgery and a decreased incidence of persistent post-operative pain. Repair of residual capsular defects has shown good outcomes with high patient satisfaction. Capsular plication remains the gold standard for hips with increased pain that show signs of capsular laxity/deficiency on exam or imaging. Capsular reconstruction has shown equivalent results to other revision hip arthroscopy procedures with low rates of complications. Ligamentum teres pathology, although rare, should be considered a source of pain, particularly in patients with laxity on exam. In cases where CAM over-resection has occurred, remplissage using allograft is an effective option for restoring the capsular suction seal and stability. Microinstability is increasingly being recognized as a source of post-operative hip pain. Patients with collagen disorders remain a challenging clinical entity with increased rates of complications and post-operative pain. CAM resection should be performed carefully and not disrupt the suction seal but be sufficient to not cause further impingement. Improved evidence including well-designed prospective studies with large sample sizes will determine the future management of this complex problem.
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Affiliation(s)
- Graeme Matthewson
- grid.25073.330000 0004 1936 8227Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, Ontario L8N 3Z5 Canada
| | - Allison Williams
- grid.28046.380000 0001 2182 2255Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Matthew Macciacchera
- grid.4912.e0000 0004 0488 7120Faculty of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ali Shahabinezhad
- grid.25073.330000 0004 1936 8227Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, Ontario L8N 3Z5 Canada
| | - Andrew Duong
- grid.25073.330000 0004 1936 8227Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, Ontario L8N 3Z5 Canada
| | - Olufemi R. Ayeni
- grid.25073.330000 0004 1936 8227Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, Ontario L8N 3Z5 Canada
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18
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Hip Pain in Ballet Dancers: Evaluation and Management. J Am Acad Orthop Surg 2022; 30:1123-1130. [PMID: 36400058 DOI: 10.5435/jaaos-d-22-00528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/10/2022] [Indexed: 11/21/2022] Open
Abstract
Hip and groin injuries are common in ballet dancers, who often begin sport-specific training at a young age. The unique demands of ballet include extreme range of motion, with an emphasis on external rotation and abduction. This creates a distinctive constellation of hip symptoms and pathology in this cohort, which may differ from other flexibility sports. When managing hip symptoms in this cohort, orthopaedic surgeons should consider the unique factors associated with ballet, including ballet-specific movements, morphologic adaptations of the hip, and the culture of the sport. Three common etiologies of hip pain in ballet dancers include femoroacetabular impingement syndrome, hip instability, and extra-articular snapping hip syndrome. First-line treatment often consists of focused physical therapy to strengthen the core and periarticular hip musculature, with surgical management reserved for patients who fail to improve with conservative measures.
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19
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Shirogane Y, Homma Y, Yanagisawa N, Higano M, Hirasawa Y, Nakamura S, Baba T, Kaneko K, Taneda H, Ishijima M. Relationship between labral length and symptoms in patients with acetabular dysplasia before rotational acetabular osteotomy. J Hip Preserv Surg 2022; 9:240-251. [PMID: 36908550 PMCID: PMC9993447 DOI: 10.1093/jhps/hnac045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/03/2022] [Accepted: 09/06/2022] [Indexed: 03/14/2023] Open
Abstract
The aim of this study was to investigate the relationship between acetabular labral length and symptoms in patients with acetabular dysplasia. In a retrospective medical record review, 218 patients with acetabular dysplasia who had undergone rotational acetabular osteotomy were identified. After implementing the inclusion and exclusion criteria, 53 patients were analyzed for preoperative symptoms measured by the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ), acetabular bone morphology parameters by anteroposterior pelvic radiographs and labral parameters by radial magnetic resonance imaging. Spearman's correlation coefficients were calculated among JHEQ scores, bone morphologic parameters and labral parameters. Multiple linear regression models to determine the predictive variables of JHEQ score and labral length were obtained. There was no correlation between bone morphologic parameters and JHEQ scores. Labral length measured anteriorly correlated with JHEQ pain {r [95% confidence interval (CI)] = -0.335 (-0.555, -0.071), P = 0.014}, movement subscale [r (95% CI) = -0.398 (-0.603, -0.143), P = 0.003], mental subscale [r (95% CI) = -0.436 (-0.632, -0.188), P = 0.001] and total JHEQ score [r (95% CI) = -0.451 (-0.642, -0.204), P = 0.001]. The multiple linear regression results showed that anterior labral length was independently associated with JHEQ subscales in some models. Meanwhile, age, acetabular head index and total JHEQ score were independently associated with anterior labral length in all models. Labral length, notably in anterosuperior area, in patients with symptomatic acetabular dysplasia was related to patient's symptom. Labral length may be an important objective image finding that can be used to assess the severity of cumulative hip instability.
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Affiliation(s)
- Yuichi Shirogane
- Department of Orthopaedic Surgery, Nishitokyo Chuo General Hospital, 2-4-19 Shibakubocho, Nishitokyo-shi, Tokyo 188-0014,Japan.,Department of Medicine for Orthopaedics and Motor Organ, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 133-8421, Japan.,Department of Orthopaedic, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-ku, Tokyo 133-8431, Japan
| | - Yasuhiro Homma
- Department of Orthopaedic Surgery, Nishitokyo Chuo General Hospital, 2-4-19 Shibakubocho, Nishitokyo-shi, Tokyo 188-0014,Japan.,Department of Medicine for Orthopaedics and Motor Organ, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 133-8421, Japan.,Department of Orthopaedic, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-ku, Tokyo 133-8431, Japan
| | - Naotake Yanagisawa
- Clinical Research and Trial Center, Juntendo University, 3-1-3 Hongo, Bunkyo-ku, Tokyo 133-8431, Japan
| | - Masanori Higano
- Department of Orthopaedic Surgery, Nishitokyo Chuo General Hospital, 2-4-19 Shibakubocho, Nishitokyo-shi, Tokyo 188-0014,Japan
| | - Yoichiro Hirasawa
- Department of Orthopaedic Surgery, Nishitokyo Chuo General Hospital, 2-4-19 Shibakubocho, Nishitokyo-shi, Tokyo 188-0014,Japan
| | - Shigeru Nakamura
- Department of Orthopaedic Surgery, Nishitokyo Chuo General Hospital, 2-4-19 Shibakubocho, Nishitokyo-shi, Tokyo 188-0014,Japan
| | - Tomonori Baba
- Department of Medicine for Orthopaedics and Motor Organ, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 133-8421, Japan.,Department of Orthopaedic, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-ku, Tokyo 133-8431, Japan
| | - Kazuo Kaneko
- Department of Medicine for Orthopaedics and Motor Organ, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 133-8421, Japan.,Department of Orthopaedic, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-ku, Tokyo 133-8431, Japan
| | - Hitoshi Taneda
- Department of Orthopaedic Surgery, Nishitokyo Chuo General Hospital, 2-4-19 Shibakubocho, Nishitokyo-shi, Tokyo 188-0014,Japan
| | - Muneaki Ishijima
- Department of Medicine for Orthopaedics and Motor Organ, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 133-8421, Japan.,Department of Orthopaedic, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-ku, Tokyo 133-8431, Japan
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20
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Devitt BM, Harrington CÍ. Editorial Commentary: Patients With Thin Hip Capsules, Capsular Redundancy, Capsular Defects, Hypermobility, Dysplasia, and Female Patients Are at Increased Risk of Hip Instability. Arthroscopy 2022; 38:3141-3142. [PMID: 36462779 DOI: 10.1016/j.arthro.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 12/05/2022]
Abstract
Patients with thin hip capsules, capsular redundancy, capsular defects, hypermobility, dysplasia, and female patients are at increased risk of hip instability. As our understanding of the factors that contribute to hip instability has increased, so too has our ability to identify "at-risk" patients, in whom we should avoid surgery or perform capsular repair or plication following hip arthroscopy to achieve optimal results. We must tailor our surgical planning accord to gender, bony morphology, capsular volume, and properties of the tissue.
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21
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Criteria for the Operating Room Confirmation of the Diagnosis of Hip Instability: The Results of an International Expert Consensus Conference. Arthroscopy 2022; 38:2837-2849.e2. [PMID: 35378192 DOI: 10.1016/j.arthro.2022.03.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/20/2022] [Accepted: 03/02/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to establish an international expert consensus on operating room findings that aid in the diagnosis of hip instability. METHODS An expert panel was convened to build an international consensus on the operating room diagnosis/confirmation of hip instability. Seventeen surgeons who have published or lectured nationally or internationally on the topic of hip instability were invited to participate. Fifteen panel members completed a pre-meeting questionnaire and agreed to participate in a 1-day consensus meeting on May 15, 2021. A review of the literature was performed to identify published intraoperative reference criteria used in the diagnosis of hip instability. Studies were included for discussion if they reported and intraoperative findings associated with hip instability. The evidence for and against each criteria was discussed, followed by an anonymous voting process. For consensus, defined a priori, items were included in the final criteria set if at least 80% of experts agreed. RESULTS A review of the published literature identified 11 operating room criteria that have been used to facilitate the diagnosis of hip instability. Six additional criteria were proposed by panel members as part of the pre-meeting questionnaire. Consensus agreement was achieved for 8 criteria, namely ease of hip distraction under anesthesia (100.0% agreement), inside-out pattern of chondral damage (100.0% agreement), location of chondral damage on the acetabulum (93.3% agreement), pattern of labral damage (93.3% agreement), anteroinferior labrum chondral damage (86.7% agreement), perifoveal cartilage damage (97.6% agreement), a capsular defect (86.7% agreement), and capsular status (80.0% agreement). Consensus was not achieved for 9 items, namely ligamentum teres tear (66.7% agreement), arthroscopic stability tests (46.7% agreement), persistent distraction after removal of traction (46.7% agreement), findings of examination under anesthesia (46.7% agreement), the femoral head divot sign (40.0% agreement), inferomedial synovitis (26.7% agreement), drive-through sign (26.7% agreement), iliopsoas irritation (26.7% agreement) and ligamentum teres-labral kissing lesion (13.3% agreement). All experts agreed on the final list of 8 criteria items reaching consensus. CONCLUSION This expert panel identified 8 criteria that can be used in the operating room to help confirm the diagnosis of hip instability. LEVEL OF EVIDENCE Level V expert opinion.
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22
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Atzmon R, Safran MR. Arthroscopic Treatment of Mild/Borderline Hip Dysplasia with Concomitant Femoroacetabular Impingement-Literature Review. Curr Rev Musculoskelet Med 2022; 15:300-310. [PMID: 35708882 PMCID: PMC9276885 DOI: 10.1007/s12178-022-09765-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 11/26/2022]
Abstract
Purpose of Review This literature review aims to survey the current knowledge about the management FAI in the setting of borderline hip dysplasia. Recent Findings With better understanding, hip arthroscopy has recently been advocated for treating mild or borderline hip dysplasia (BDH) with concomitant femoroacetabular impingement (FAI) despite early studies that condemned its use. Recent outcome data have demonstrated that hip arthroscopy is a viable option in BDH, with and without FAI, and has been gaining wider acceptance. Hip arthroscopy can address the concomitant soft tissue and bony intra-articular pathologies and obviate the necessity for other surgeries. Moreover, hip arthroscopy may be used as an adjuvant treatment to other procedures such as a periacetabular osteotomy (PAO). Summary Hip arthroscopy for BDH is an evolving procedure with promising short- and mid-term outcomes. The combination of BDH and FAI is becoming recognized as a problem in its own right, requiring dedicated treatment.
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Affiliation(s)
- Ran Atzmon
- Department of Orthopaedics Surgery, Stanford University, 450 Broadway, Redwood City, CA 94063 USA
| | - Marc R Safran
- Department of Orthopaedics Surgery, Stanford University, 450 Broadway, Redwood City, CA 94063 USA
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23
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Ruh E, Johnson C, Frankston N, Charles S, Anderst W, McClincy M. Does Femoral Head Translation Vary by Sex and Side in Asymptomatic Hips During a Weightbearing Apprehension Test? Clin Orthop Relat Res 2022; 480:1104-1111. [PMID: 35195575 PMCID: PMC9263503 DOI: 10.1097/corr.0000000000002144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 01/27/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hip microinstability is an increasingly recognized source of pain and dysfunction but has no agreed upon diagnostic criteria and the pathophysiology remains unclear. It has been suggested that pain associated with microinstability is caused by excess translation of the femoral head. Recent research indicates that single-plane femoral head translation can be reliably measured using dynamic ultrasonography during a supine clinical examination; however, the overall accuracy of that technique has not been established, and the range of femoral head translation values that are found in individuals with no history of surgery or symptomatic pathology is unknown. QUESTIONS/PURPOSES (1) How much femoral head translation is present in native, uninjured hips during a weightbearing apprehension position for females and males? (2) How large is the side-to-side difference in hip translation and rotation within the same individual in females and males with no history of surgery or pain during the weightbearing apprehension position? (3) What differences exist in femoral head translation and rotation when comparing females to males? METHODS Twenty-two young adults (11 males, 11 females; mean age 22 ± 2 years; BMI 22 ± 5 kg/m2) with no history of hip pain, no known hip injury, and who never had hip surgery participated in this study. High-resolution CT images of the femur and pelvis were acquired for each participant, and the bone tissue was segmented from the CT volume. Synchronized biplane radiographs were collected during a neutral standing trial and during a static weightbearing apprehension position in which the participant extended, externally rotated, and abducted at their back hip while standing with their feet split in the AP direction. A validated volumetric model-based tracking technique was used to match the patient-specific bone models to the biplane radiographs with an accuracy of 0.3 mm for translation and 0.8° for rotation. Translation of the center of the femoral head relative to the center of the acetabulum and rotation of the femur relative to the pelvis from neutral to the weightbearing apprehension position were calculated. Sex-based differences in hip kinematics were assessed by bivariate linear regression. RESULTS The median (range) translation during the weightbearing apprehension position in females was 0.9 mm (0.2 to 2.7 mm), which was less than in the 1.3 mm (0.2 to 2.6 mm) translation found in males (median difference of 0.5 mm; p = 0.04). The median absolute side-to-side difference in translation during the pivot was 1.4 mm (0.1 to 3.8 mm) in females and 1.3 mm (0.1 to 4.4 mm) in males. CONCLUSION These findings demonstrate that the femoral head translates the same under bodyweight loading as previously observed during supine exam, showing the inherent stability of the hip with no history of surgery or symptomatic pathology. This study also provides normal values for comparison with individuals who have suspected microinstability. Future directions for research include directly comparing biplane radiography to alternative imaging techniques, such as dynamic ultrasound, for identifying hip microinstability and identifying threshold values for symptomatic hip microinstability. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Ethan Ruh
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Camille Johnson
- Biodynamics Laboratory, University of Pittsburgh, Pittsburgh, PA, USA
| | - Naomi Frankston
- Biodynamics Laboratory, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - William Anderst
- Biodynamics Laboratory, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael McClincy
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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24
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Female gender, decreased lateral center edge angle and a positive hyperextension-external rotation test are associated with ease of hip distractability at time of hip arthroscopy. Knee Surg Sports Traumatol Arthrosc 2022; 30:2188-2194. [PMID: 35316369 DOI: 10.1007/s00167-022-06925-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/21/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To identify factors associated with ease of hip distraction at the time of hip arthroscopy. METHODS A retrospective review of patients 17-50 years old undergoing hip arthroscopy with a single high-volume hip arthroscopist was performed from 2014 to 2020. Demographics, clinical history, examination, and imaging findings were collected. Distractibility was quantified using turns of fine traction (1 turn = 4 mm axial distraction) with the patient paralyzed on a fracture table with a well-padded perineal post Fine axial traction was applied after the patient's perineum contacted the post. Demographic and clinical predictors of ease of distractibility were analyzed with simple linear regression models. Significant predictors were subsequently added to a multivariable linear regression model, estimating the effect of each variable. RESULTS In total, 453 patients were included, with an average age of 31.6 years (± 9.2) and 45.9% females. In univariate analysis, gender, race, BMI, range of motion, hyperextension-external rotation (HEER) test, the abduction-extension-external rotation test, and lateral center edge angle (LCEA) were associated with the number of fine traction turns required to distract the hip. On multivariable analysis, lower LCEA (p = 0.002), female gender (p < 0.001), and a positive HEER test (p = 0.045) were associated with decreased turns required for adequate hip distraction. CONCLUSION Female gender, decreased LCEA, and a positive HEER test are associated with decreased axial traction required for adequate hip distraction at the time of hip arthroscopy. As ease of distractibility has been associated with hip microinstability, these findings may allow pre-operative identification of hip instability patients and aid in pre-operative counseling, risk stratification and capsular management planning. LEVEL OF EVIDENCE IV. CLINICAL RELEVANCE Preoperative identification of risk factors for ease of hip distraction may raise pre-surgical suspicion and, when coupled with other intraoperative findings, may aid in the diagnosis and management of hip microinstability.
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25
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Martin H, Robinson PG, Maempel JF, Hamilton D, Gaston P, Safran MR, Murray IR. Pre- and intraoperative decision-making challenges in hip arthroscopy for femoroacetabular impingement. Bone Joint J 2022; 104-B:532-540. [PMID: 35491576 DOI: 10.1302/0301-620x.104b5.bjj-2021-1553.r1] [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] [Indexed: 11/05/2022]
Abstract
There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article: Bone Joint J 2022;104-B(5):532-540.
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Affiliation(s)
- Hannah Martin
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedic Surgery, The University of Edinburgh, Edinburgh, UK
| | - Patrick G Robinson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedic Surgery, The University of Edinburgh, Edinburgh, UK
| | | | - David Hamilton
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedic Surgery, The University of Edinburgh, Edinburgh, UK.,School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Paul Gaston
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedic Surgery, The University of Edinburgh, Edinburgh, UK
| | - Marc R Safran
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Iain R Murray
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedic Surgery, The University of Edinburgh, Edinburgh, UK
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26
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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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27
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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] [MESH Headings] [Grants] [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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28
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Parker EA, Meyer AM, Nasir M, Willey MC, Brown TS, Westermann RW. Abnormal Femoral Anteversion Is Associated With the Development of Hip Osteoarthritis: A Systematic Review and Meta-Analysis. Arthrosc Sports Med Rehabil 2021; 3:e2047-e2058. [PMID: 34977664 PMCID: PMC8689222 DOI: 10.1016/j.asmr.2021.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/30/2021] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To perform a systematic review and meta-analysis of literature and to evaluate the relationship between abnormal femoral version and the development of hip osteoarthritis (OA). METHODS A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, evaluating Level I and II studies. Included studies had to provide granular femoral version (FV) information. The severity of OA was ranked on the Kellgren-Lawrence (KL) scale. Excel version 1808 (Microsoft, Redmond, WA) was used to perform a student t test statistical analyses. RESULTS Our review identified 19 qualifying studies-5 Level I and 14 Level II with 1,756 patients. Patients with FV above normal range (>14°) had greater KL scores than patients with normal range FV (mean ± standard deviation; 3.37 ± 1.44 vs 2.05 ± 1.72, P < .05). Analysis of KL scores in patients with FV >24° (>1 standard deviation) versus patients with FV >14° but <24° also demonstrated a positive correlation between increasing FV and KL (4.00 ± 1.96 vs 2.34 ± 0). This was significant independent of the presence or absence of developmental dysplasia of the hip. Retroverted hips (FV<10°) in the present study showed variable OA results upon analysis. CONCLUSIONS The present review suggests that elevated FV may be a risk factor for more severe hip OA with or without the presence of concurrent dysplasia of the hip. The relative amount of increased anteversion appears positively correlated with severity of OA. Although femoral retroversion may impact hip mechanics, in this review it does not appear to strongly correlate with the development of OA. LEVEL OF EVIDENCE II: systematic review of Level I and II studies.
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Affiliation(s)
- Emily A Parker
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Alex M Meyer
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Momin Nasir
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Michael C Willey
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Timothy S Brown
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Robert W Westermann
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
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29
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Watchmaker LE, Hetzel SJ, Sink EL, Spiker AM. Interrater Reliability of the Prone Apprehension Relocation Test. Orthop J Sports Med 2021; 9:23259671211032229. [PMID: 34568506 PMCID: PMC8461127 DOI: 10.1177/23259671211032229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/01/2021] [Indexed: 11/30/2022] Open
Abstract
Background: The Prone Apprehension Relocation Test (PART) augments existing radiographic measures and clinical provocative maneuvers in diagnosing hip instability. One measure of the potential clinical utility of the PART depends on the reproducibility of test results by evaluating providers including physicians, licensed athletic trainers, and physical therapists. Purpose: To determine the interrater reliability of the PART among health care providers. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: We retrospectively identified patients in our institution’s hip preservation registry who presented between September 2017 and June 2019 for evaluation of hip pain. Patients included in the study had the PART performed by a single physician as well as 1 of 12 physician extenders (a licensed athletic trainer or a physical therapist). The providers were blinded to the findings of the other examining professional. Interrater reliability was assessed using the Cohen κ (≥0.75 was considered excellent; between 0.75 and 0.40, moderate; and ≤0.40, poor). Results: A total of 96 patients (190 hips) were included in this study (61 women and 35 men, average age 32 ± 12.1 years). A total of 23 hips had a positive PART from both examiners. Interrater reliability was excellent between health care professionals for the PART when evaluating the right hip (κ = 0.80), left hip (κ = 0.82), and when combining the results for left and right (κ = 0.81). A subanalysis of patients with a positive PART from both raters demonstrated that 19 of the 23 hips had a lateral center-edge angle >25°. Conclusion: Our study demonstrated excellent interrater reliability of the PART, supporting its use in the physical evaluation of painful hips.
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Affiliation(s)
- Lauren E Watchmaker
- Department of Orthopedic Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Scott J Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ernest L Sink
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Andrea M Spiker
- Department of Orthopedic Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
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30
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Editorial Commentary: Hip Cam Overresection May Result in Inferior Outcomes: The Goldilocks Paradox of Too Little, Too Much, or Just Right? Arthroscopy 2021; 37:2817-2819. [PMID: 34481622 DOI: 10.1016/j.arthro.2021.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 02/02/2023]
Abstract
Femoroacetabular impingement is a recognized source of hip pain and cause of labral and articular cartilage injury. Persistent femoroacetabular impingement has been recognized as a source of inferior patient-reported outcomes, and attempts to define a "normal" α-angle has resulted in more aggressive resection of cam lesions. An overzealous femoroplasty may result in iatrogenic hip instability. A dynamic intraoperative examination may be the best way to truly recognize this problem, in particular, by visualizing the loss of the suction seal, as the cam resection engages the acetabulum, resulting in subluxation. A soft tissue "remplissage" salvage procedure may offer an option to correct cam overresection and improve patient outcomes during revision arthroscopy, as we continue to search for the "right" amount of cam correction to perform.
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31
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Ankem HK, Ouyang VW, Saks BR, Jimenez AE, Sabetian PW, Maldonado DR, Lall AC, Domb BG. Is there enough evidence to support hip capsular reconstruction? A systematic review of biomechanical studies. J Hip Preserv Surg 2021; 8:156-163. [PMID: 35145712 PMCID: PMC8826158 DOI: 10.1093/jhps/hnab059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/09/2021] [Accepted: 07/19/2021] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to review and summarize the available biomechanical data on hip capsular reconstruction to guide clinical decision-making. A literature search was completed in December 2020 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify biomechanical cadaver studies on hip capsular reconstruction, hip capsulectomy or hip capsular defect. The investigated parameters included maximum distraction force, capsular state affecting range of motion (ROM), rotation and translation. Four studies met al. the inclusion–exclusion criteria. The median effective force for resisting maximum distraction for the reconstruction state, capsular defect state and the intact state was 171, 111 and 206 N, respectively. The defect capsule force was significantly lower (P = 0.00438) than the intact capsule force. The reconstruction state had a higher distraction force than that of the capsular defect, but due to heterogeneity, the overall effect size was not statistically significant. The capsular reconstruction state reduced excess motion and the degree of instability compared to the capsular defect state but restored the hip close to its native capsular state in the cadaveric model. When compared to capsulectomy/defect state, hip capsular reconstruction significantly improved the rotational stability and effective force at maximum distraction and minimized translation. However, no conclusions can be made regarding the most effective protocol due to the high heterogeneity between the four studies. Further biomechanical studies are needed to test various types of grafts under the same protocol.
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Affiliation(s)
- Hari K Ankem
- American Hip Institute Research Foundation, Chicago, IL 60018, USA
| | - Vivian W Ouyang
- American Hip Institute Research Foundation, Chicago, IL 60018, USA
| | - Benjamin R Saks
- American Hip Institute Research Foundation, Chicago, IL 60018, USA
- AMITA Health St. Alexius Medical Center, Hoffman Estates, IL 60169, USA
| | - Andrew E Jimenez
- American Hip Institute Research Foundation, Chicago, IL 60018, USA
| | - Payam W Sabetian
- American Hip Institute Research Foundation, Chicago, IL 60018, USA
| | | | - Ajay C Lall
- American Hip Institute Research Foundation, Chicago, IL 60018, USA
- American Hip Institute, Chicago, IL 60018, USA
- AMITA Health St. Alexius Medical Center, Hoffman Estates, IL 60169, USA
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, IL 60018, USA
- American Hip Institute, Chicago, IL 60018, USA
- AMITA Health St. Alexius Medical Center, Hoffman Estates, IL 60169, USA
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32
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Yin QF, Wang L, Liang T, Zhao H, Wang XS. Longitudinal Capsulotomy in Hip Arthroscopy: A Safe and Feasible Procedure for Cam-Type Femoracetabular Impingement. Orthop Surg 2021; 13:1793-1801. [PMID: 34351688 PMCID: PMC8523749 DOI: 10.1111/os.13041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To evaluate the surgical security, feasibility, and clinical efficacy of the longitudinal outside‐in capsulotomy in hip arthroscopic treatment for cam‐type femoracetabular impingement (FAI). Methods We retrospectively reviewed patients with cam‐type FAI who underwent hip arthroscopy in our institute from January 2018 to June 2019. All hip arthroscopic procedures were performed by one experienced surgeon in the same manner, except the fashions of capsulotomy. Fifty six patients with mean age of 39.1 and mean body mass index (BMI) of 24.5 were categorized into two groups according to the fashions of capsulotomy. Twenty six cases with longitudinal outside‐in capsulotomy were categorized into Group L, and 30 cases with transversal interportal capsulotomy were categorized into Group T as the control group. The demographic parameters were retrieved from medical documents and compared between the two groups. Surgical outcome including overall surgical time, traction time, complications, visual analogue score (VAS), and intraoperative radiation exposure were compared to investigate the security and feasibility. Radiographic assessment, and functional outcome were compared between the two groups to determine the clinical efficacy of the longitudinal capsulotomy. Results There was no significant difference in the demography and duration of follow‐up between the two groups. The overall surgical time demonstrated no significant difference between Group L and Group T (130.8 ± 16.6 min and 134.0 ± 14.7 min, P = 0.490). Significantly decreased traction time was found in Group L (43.2 ± 8.4 min and 62.2 ± 8.6 min, P < 0.001) compared to Group T. The Median of the fluoroscopic shot was 1 and 3 (P < 0.001). No major complications and reoperation were reported in both groups. The case of intraoperative iatrogenic injure was 0 (0%) and 6 (20%) in Group L and Group T respectively (P = 0.035), and the case of postoperative neurapraxia was 0 (0%) and 8 (26.6%) in Group L and Group T respectively (P = 0.017). The Median of postoperative VAS was 2 and 3 in Group L Group T (P = 0.002). The postoperative α angle was 42.3° ± 3.4° and 44.4° ± 3.5° in group L and group T respectively (P = 0.001). The postoperative iHOT‐12 score at final follow‐up was 79.3 ± 6.7 and 77.0 ± 7.9 respectively (P = 0.141). Conclusion Longitudinal outside‐in capsulotomy with less radiation exposure, reduced traction time, and reduced complications could be a safe and feasible procedure in arthroscopic treatment for cam FAI. Its clinical efficacy was not worse compared with traditional interportal capsulotomy in short‐term follow‐up.
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Affiliation(s)
- Qing-Feng Yin
- Department of Orthopedics, The Second Hospital of Shandong University, Jinan, China
| | - Long Wang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Tao Liang
- Department of Orthopedics, The First People's Hospital of Ningyang county, Taian, China
| | - Heng Zhao
- Department of Orthopedics, The Second Hospital of Shandong University, Jinan, China
| | - Xue-Song Wang
- Department of Sports Medicine, Beijing Jishuitan Hospital, Beijing, China
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Mazek J, Gnatowski M, Salas AP, Domżalski M, Wójcicki R, Skowronek J, Skowronek P. Ligamentum teres reconstruction with labrum and capsule repair after posterior acetabular wall fracture: a case report. J Hip Preserv Surg 2021; 8:i41-i45. [PMID: 34178370 PMCID: PMC8221382 DOI: 10.1093/jhps/hnab029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/16/2021] [Indexed: 01/12/2023] Open
Abstract
The aim of this case study is to present arthroscopic treatment of recurrent hip instability after acute post-traumatic posterior hip dislocation with a fracture of the posterior acetabular wall. A male patient aged 35 suffered a dislocation of the right hip joint with a fracture of the posterior acetabular wall due to an accident. The fracture was stabilized during emergency surgery with a locking compression plate, and the patient was released home in a hip brace. Multiple dislocations of the hip joint followed with the implant being confirmed as stable. Decision was made to qualify the patient for a right hip arthroscopy. During the surgery, ligamentum teres was reconstructed using gracilis and semitendinous muscle grafts, followed by the labrum and joint capsule repair, where the surgery that stabilized the acetabular wall fracture had damaged them. There were no complications following the procedure. Short-term follow-up of 3 months demonstrates the patient has a stable hip, reduced pain and has returned to pre-injury activities.
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Affiliation(s)
- Jacek Mazek
- Jan Kochanowski University in Kielce, Orthopaedic and Traumatology Clinic, Kielce, Poland.,Center for Specialized Surgery Ortopedika, 03-152 Warsaw, Poland
| | - Maciej Gnatowski
- Center for Specialized Surgery Ortopedika, 03-152 Warsaw, Poland
| | | | - Marcin Domżalski
- Orthopaedic and Trauma Department, Medical University of Lodz, Lodz, Poland
| | - Rafał Wójcicki
- Jan Kochanowski University in Kielce, Orthopaedic and Traumatology Clinic, Kielce, Poland
| | - Jacek Skowronek
- Jan Kochanowski University in Kielce, Orthopaedic and Traumatology Clinic, Kielce, Poland
| | - Paweł Skowronek
- Jan Kochanowski University in Kielce, Orthopaedic and Traumatology Clinic, Kielce, Poland
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Abstract
Hip pain is a common complaint in athletes and can result in a significant amount of time lost from sport. Diagnosis of the source of hip pain can be a clinical challenge because of the deep location of the hip and the extensive surrounding soft tissue envelope. Establishing whether the source of hip pain is intra-articular or extra-articular is the first step in the process. A thorough history and a consistent and comprehensive physical examination are the foundation for the proper management of athletes with hip pain.
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Affiliation(s)
- Jacob G Calcei
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA. https://twitter.com/drcalcei
| | - Marc R Safran
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, CA, USA.
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35
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Arbeloa-Gutierrez L, Arenas-Miquelez A. Atraumatic Anterior Hip Dislocation as High Grade of Hip Instability: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00024. [PMID: 33979811 DOI: 10.2106/jbjs.cc.20.00542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Fifty-year-old woman who presented an atraumatic anterior hip dislocation during a local traditional dance exhibition. The dislocation occurred during a dance step in which extreme hip position in extension and external rotation was held. After urgent closed reduction under general anesthesia, the patient underwent conservative management with a follow-up of 24 months. There were no further dislocation events or sequelae, with the Hip Disability and Osteoarthritis Outcome Score-12 scale score was 100 points at the end of follow-up. CONCLUSIONS Atraumatic hip dislocation is the highest grade and exceptional presentation of hip instability and requires immediate treatment. Conservative treatment is satisfactory, although in case of recurrence or persistent residual symptoms, other treatments are warrant.
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Haskel JD, Kaplan DJ, Kirschner N, Fried JW, Samim M, Burke C, Youm T. Generalized Joint Hypermobility Is Associated With Decreased Hip Labrum Width: A Magnetic Resonance Imaging-Based Study. Arthrosc Sports Med Rehabil 2021; 3:e765-e771. [PMID: 34195643 PMCID: PMC8220610 DOI: 10.1016/j.asmr.2021.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/24/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose To explore the relationship between generalized joint hypermobility and hip labrum width. Methods A retrospective review was performed of a single-surgeon database containing patients who underwent hip arthroscopy between 2014 and 2017. Patients were assessed for generalized laxity via Beighton Test Scoring (BTS), which tests for hyperextension of the fifth metacarpophalangeal joint, thumb apposition, elbow hyperextension, knee hyperextension, and trunk flexion on a 9-point scale. Patients were stratified into a "high BTS cohort" with a BTS ≥4, and a control cohort with BTS <4. Magnetic resonance imaging measurements of labral width for each patient were conducted by 2 blinded, musculoskeletal fellowship-trained radiologists at standardized "clockface" locations using a previously validated technique. Statistical analyses used to determine associations between BTS and labral width included Mann-Whitney U and Fisher exact testing as well as linear regression. Results Thirty-four patients met inclusion criteria (17 cases, 17 controls). Both groups were composed exclusively of female patients. There was no significant difference between cases or controls in terms of age (33.3 ± 10.4 years vs 35.2 ± 8.3 years, P = .57) or body mass index (26.1 ± 9.3 vs 23.6 ± 3.4, P = .36). The high Beighton score cohort had significantly thinner labrae at the indirect rectus (5.35 ± 1.2 mm vs 7.1 ± 1.1 mm, P < .001) and anterosuperior position (5.53 ± 1.4 mm vs 7.27 ± 1.6 mm, P = .003). There was no statistical difference between the high Beighton score cohort and controls at the psoas U position (6.47 ± 1.6 mm vs 7.43 ± 1.7 mm, P = .112). Linear regression analysis demonstrated Beighton score was significantly negatively associated with labrum width at the indirect rectus position (R2 = 0.33, P < .001) and the anterosuperior position (R2 = 0.25, P = .004). Conclusions Patients with a BTS ≥4 were found to have significantly thinner labra than those with a BTS of <4. Level of Evidence III, retrospective comparative trial.
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Affiliation(s)
- Jonathan D Haskel
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, U.S.A
| | - Daniel J Kaplan
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, U.S.A
| | - Noah Kirschner
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, U.S.A
| | - Jordan W Fried
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, U.S.A
| | - Mohammad Samim
- Department of Radiology, NYU Langone Health, New York, New York, U.S.A
| | - Christopher Burke
- Department of Radiology, NYU Langone Health, New York, New York, U.S.A
| | - Thomas Youm
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, U.S.A
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Parvaresh KC, Rasio J, Azua E, Nho SJ. Hip Instability in the Athlete: Anatomy, Etiology, and Management. Clin Sports Med 2021; 40:289-300. [PMID: 33673887 DOI: 10.1016/j.csm.2020.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In this review, the recent literature evaluating the anatomic considerations, etiology, and management options for athletes with hip instability are investigated. Studies on the osseous, chondrolabral capsuloligamentous, and dynamic muscular contributions to hip stability are highlighted. Microinstability, iatrogenic instability, and femoroacetabular impingement-induced instability are discussed with a focus on demographic and outcomes research in athletes. Surgical techniques including both open and arthroscopic approaches are additionally evaluated.
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Affiliation(s)
- Kevin C Parvaresh
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA
| | - Jonathan Rasio
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA.
| | - Eric Azua
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA
| | - Shane J Nho
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA
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38
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Degen RM, Pasic N, Baha P, Getgood A, Burkhart TA. Biomechanical evaluation of a hybrid suture and anchor-based hip capsular repair. Clin Biomech (Bristol, Avon) 2021; 81:105246. [PMID: 33338896 DOI: 10.1016/j.clinbiomech.2020.105246] [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: 06/08/2020] [Revised: 11/18/2020] [Accepted: 12/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hip capsulotomies, performed routinely during hip arthroscopy, can contribute to adverse joint kinematics. Direct repair is not always feasible. Therefore, the aim of this study was to evaluate the biomechanics of a conventional all-suture repair versus a hybrid suture and anchor-based capsular repair. METHODS Nine paired (n = 18) hips were tested on a joint-motion simulator, utilizing optical trackers to capture kinematic data. Pairs were randomly allocated to capsular repair type and tested as (1) intact, (2) after T-capsulotomy, and (3) repair each at 0°, 45°, and 90° flexion. Internal and external rotation torques and abduction/adduction torques of 3 N·m were applied and rotational range of motion and joint translations recorded. FINDINGS At 0°, following repair there were no significant differences in joint rotation or translations between repairs (p > 0.134). At 45°, both repair types restored motion to near intact values, with no significant differences between groups. Similarly, there were no significant differences in joint translations between repairs. At 90°, both types of capsular repair failed to restore rotational range of motion, with persistent increases in motion (47.0 ± 16.7°) compared to the intact condition (44.1 ± 15.8°, p = 0.006); however, there were no significant differences between repair groups. There were no significant differences in joint translations between repairs. INTERPRETATION Use of a hybrid repair produced comparable joint rotation and translation under all testing conditions as an all-suture repair. As such, this technique represents a viable option for capsular repair where proximal capsular tissue is deficient.
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Affiliation(s)
- Ryan M Degen
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, Ontario N6A 3K7, Canada.
| | - Nick Pasic
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, Ontario N6A 3K7, Canada
| | - Pardis Baha
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, Ontario N6A 3K7, Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, Ontario N6A 3K7, Canada
| | - Timothy A Burkhart
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, Ontario N6A 3K7, Canada
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39
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Nepple JJ, Ambastha C, Abu-Amer W, Clohisy JC. Mid-Term Outcomes of Combined Hip Arthroscopy and Limited Open Capsular Plication in the Non-Dysplastic Hip. THE IOWA ORTHOPAEDIC JOURNAL 2021; 41:133-139. [PMID: 34552415 PMCID: PMC8259207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Hip microinstability remains poorly-defined but increasingly diagnosed in the setting of borderline dysplasia (LCEA 20-25°), soft tissue laxity, or following unrepaired arthroscopic capsulotomy. While hip microinstability is com-monly treated with arthroscopic capsular plication with short-term outcomes reported, this procedure has been performed open for some time. The purpose of current study was to assess the durability of outcomes of combined arthroscopy and open capsular plication in treating symptomatic hip microinstability at mid-term follow-up. METHODS We retrospectively identified hips that underwent combined hip arthroscopy and open capsular plication for symptomatic microinstability between 2008 and 2013. Hips with excessive femoral anteversion (femoral version >35°) or classic acetabular dysplasia (LCEA <20°) were treated with bony reorientation and were not included in the current study. Patient reported outcomes scores were collected preoperatively and at a minimum five year follow-up. Hips that required reoperation or did not meet criteria for minimally clinically important difference (MCID, ≥8 increase in mHHS) or patient acceptable symptom scores (PASS, mHHS) were considered failures. RESULTS A total of 27 hips met criteria for inclusion and follow-up was obtained for 22 hips (81.5%) at a mean of 7.1 years. All patients were female with a mean age of 25.9 years and 7 (32%) hips had previous surgery. Patients undergoing the combined procedure improved from a mean baseline mHHS of 55.3±13 to a mean follow-up mHHS of 74.5±20.9 (p<0.001). At midterm follow-up, 54.5% of hips met criteria for PASS and 68.2% of hips met criteria for MCID, with 72.7% of hips meeting criteria for either MCID or PASS. Overall, 10 hips (45%) were considered failures with 6 hips (27%) requiring reoperation and an additional 4 hips (18%) with clinical failure. Hips without previous surgery had a failure rate of 33.3% (5/15) while 71.4% (5/7) of those with previous surgery failed (P=.09). CONCLUSION Our study demonstrates a high (45%) rate of reoperations and persistent symptoms in hips with microinstability treated with combined arthroscopy and open capsular plication. Further mid- and long-term studies evaluating soft tissue plication are needed, as well as comparisons with bony procedures in the setting of microinstability are needed.Level of Evidence: III.
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Affiliation(s)
| | - Chetan Ambastha
- Washington University School of Medicine, St. Louis, MO, USA
| | - Wahid Abu-Amer
- Washington University School of Medicine, St. Louis, MO, USA
| | - John C. Clohisy
- Washington University School of Medicine, St. Louis, MO, USA
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40
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Hatem MA, Helal A, Khoury AN, Martin HD. Anteroinferior Hip Instability in Flexion During Dynamic Arthroscopic Examination Is Associated With Abnormal Anterior Acetabular Horn. Orthop J Sports Med 2020; 8:2325967120965564. [PMID: 33415172 PMCID: PMC7750772 DOI: 10.1177/2325967120965564] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/29/2020] [Indexed: 11/16/2022] Open
Abstract
Background: The stabilization of the femoral head is provided by the distal acetabulum
when the hip is in a flexed position. However, the osseous parameters for
the diagnosis of hip instability in flexion are not defined. Purpose/Hypothesis: To determine whether the osseous parameters of the distal acetabulum are
different in hips demonstrating anteroinferior subluxation in flexion under
dynamic arthroscopic examination, compared with individuals without hip
symptoms. The hypothesis was that the morphometric parameters of the
anterior acetabular horn are distinct in hips with anteroinferior
instability compared with asymptomatic hips. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 30 hips with anteroinferior instability in flexion under dynamic
arthroscopic examination were identified. A control group of 60 hips (30
patients), matched by age and sex, was formed from individuals who had
undergone pelvis magnetic resonance imaging (MRI) for nonorthopaedic
reasons. Unstable and control hips were compared according to the following
parameters assessed on axial MRI scans of the pelvis: anterior sector angle
(ASA), anterior horn angle (AHA), posterior sector angle (PSA), posterior
horn angle (PHA), acetabular version, lateral center-edge angle, acetabular
inclination (Tönnis angle), and femoral head diameter. Results: The coverage of the femoral head by the anterior acetabular horn was
decreased in unstable hips compared with the control group (mean ASA, 54.8°
vs 61°, respectively; P < .001). Unstable hips also had
a steeper anterior acetabular horn, with an increased mean AHA compared with
controls (52.5° vs 46.8°, respectively; P < .001). An
ASA <58° had a sensitivity of 0.8, a specificity of 0.68, a negative
predictive value of 0.87, and a positive predictive value of 0.56 for
anteroinferior hip instability. An AHA >50° had a sensitivity of 0.77, a
specificity of 0.72, a negative predictive value of 0.86, and a positive
predictive value of 0.57 for anteroinferior hip instability. There was no
statistically significant difference in the mean PSA, PHA, acetabular
version, lateral center-edge angle, acetabular inclination, or femoral head
diameter between unstable hips and controls. Conclusion: Abnormal morphology of the anterior acetabular horn is associated with
anteroinferior instability in hip flexion. The ASA and AHA can aid in the
diagnosis of hip instability.
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Affiliation(s)
- Munif A Hatem
- Hip Preservation Center at Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Asadullah Helal
- Hip Preservation Center at Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Anthony N Khoury
- Hip Preservation Center at Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Hal David Martin
- Hip Preservation Center at Baylor University Medical Center at Dallas, Dallas, Texas, USA
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41
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Woodward RM, Vesey RM, Bacon CJ, White SG, Brick MJ, Blankenbaker DG. Microinstability of the hip: a systematic review of the imaging findings. Skeletal Radiol 2020; 49:1903-1919. [PMID: 32583134 DOI: 10.1007/s00256-020-03516-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/31/2020] [Accepted: 06/10/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To undertake a systematic review of the morphologic features associated with hip microinstability and determine whether there are suggestive or diagnostic imaging findings. METHODS Four electronic databases were searched up to September 2019 to identify original research reporting morphologic features in individuals with either a clinical diagnosis of hip microinstability (instability without overt subluxation/dislocation) or those with symptomatic laxity demonstrated on imaging (increased femoral head translation/distraction or capsular volume). Studies focussing on individuals with pre-existing hip conditions (including definite dysplasia (lateral centre edge angle < 20°), significant trauma, previous dislocation or surgery were excluded. Methodological quality was assessed by the Quality Assessment of Diagnostic Accuracy Studies 2 tool. RESULTS Twenty-two studies met inclusion criteria (clinical diagnosis of microinstability n = 15 and demonstration of laxity n = 7). Imaging information gathered from the studies includes radiographs (n = 14), MRI (n = 6), MR arthrography (n = 4), CT (n = 1) and intraoperative examination. Most studies exhibited design features associated with an overall high or unclear risk of bias. Some dysplastic features are associated with microinstability or laxity reference measures; however, microinstability is frequently diagnosed in those with a lateral centre edge angle > 25°. Other associated imaging findings reported include impingement morphology, anterior labral tearing, femoral head chondral injury, ligamentum teres tears and capsular attenuation. CONCLUSIONS The current literature does not provide strong evidence for imaging features diagnostic of microinstability. In the appropriate clinical context, dysplastic morphology, anterior labral tears and ligamentum teres tears may be suggestive of this condition although further research is needed to confirm this. PROSPERO REGISTRATION CRD42019122406.
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Affiliation(s)
- Rebecca M Woodward
- Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand.,Auckland Radiology Group, Auckland, New Zealand
| | - Renuka M Vesey
- Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand.
| | - Catherine J Bacon
- Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand.,Orthosports North Harbour Ltd., Millennium Institute of Sport & Health, Auckland, New Zealand
| | - Steve G White
- Active Living and Rehabilitation: Aotearoa New Zealand, Health and Rehabilitation Research Institute, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand.,Department of Physiotherapy, School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Matthew J Brick
- Orthosports North Harbour Ltd., Millennium Institute of Sport & Health, Auckland, New Zealand
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42
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Pasic N, Burkhart TA, Baha P, Ayeni OR, Getgood A, Degen RM. A Biomechanical Comparison of 2 Hip Capsular Reconstruction Techniques: Iliotibial Band Autograft Versus Achilles Tendon Allograft. Am J Sports Med 2020; 48:3288-3295. [PMID: 33044838 DOI: 10.1177/0363546520962071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Several techniques for hip capsular reconstruction have been described to address gross instability or microinstability due to capsular deficiency. However, objective biomechanical data to support their use are lacking. PURPOSE To compare the kinematic effect of 2 capsular reconstruction techniques (iliotibial band [ITB] graft and Achilles tendon graft). Kinematic effect encompassed rotational range of motion (ROM) as well as joint translation in the coronal, sagittal, and axial planes. STUDY DESIGN Controlled laboratory study. METHODS 8 paired, fresh-frozen hemi-pelvises (16 hips) were tested on a custom-designed joint motion simulator in the intact state and after capsulectomy. Pairs were randomly allocated to either ITB or Achilles reconstruction and retested. Testing was performed at 0°, 45°, and 90° of flexion. Internal-external rotation (IR-ER) torques and abduction-adduction torques of 3 N·m were applied to the femur via a load cell at each position, and rotational ROM and joint translation in the coronal, sagittal, and axial planes were recorded. RESULTS At 45° and 90°, there was a significant effect of the condition of the hip on the total IR-ER (P = .004, effect size [ES] = 0.305; and P < .001, ES = 0.497; respectively). At 45°, mean ± SD total rotation was significantly greater for the capsulectomy (59.7°± 15.9°) state compared with intact (53.3°± 13.2°; P = .007). At 90°, reconstruction significantly decreased total rotation to 49.0°± 18.9° compared with a mean total rotation of 52.8°± 18.7° after capsulectomy (P = .02). No difference was seen in the total abduction-adduction of the hip between conditions. Comparisons of the 2 different reconstruction techniques showed no significant differences in total IR-ER or abduction-adduction ROM or joint translation in the coronal, sagittal, or axial planes. For translation, at both 0° and 45° there was a statistically significant effect of the condition on the medial-lateral translation (P = .033; ES = 0.204). Reconstruction, independent of technique, was successful in significantly decreasing (P = .030; P = .014) the mean medial-lateral translation at 0° and 45° of hip flexion from 5.2 ± 3.8 mm and 5.6 ± 4.0 mm to 2.8 ± 1.9 mm and 3.9 ± 3.2 mm, respectively. CONCLUSION The integrity of the native hip capsule played a significant role in rotational stability, where capsulectomy significantly increased rotational ROM. Both ITB and Achilles reconstruction techniques restored normal rotational ROM of the hip at 90° of flexion as well as coronal plane stability at 0° and 45° of hip flexion. No differences were seen between ITB and Achilles reconstruction techniques. CLINICAL RELEVANCE Both capsular reconstruction techniques provide comparable joint kinematics, restoring rotation and translation to normal values with the exception of rotational ROM at 45°, which remained significantly greater than the intact state. The most significant results were the rotational stability at 90° of hip flexion and coronal plane stability at 0° and 45° of hip flexion, which were significantly improved compared with the capsulectomy state.
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Affiliation(s)
- Nicholas Pasic
- Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Timothy A Burkhart
- Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada.,Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada.,School of Kinesiology, Western University, London, Ontario, Canada
| | - Pardis Baha
- School of Kinesiology, Western University, London, Ontario, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ryan M Degen
- Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
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Hoshino H, Furuhashi H, Shimizu Y, Matsuyama Y. Deviation of the centre of rotation of the femoral head in dysplastic hip joints. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:603-609. [PMID: 33079287 DOI: 10.1007/s00590-020-02769-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/12/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Hip instability may be based not only on some mismatch between the size of the femoral head and acetabulum but also on the deviation of the centre of rotation of the femoral head. The aim of this study was to compare the differences between the centre of rotation of the femoral head and that of the acetabulum in normal and dysplastic hips. MATERIALS AND METHODS Thirty dysplastic hips and 30 control hips without dysplastic hip were included in this study. Computed tomography data were imported into three-dimensional analysis software. The sphere radius of the acetabulum, the sphere radius of the femoral head, and the deviation of the centre of rotation of the femoral head from that of the acetabulum were analysed. RESULTS The sphere radii of the acetabulum and femoral head were significantly larger in dysplastic hips. Distances between the centre of rotation of the acetabulum and that of the femoral head were significantly larger in dysplastic group than in control group. The centre of rotation of the femoral head was significantly deviated anterosuperiorly in dysplastic hips. We found significant negative correlations between centre-edge angle and the distance between the centre of rotation of the acetabulum and that of the femoral head in all subjects. CONCLUSION In dysplastic hip joints, the centre of rotation of the femoral head was more deviated anterosuperiorly from that of the acetabulum than in normal hip joints even in static condition, which might be clinically associated with the micro-instability in dysplastic hips.
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Affiliation(s)
- Hironobu Hoshino
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan.
| | - Hiroki Furuhashi
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Yuta Shimizu
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
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44
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Lall AC, Walsh JP, Maldonado DR, Pinto LE, Ashberg LJ, Lodhia P, Radha S, Correia APR, Domb BG, Perez-Carro L, Marín-Peña O, Griffin DR. Teamwork in hip preservation: the ISHA 2019 Annual Scientific Meeting. J Hip Preserv Surg 2020; 7:2-21. [PMID: 33072394 PMCID: PMC7546541 DOI: 10.1093/jhps/hnaa037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Hip preservation surgery is now an established part of orthopedic surgery and sports medicine. This report describes the key findings of the 11th Annual Scientific Meeting of International Society for Hip Arthroscopy-the International Hip Preservation Society-in Madrid, Spain from 16 to 19 October 2019. Lectures, seminars and debates explored the most up-to-date and expert views on a wide variety of subjects, including: diagnostic problems in groin pain, buttock pain and low back pain; surgical techniques in acetabular dysplasia, hip instability, femoroacetabular impingement syndrome, labral repair and reconstruction, cartilage defects, adolescent hips and gluteus medius and hamstring tears; and new ideas about femoral torsion, hip-spine syndrome, hip capsule surgery, impact of particular sports on hip injuries, registries, robotics and training for hip preservation specialists. Surgeons, sports physicians, radiologists and physiotherapists looking after young people with hip problems have an increasingly sophisticated armoury of ideas and techniques with which to help their patients. The concept of hip preservation has developed incredibly fast over the last decade; now it is clear that the best results can only be achieved by a multidisciplinary team working together. The 2020s will be the decade of 'Teamwork in Hip Preservation'.
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Affiliation(s)
- Ajay C Lall
- American Hip Institute Research Foundation, 999 E Touhy Ave Ste 450, Des Plaines, IL 60018, USA.,American Hip Institute, 999 E Touhy Ave Ste 450, Des Plaines, IL 60018, USA
| | - John P Walsh
- American Hip Institute Research Foundation, 999 E Touhy Ave Ste 450, Des Plaines, IL 60018, USA.,Des Moines University, Desert Orthopaedic Center, 2800 E, Desert Inn Rd, Las Vegas, NV 89121, USA
| | - David R Maldonado
- American Hip Institute Research Foundation, 999 E Touhy Ave Ste 450, Des Plaines, IL 60018, USA
| | - Leonardo E Pinto
- Centro Medico Decente La Trinidad (Trinity Medical Center), Av. Principal de El Hatillo, Caracas 1080, Metropolitan District of Caracas, Venezuela
| | - Lyall J Ashberg
- Atlantis Orthopaedics, 4560 Lantana Rd Suite 100, Lake Worth, Atlantis, FL 33463, USA
| | - Parth Lodhia
- Footbridge Centre for Integrated Orthopaedic Care, 181 Keefer Pl #221, Vancouver, BC V6B 6C1, Canada
| | - Sarkhell Radha
- Croydon University Hospital, 530 London Rd, Thornton Heath CR7 7YE, London, UK
| | | | - Benjamin G Domb
- American Hip Institute Research Foundation, 999 E Touhy Ave Ste 450, Des Plaines, IL 60018, USA.,American Hip Institute, 999 E Touhy Ave Ste 450, Des Plaines, IL 60018, USA
| | - Luis Perez-Carro
- Hospital Clinica Mompia, Av. de los Condes, s/n, 39108 Mompía, Cantabria, Spain
| | - Oliver Marín-Peña
- University Hospital Infanta Leonor, Av. Gran Vía del Este, 80, 28031 Madrid, Spain and
| | - Damian R Griffin
- Warwick Medical School, University of Warwick and University Hospitals of Coventry and Warwickshire, Coventry CV4 7AL, UK
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45
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Packer JD, Foster MJ, Riley GM, Stewart R, Shibata KR, Richardson ML, Boutin RD, Safran MR. Capsular thinning on magnetic resonance arthrography is associated with intra-operative hip joint laxity in women. J Hip Preserv Surg 2020; 7:298-304. [PMID: 33163215 PMCID: PMC7605766 DOI: 10.1093/jhps/hnaa018] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/04/2020] [Accepted: 04/18/2020] [Indexed: 01/01/2023] Open
Abstract
Hip microinstability is a recognized cause of hip pain in young patients. Intra-operative evaluation is used to confirm the diagnosis, but limited data exist associating magnetic resonance arthrography (MRA) findings with hip microinstability. To determine if a difference exists in the thickness of the anterior joint capsule and/or the width of the anterior joint recess on MRA in hip arthroscopy patients with and without an intra-operative diagnosis of hip laxity. Sixty-two hip arthroscopy patients were included in the study. Two musculoskeletal radiologists blinded to surgical results reviewed the MRAs for two previously described findings: (i) anterior joint capsule thinning; (ii) widening of the anterior joint recess distal to the zona orbicularis. Operative reports were reviewed for the diagnosis of joint laxity. In all patients with and without intra-operative laxity, there were no significant differences with either MRA measurement. However, twenty-six of 27 patients with intra-operative laxity were women compared with 11 of 35 patients without laxity (P < 0.001). In subgroup analysis of women, the intra-operative laxity group had a higher rate of capsular thinning compared with the non-laxity group (85% versus 45%; P = 0.01). A 82% of women with capsular thinning also had intra-operative laxity, compared with 40% without capsular thinning (P = 0.01). There were no differences regarding the width of the anterior joint recess. In this study, there was an association between capsular thinning and intra-operative laxity in female patients. Measuring anterior capsule thickness on a pre-operative MRA may be useful for the diagnosis of hip microinstability.
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Affiliation(s)
- Jonathan D Packer
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Michael J Foster
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Geoffrey M Riley
- Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Russell Stewart
- Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Kotaro R Shibata
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Michael L Richardson
- Department of Radiology, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Robert D Boutin
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Marc R Safran
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
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46
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Hunt SA. Editorial Commentary: "Loose Lips Sink Ships"-But What About "Loose Hips"? Arthroscopy 2020; 36:2183-2185. [PMID: 32747062 DOI: 10.1016/j.arthro.2020.05.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023]
Abstract
Hip instability continues to be a challenge in hip preservation. Our understanding of the role of osseous anatomy, labral integrity and soft-tissue stabilizers has increased dramatically over the past several decades. Connective-tissue disorders such as Ehlers-Danlos syndrome pose a significant challenge to the management of instability in all joints but particularly in the hip. Ligamentum teres tears have been found to be more common than previously thought, although their significance is still not well understood. In patients with both Ehlers-Danlos syndrome and ligamentum teres tears, reconstruction and capsular plication result in moderate success, but not in all cases.
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47
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Han S, Owens VL, Patel RV, Ismaily SK, Harrington MA, Incavo SJ, Noble PC. The continuum of hip range of motion: From soft-tissue restriction to bony impingement. J Orthop Res 2020; 38:1779-1786. [PMID: 31965588 DOI: 10.1002/jor.24594] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 01/13/2020] [Indexed: 02/04/2023]
Abstract
Traditional studies of hip kinematics have not identified which anatomic structures limit the range of motion (ROM) when the hip is placed in different maneuvers. In this study, we attempted to answer two questions: (a) During which maneuvers is the motion of the hip limited by bony impingement between the femur and pelvis? (b) When is hip ROM determined by the constraint of soft tissues and to what extent? ROM of eight cadaveric hips was measured in 17 maneuvers using a motion capture system. The maneuvers were recreated in silico using 3D CT models of each specimen to detect the occurrence of bony impingement. If bony impingement was not detected, the variable component of 3D hip motion was increased until a collision was detected. The difference between the virtual ROM at the point of bony impingement and the initial ROM measured experimentally was termed as the soft-tissue restriction. The results showed that bony impingement was present in normal hips during maneuvers consisting of high abduction with flexion, and high flexion combined with adduction and internal rotation. At impingement-free maneuvers, the degree of soft tissue restriction varies remarkably, ranging from 4.9° ± 3.8° (internal rotation) at 90° of flexion to 80.0° ± 12.5° (internal rotation) at maximum extension. The findings shed light on the relative contributions of osseous and soft tissues to the motion of the hip in different maneuvers and allow for a better understanding of physical exams of different purposes in diagnosing bone- or soft tissue-related diseases.
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Affiliation(s)
- Shuyang Han
- Institute of Orthopedic Research and Education, Houston, Texas.,McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | | | - Rikin V Patel
- Institute of Orthopedic Research and Education, Houston, Texas
| | - Sabir K Ismaily
- Institute of Orthopedic Research and Education, Houston, Texas.,McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Melvyn A Harrington
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Philip C Noble
- Institute of Orthopedic Research and Education, Houston, Texas.,Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas
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48
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Lawrenson PR, Vicenzino BT, Hodges PW, Crossley KM, Heerey JJ, Semciw AI. Pericapsular hip muscle activity in people with and without femoroacetabular impingement. A comparison in dynamic tasks. Phys Ther Sport 2020; 45:135-144. [PMID: 32777711 DOI: 10.1016/j.ptsp.2020.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 06/07/2020] [Accepted: 06/09/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Compare anterior pericapsular muscle activity between individuals with and without femoroacetabular impingement syndrome (FAIS) during dynamic tasks, to investigate whether muscle activity is consistent with a role in retracting the capsule to prevent impingement and active restraint of the femoral head in walking. DESIGN Cross-sectional. SETTING University-laboratory. PARTICIPANTS Thirteen athletes with FAIS and 13 pain-free controls. MAIN OUTCOME MEASURES Muscle activity was recorded using fine-wire (Iliocapsularis, iliacus and anterior gluteus minimus) and surface (rectus femoris) electromyography (EMG), during three hip flexion tasks (active and assisted hip flexion; squatting) and four walking trials. RESULTS Iliocapsularis EMG amplitude was no different between active and assisted hip flexion tasks around 90° of hip flexion in FAIS. There was no difference in EMG between groups in squatting. The pattern of burst activity preceding peak hip extension in iliacus, iliocapsularis, and anterior gluteus minimus was similar in both groups during walking. CONCLUSION In FAIS, similar activation of iliocapsularis during active and assisted hip flexion, despite reduced flexion torque demand in the latter, suggests a role in capsular retraction or enhanced hip joint protection. Pericapsular muscle activity in advance of peak hip extension during walking is consistent with a proposed contribution to femoral head control.
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Affiliation(s)
- Peter R Lawrenson
- The University of Queensland, School of Health & Rehabilitation Sciences, Brisbane, Queensland, 4072, Australia.
| | - Bill T Vicenzino
- The University of Queensland, School of Health & Rehabilitation Sciences, Brisbane, Queensland, 4072, Australia.
| | - Paul W Hodges
- The University of Queensland, School of Health & Rehabilitation Sciences, Brisbane, Queensland, 4072, Australia.
| | - Kay M Crossley
- The University of Queensland, School of Health & Rehabilitation Sciences, Brisbane, Queensland, 4072, Australia; La Trobe Sport and Exercise Medicine Research Centre (LASEM), College of Science, Health and Engineering, School of Allied Health, La Trobe University, Melbourne, Victoria, 3086, Australia.
| | - Joshua J Heerey
- La Trobe Sport and Exercise Medicine Research Centre (LASEM), College of Science, Health and Engineering, School of Allied Health, La Trobe University, Melbourne, Victoria, 3086, Australia.
| | - Adam I Semciw
- The University of Queensland, School of Health & Rehabilitation Sciences, Brisbane, Queensland, 4072, Australia; La Trobe Sport and Exercise Medicine Research Centre (LASEM), College of Science, Health and Engineering, School of Allied Health, La Trobe University, Melbourne, Victoria, 3086, Australia. https://twitter.com/ASemciw
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49
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Oishi T, Kobayashi N, Choe H, Tezuka T, Kobayashi D, Higashihira S, Inaba Y. Posterior acetabular uptake on 18F-fluoride positron emission tomography/computed tomography reveals a putative contrecoup region in patients with femoroacetabular impingement. J Orthop Surg (Hong Kong) 2020; 27:2309499019868929. [PMID: 31470763 DOI: 10.1177/2309499019868929] [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] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND PURPOSE The pathology of the posterior acetabular lesions, so-called "contrecoup regions", in femorocacetabular impingement (FAI) has not been elucidated fully. 18F-fluoride positron emission tomography/computed tomography (PET/CT) can visualize abnormal uptake caused by impingement. Therefore, we aimed to evaluate posterior acetabular uptake on PET/CT in FAI patients. PATIENTS AND METHODS Patients with FAI who underwent 18F-fluoride PET/CT between October 2014 and October 2016 were retrospectively evaluated. The maximum standardized uptake value (SUVmax) in the posterior acetabulum was evaluated. The mean SUVmax of FAI with cam morphology (the cam group) was compared with that of FAI with pincer morphology (the pincer group). In addition, the numbers of cases with SUVmax ≥ 6 and SUVmax < 6 in each group were evaluated. The entire study cohort was also grouped according to SUVmax, and the mean α and center edge angles were evaluated. RESULTS In total, 41 hips were analyzed (34 hips in the cam group and 7 in the pincer group). The mean SUVmax of the cam group (11.2 ± 7.4) was significantly higher than that of the pincer group (4.9 ± 1.9) (p < 0.01). The incidence of cases with SUVmax ≥ 6 in the cam group was significantly high (p < 0.01). In the overall cohort, the mean α angle of the SUVmax ≥ 6 group was significantly higher than that of the SUVmax < 6 group (p < 0.01). CONCLUSION Evaluation of posterior acetabular uptake suggests an association between cam morphology and increased posterior acetabular uptake.
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Affiliation(s)
- Takayuki Oishi
- 1 Department of Orthopedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Naomi Kobayashi
- 1 Department of Orthopedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Hyonmin Choe
- 2 Department of Orthopedic Surgery, Yokohama City University, Yokohama, Japan
| | - Taro Tezuka
- 2 Department of Orthopedic Surgery, Yokohama City University, Yokohama, Japan
| | - Daigo Kobayashi
- 2 Department of Orthopedic Surgery, Yokohama City University, Yokohama, Japan
| | - Shota Higashihira
- 2 Department of Orthopedic Surgery, Yokohama City University, Yokohama, Japan
| | - Yutaka Inaba
- 2 Department of Orthopedic Surgery, Yokohama City University, Yokohama, Japan
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50
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Spiker AM, Fabricant PD, Wong AC, Suryavanshi JR, Sink EL. Radiographic and clinical characteristics associated with a positive PART (Prone Apprehension Relocation Test): a new provocative exam to elicit hip instability. J Hip Preserv Surg 2020; 7:288-297. [PMID: 33163214 PMCID: PMC7605765 DOI: 10.1093/jhps/hnaa021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 04/08/2020] [Accepted: 04/18/2020] [Indexed: 12/13/2022] Open
Abstract
Hip instability due to mild dysplasia can be a diagnostic challenge. The physical exam is an important adjunct to radiographic evaluation for the clinical diagnosis of hip instability. Herein, we describe a new maneuver to replicate hip instability pain, called the PART (Prone Apprehension Relocation Test). We retrospectively identified patients in our institution’s hip preservation registry who presented for evaluation of hip pain. We divided patients into ‘positive’ or ‘negative’ PART and analyzed associated clinical and radiographic findings. Ninety patients (159 hips) were included, 83 female and 7 male, average age 27.3 ± 9.1 years. Thirty-four hips (21.4%) had a positive PART. There were no significant differences in hip range of motion, lateral center edge angle, or in acetabular depth. There was, however, a significant difference in acetabular version at 3 o’clock between the two test groups (18.5 ± 6.9° in negative, 21.2 ± 4.9° in positive, P = 0.045). There was no association between PART and previously described anterior apprehension testing. Historical methods of diagnosing hip dysplasia may not adequately identify patients with clinical hip instability. We describe a new provocative exam, the PART, which may be helpful in replicating hip instability symptoms in patients with anterior acetabular undercoverage. PART positive patients had significantly more acetabular anteversion at the 3 o’clock position, which is measured on computed tomography and is not visible on standard anteroposterior (AP) pelvis or false profile radiographs. We believe that the PART is a valuable supplement to clinical examination and radiographic measurements to identify patients with symptomatic hip instability.
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Affiliation(s)
- Andrea M Spiker
- Department of Orthopedic Surgery, University of Wisconsin - Madison, UW Health at The American Center, 4602 Eastpark Blvd, Madison, WI 53718, USA
| | - Peter D Fabricant
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Alexandra C Wong
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Joash R Suryavanshi
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Ernest L Sink
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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