Effect of hip angle on anterior hip joint force during gait

Medial helical versus straight lateral plating of distal femoral fractures-a biomechanical comparative study

BACKGROUND

Distal femoral fractures are commonly treated with lateral straight plates. However, the lateral approach may not always be desirable, and 180°-helical plates may be an alternative.

AIM

To investigate the biomechanical competence of 180°-helical plating versus standard straight lateral plating of unstable fractures at the distal femur.

METHODS

Twelve left artificial femora were instrumented with a 15-hole Locking Compression Plate-Distal Femur, using either 180°-helical plates (group 1) or conventional straight lateral plates (group 2). An unstable distal femoral fracture AO/OTA 33-A3.3 was simulated. All specimens were biomechanically tested under quasi-static and progressively increasing combined cyclic axial and torsional loading in internal rotation until failure.

FINDINGS

Initial axial stiffness (N/mm) was significantly higher in group 1 (185.6 ± 50.1) compared to group 2 (56.0 ± 14.4), p < 0.001. Group 1 demonstrated significantly higher initial interfragmentary flexion (°) and significantly lower initial varus/valgus deformation (°) under 500 N static axial compression versus group 2 (2.76 ± 1.02 versus 0.87 ± 0.77 and 4.08 ± 1.49 versus 6.60 ± 0.47), p ≤ 0.005. Shear displacement (mm) under 6 Nm static torsion was significantly higher in group 1 versus group 2 in both internal (1.23 ± 0.28 versus 0.40 ± 0.42) and external (1.21 ± 0.40 versus 0.57 ± 0.33) rotation, p ≤ 0.013. Cycles to failure and failure load (N) (clinical/catastrophic) were significantly higher in group 1 (12,484 ± 2116/13,752 ± 1518 and 1748.4 ± 211.6/1875.2 ± 151.8) compared to group 2 (7853 ± 1262/9727 ± 836 and 1285.3 ± 126.2/1472.7 ± 83.6), p ≤ 0.001.

INTERPRETATION

Although 180°-helical plating using a pre-contoured standard straight lateral plate was associated with higher shear and flexion movements, it demonstrated improved initial axial stability and resistance against varus/valgus deformation compared to straight lateral plating. Moreover, the helical plates were associated with significantly higher endurance to failure. From a biomechanical perspective, 180°-helical plating may be considered as a valuable alternative to standard straight lateral plating of unstable distal femoral fractures.

Trunk orthosis with joints providing resistive force improves dynamic sagittal alignment in postoperative patients with lumbar spinal stenosis

This study aimed to determine whether a trunk orthosis with joints providing resistive force (TORF) modifies sagittal malalignment during level walking in patients with lumbar spinal stenosis (LSS). Fifteen patients, 6 months after undergoing surgery for LSS, performed level walking at a self-selected speed while wearing a TORF. Dynamic sagittal alignment, including sagittal vertical axis, lumbar lordosis, and pelvic tilt, and spatiotemporal data as well as lower limb kinematic and kinetic data were recorded using a three-dimensional motion analysis system and six force plates. Statistical analysis was performed to compare these data with and without the TORF, respectively. Compared to the condition without the TORF, the use of the TORF significantly decreased positive sagittal vertical axis (p < 0.05) and increased the lumbar lordosis and pelvic tilt (p < 0.05). Peak hip flexion angle and extension moment during loading response (LR) significantly increased (p < 0.05), and peak hip extension angle and flexion moment during PS statistically decreased (p < 0.05). There was no difference in spatiotemporal data between the two conditions. Our findings suggest that TORF may modify the dynamic sagittal global alignment and lower limb kinematic and kinetics in postoperative LSS patients during level walking.

Is augmented femoral lateral plating with helically shaped medial plates biomechanically advantageous over straight medial plates?

Dual plating of comminuted distal femoral fractures allows for early patient mobilization. An additional helically shaped medial plate avoids the medial vital structures of the thigh. The aim of this study is to investigate the biomechanical competence of an augmented lateral locking compression plate distal femur (LCP-DF) using an additional straight versus a helically shaped medial LCP of the same length. Ten pairs of human cadaveric femora were instrumented with a lateral anatomical 15-hole LCP-DF. Following, they were pairwise instrumented with either an additional medial straight 14-hole LCP (group 1) or a 90°-helical shape LCP (group 2). All specimens were biomechanically tested under quasi-static and progressively increasing combined cyclic axial and torsional loading until failure. Initial interfragmentary axial displacement and flexion under static compression were significantly smaller in group 1 (0.11 ± 0.12 mm and 0.21 ± 0.10°) versus group 2 (0.31 ± 0.14 mm and 0.68 ± 0.16°), p ≤ 0.007. Initial varus deformation under static compression remained not significantly different between group 1 (0.57 ± 0.23°) and group 2 (0.75 ± 0.34°), p = 0.085. Flexion movements during dynamic loading were significantly bigger in group 2 (2.51 ± 0.54°) versus group 1 (1.63 ± 1.28°), p = 0.015; however, no significant differences were observed in terms of varus, internal rotation, and axial and shear displacements between the groups, p ≥ 0.204. Cycles to failure and load at failure were higher in group 2 (25,172 ± 6376 and 3017 ± 638 N) compared to group 1 (22,277 ± 4576 and 2728 ± 458 N) with no significant differences between them, p = 0.195. From a biomechanical perspective, helical double plating may be considered a useful alternative to straight double plating, demonstrating ameliorated damping capacities during flexion deformation and safer application as the medial neurovascular structures of the thigh are avoided.

Females with hip-related pain demonstrate reduced kinetics at the hip and ankle during terminal stance of gait

BACKGROUND

Individuals with hip-related pain (HRP) commonly report pain with walking and demonstrate altered movement patterns compared to healthy controls (HCs). Individuals with HRP may attempt to reduce pain during walking by decreasing kinetics and joint forces at the hip through increased use of the ankle during pushoff.

RESEARCH QUESTION

Do individuals with HRP have increased kinetics at the ankle and decreased kinetics at the hip during pushoff in gait compared to HCs, and do kinetic patterns differ between males and females with HRP?

METHODS

This retrospective observational study included 42 individuals with HRP and 20 HCs. Participants completed overground gait trials at their self-selected speed while kinematics and kinetics were recorded through a motion capture system and force plates. Peak internal hip and ankle moments and hip flexion and ankle plantarflexion angular impulse during terminal stance were used in general estimating equations for comparison of group by limb interactions for males and females separately, as well as a comparison of males and females within the HRP group.

RESULTS

Females with HRP demonstrated reduced hip flexion impulse on their involved limb (.070 Nm*s/kg*m) compared to female HCs (.083Nm*s/kg*m; p = .032), as well as reduced peak ankle plantarflexion moment (-.94Nm/kg*m) compared to their contralateral limb (-.99Nm/kg*m) and the involved limb of HRP males (-1.00Nm/kg*m) (p ≤ .007). There were no between-limb or between-group differences in hip or ankle peak moments or impulses in males.

SIGNIFICANCE

Females with HRP show decreased kinetics at both the hip and ankle; these patterns were not identified in males. Future investigations should examine whether increasing ankle kinetics during pushoff reduces pain at the hip, as this may be a valuable clinical treatment strategy.

The novel magnesium-titanium hybrid cannulated screws for the treatment of vertical femoral neck fractures: Biomechanical evaluation

Background

Conventional cannulated screws are commonly used for internal fixation in the treatment of vertical femoral neck fractures. However, the noticeably high rates of undesirable outcomes such as nonunion, malunion, avascular necrosis, and fixation failure still troubled the patients and surgeons. It is urgent to develop new cannulated screws to improve the above clinical problems. The purpose of this study was to design a novel magnesium-titanium hybrid cannulated screw and to further evaluate its biomechanical performance for the treatment of vertical femoral neck fractures.

Methods

A novel magnesium-titanium hybrid cannulated screw was designed, and the conventional titanium cannulated screw was also modeled. The finite element models for vertical femoral neck fractures with magnesium-titanium hybrid cannulated screws and conventional cannulated screws were respectively established. The hip joint contact force during walking gait calculated by a subject-specific musculoskeletal multibody dynamics model, was used as loads and boundary conditions for both finite element models. The stress and displacement distributions of the cannulated screws and the femur, the micromotion of the fracture surfaces of the femoral neck, and the overall stiffness were calculated and analyzed using finite element models. The biomechanical performance of the Magnesium-Titanium hybrid cannulated screws was evaluated.

Results

The maximum stresses of the magnesium-titanium hybrid cannulated screws and the conventional cannulated screws were 451.5 ​MPa and 476.8 ​MPa, respectively. The maximum stresses of the femur with the above different cannulated screws were 140.3 ​MPa and 164.8 ​MPa, respectively. The maximum displacement of the femur with the hybrid cannulated screws was 6.260 ​mm, lower than the femur with the conventional cannulated screws, which was 7.125 ​mm. The tangential micromotions in the two orthogonal directions at the fracture surface of the femoral neck with the magnesium-titanium hybrid cannulated screws were comparable to those with the conventional cannulated screws. The overall stiffness of the magnesium-titanium hybrid cannulated screw system was 490.17 ​N/mm, higher than that of the conventional cannulated screw system, which was 433.92 ​N/mm.

Conclusion

The magnesium-titanium hybrid cannulated screw had superior mechanical strength and fixation stability for the treatment of the vertical femoral neck fractures, compared with those of the conventional cannulated screw, indicating that the magnesium-titanium hybrid cannulated screw has great potential as a new fixation strategy in future clinical applications.The translational potential of this article: This study highlights an innovative design of the magnesium-titanium hybrid cannulated screw for the treatment of vertical femoral neck fractures. The novel magnesium-titanium hybrid cannulated screw not only to provide sufficient mechanical strength and fixation stability but also to contribute to the promotion of fracture healing, which could provide a better treatment for the vertical femoral neck fractures, beneficially reducing the incidence of nonunion and reoperation rates.

Quantitative assessment of the gait improvement effect of LSVT BIG® using a wearable sensor in patients with Parkinson's disease

Background

The main effects of Lee Silvermann Voice Treatment-BIG® therapy (LSVT-BIG) on gait function are improvements in gait speed and stride length. Considering the mechanism of this improvement, LSVT-BIG may affect joint angles of the lower extremities. Therefore, further investigation of the effect of LSVT-BIG on gait function, especially joint angles, is needed.

Methods

Patients with Parkinson's disease (PD) who were eligible for LSVT-BIG were recruited. We measured the following items pre- and post-LSVT-BIG: MDS-Unified Parkinson's Disease Rating Scale (MDS-UPDRS), Functional Independence Measure (FIM), timed up and go test (TUG), and gait parameters using RehaGait®. Gait parameters included gait speed, stride duration and length, the standard deviation of stride duration and length, cadence, the ratio of the stance/swing phase, and the flexion and extension angles of the hip, knee, and ankle joints. Range of motion (ROM) was calculated as the difference of values between the maximum flexion and extension angles of each joint.

Results

Twenty-four participants completed the LSVT-BIG. Significant improvement was observed in the MDS-UPDRS (mean changes: Part I, -2.4 points; Part II, -3.5 points; Part III -8.9 points), TUG (-0.61 s), gait speed (+0.13 m/s), stride length (+0.12 m), flexion and extension angles and ROM of the hip joints (flexion, +2.0°; extension, +2.0; ROM, +4.0°). Enlargement in ROM of the hip joint was strongly correlated with increase in gait speed and stride length (r = 0.755, r = 0.804, respectively).

Conclusions

LSVT-BIG enlarged flexion and extension angles and ROM of the hip joint significantly. Change of ROM of the hip joint was directly related to the increase in stride length and gait speed observed in patients with PD after LSVT-BIG.

Criteria-Based Rehabilitation Following Revision Hip Arthroscopy: A Clinical Commentary

Hip revision arthroscopy is becoming an increasingly popular surgery for those with unsatisfactory outcomes following primary hip arthroscopy. With the relatively uncommon but potentially increased difficulty of rehabilitation from this surgery, a lack of established research regarding rehabilitative programs remains. Therefore, the purpose of this clinical commentary is to propose a criterion-based progression that considers the intricacies present following a hip revision arthroscopy from early rehabilitation through return to sport. Criteria are presented clearly to promote objective progression through rehabilitation as opposed to relying on time since surgery as revision surgeries do not always follow traditional tissue healing time-frames. This criterion based progression promotes range of motion (ROM), strength, gait, neuromuscular control, load introduction and gradual return to play.

Level of Evidence

5.

Statistical Shape Modelling the In Vivo Location of Acetabular Wear in Retrieved Hip Implants

Edge-wear in acetabular cups is known to be correlated with greater volumes of material loss; the location of this wear pattern in vivo is less understood. Statistical shape modelling (SSM) may provide further insight into this. This study aimed to identify the most common locations of wear in vivo, by combining CT imaging, retrieval analysis and SMM. Shape variance was described in 20 retrieved metal-on-metal acetabular surfaces. These were revised after a mean of 90 months, from 13 female and seven male patients. They were positioned with a mean inclination and anteversion of 53° and 30°, respectively. Their orientation, in vivo, was established using their stabilising fins, visible in pre-revision CT imaging. The impact of wear volume, positioning, time, gender and size on the in vivo location of wear was investigated. These surfaces had a mean wear volume of 49.63 mm³. The mean acetabular surface displayed superior edge-wear centred 7° within the posterosuperior quadrant, while more of the volumetric wear occurred in the anterosuperior quadrant. Components with higher inclination had greater superior edge-wear scars, while a relationship was observed between greater anteversion angles and more posterosuperior edge-wear. This SSM method can further our understanding of hip implant function, informing future design and may help to refine the safe zone for implant positioning.

Comparison of Walking Biomechanics After Physical Therapist-Led Care or Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Secondary Analysis From a Randomized Controlled Trial

BACKGROUND

Femoroacetabular impingement syndrome is characterized by chondrolabral damage and hip pain. The specific biomechanics used by people with femoroacetabular impingement syndrome during daily activities may exacerbate their symptoms. Femoroacetabular impingement syndrome can be treated nonoperatively or surgically; however, differential treatment effects on walking biomechanics have not been examined.

PURPOSE

To compare the 12-month effects of physical therapist-led care or arthroscopy on trunk, pelvis, and hip kinematics as well as hip moments during walking.

STUDY DESIGN

Secondary analysis of multi-centre, pragmatic, two-arm superiority randomized controlled trial subsample; Level of evidence, 1.

METHODS

A subsample of 43 participants from the Australian Full randomised controlled trial of Arthroscopic Surgery for Hip Impingement versus best cONventional (FASHIoN trial) underwent gait analysis and completed the International Hip Outcome Tool (iHOT-33) at both baseline and 12 months after random allocation to physical therapist-led care (personalized hip therapy; n = 22; mean age 35; 41% female) or arthroscopy (n = 21; mean age 36; 48% female). Changes in trunk, pelvis, and hip biomechanics were compared between treatment groups across the gait cycle using statistical parametric mapping. Associations between changes in iHOT-33 and changes in hip kinematics across 3 planes of motion were examined.

RESULTS

As compared with the arthroscopy group, the personalized hip therapy group increased its peak hip adduction moments (mean difference = 0.35 N·m/body weight·height [%] [95% CI, 0.05-0.65]; effect size = 0.72; P = .02). Hip adduction moments in the arthroscopy group were unchanged in response to treatment. No other between-group differences were detected. Improvements in iHOT-33 were not associated with changes in hip kinematics.

CONCLUSION

Peak hip adduction moments were increased in the personalized hip therapy group and unchanged in the arthroscopy group. No biomechanical changes favoring arthroscopy were detected, suggesting that personalized hip therapy elicits greater changes in hip moments during walking at 12-month follow-up. Twelve-month changes in hip-related quality of life were not associated with changes in hip kinematics.

Three dimensional analysis of hip joint reaction force using Q Hip Force (AQHF) software: Implication as a diagnostic tool

Assessment of hip joint reaction force (JRF) is one of the analytical methods that can enable an understanding of the healthy walking index and the propensity towards disease. In this study, we have designed software, Analysis Q Hip Force (AQHF), to analyze the data retrieved from the mathematical equations for calculating the JRF and ground reaction force (GRF) that act on the hip joint during the early part of the stance phase. The stance phase is considered the least stable sub-phase during walking on level ground, and the gait stability is sequentially minimized during walking on elevated ramps. We have calculated the JRF and GRF values of walking stances on varied inclinations. The data obtained from these calculations during walking on elevated ramps were exported from mathematical equations to Q Hip Force software as two separate values, namely the JRF data and GRF data of the hip joint. The Q Hip Force software stores the two reaction force data in a text file, which allows the import and easy readability of the analyzed data with the AQHF application. The input and output data from the AQHF software were used to investigate the effect of different walking ramps on the magnitude of the hip JRF and GRF. The result of this study demonstrates a significant correlation between the JRF/GRF values and healthy walking indices till a ramp elevation of 70°. The software is designed to calculate and extrapolate data to analyze the possibility of stress in the hip joint. The framework developed in this study shows promise for preclinical and clinical applications. Studies are underway to use the results of JRF and GRF values as a diagnostic and prognostic tools in different diseases.

Elevated loading at the posterior acetabular edge of dysplastic hips during double-legged squat

Hips with developmental dysplasia (DDH) are at a heightened risk of premature hip osteoarthritis, which is often expedited by mechanically induced articular tissue damage. A prevalent form of damage in DDH is labral tears caused by abnormal loading at the shallow acetabular edge. Although the majority of reported DDH-related labral tears occur in the antero-superior acetabulum, posterior labral tears are prevalent in individuals whose lifestyle involves frequent high hip flexion tasks such as squatting. To better understand region-specific risks for chondrolabral damage during high hip flexion, we used image-based musculoskeletal models to compare acetabular edge loading (AEL) during double-legged squat between hips with symptomatic DDH (n = 10) and healthy controls (n = 10). Compared to controls, hips with DDH had higher instantaneous posterior AEL at the lowest point of squat (2.6 vs. 1.8 ×BW, p ≤ 0.04), and higher accumulative loading across the duration of the squatting motion (2.6 vs. 1.9 ×BW*s, p ≤ 0.04). Elevated posterior AEL coincided with increased net hip extension moments and posterior joint reaction forces, and was correlated with the severity of DDH acetabular deformity. Our findings suggest that posterior AEL is elevated in hips with symptomatic DDH during double-legged squat, which may contribute to chondrolabral damage in individuals who often perform such high hip flexion tasks. Clinical evaluation of DDH should consider patient-specific anatomy and lifestyle factors when establishing diagnoses and planning personalized treatment.

Effects of Knee Flexion Angles on the Joint Force and Muscle Force during Bridging Exercise: A Musculoskeletal Model Simulation

Bridging exercise is commonly used to increase the strength of the hip extensor and trunk muscles in physical therapy practice. However, the effect of lower limb positioning on the joint and muscle forces during the bridging exercise has not been analyzed. The purpose of this study was to use a musculoskeletal model simulation to examine joint and muscle forces during bridging at three different knee joint angle positions. Fifteen healthy young males (average age: 23.5 ± 2.2 years) participated in this study. Muscle and joint forces of the lumbar spine and hip joint during the bridging exercise were estimated at knee flexion angles of 60°, 90°, and 120° utilizing motion capture data. The lumbar joint force and erector spinae muscle force decreased significantly as the angle of the knee joint increased. The resultant joint forces were 200.0 ± 23.2% of body weight (%BW), 174.6 ± 18.6% BW, and 150.5 ± 15.8% BW at 60°, 90°, and 120° knee flexion angles, respectively. On the other hand, the hip joint force, muscle force of the gluteus maxims, and adductor magnus tended to increase as the angle of the knee joint increased. The resultant joint forces were 274.4 ± 63.7% BW, 303.9 ± 85.8% BW, and 341.1 ± 85.7% BW at a knee flexion angle of 60°, 90°, and 120°, respectively. The muscle force of the biceps femoris decreased significantly with increased knee flexion during the bridging exercise. In conclusion, the knee flexion position during bridging exercise has different effects on the joint and muscle forces around the hip joint and lumbar spine. These findings would help clinicians prescribe an effective bridging exercise that includes optimal lower limb positioning for patients who require training of back and hip extensor muscles.

Effect of Simulated Changes in Pelvic Tilt on Hip Joint Forces

Musculoskeletal modeling is commonly used to simulate and compare various movements between individuals. For conditions such as femoroacetabular impingement syndrome (FAIS), individuals tend to walk with more anterior pelvic tilt than those without FAIS. However, it is unknown whether accounting for pelvic tilt in musculoskeletal modeling would lead to a change in muscle forces and in turn, joint forces. Gait data of six individuals were collected and processed using Vicon and Visual3D. Each participant's pelvic tilt was adjusted by ± 10° at all time points during gait. Three analyses were performed per individual: no adjustment in tilt, one posterior (positive) tilt, and one anterior (negative) tilt. The resulting data were imported into OpenSim to determine muscle forces and the resulting femur-on-acetabulum (hip joint) forces in the pelvic and femoral reference frames. Data for each participant were normalized for gait cycle and body weight in MATLAB, and statistical parametric mapping was used to determine if the differences in joint and muscle forces were significant across different pelvic orientations. Shifting from posterior to anterior pelvic tilt reduced resultant forces. In the pelvic reference frame, anteriorly-directed joint forces decreased, while medially-directed forces increased. In the femoral reference frame, anteriorly- and medially-directed joint forces increased, while superiorly-directed forces decreased. Anterior gluteus medius and iliacus muscle forces decreased, while quadratus femoris, piriformis, and gemellus muscle forces increased. Given these results, future studies using musculoskeletal modeling should account for pelvic tilt in musculoskeletal models to obtain more realistic comparisons between healthy and pathological conditions.

Chair design for older immobile people: Comparison of pressure mapping and manual handling outcomes

The number of older adults unable to transfer or ambulate independently is increasing. High support chairs enable people experiencing loss of mobility to be mobile, but current chair designs are associated with global functional loss and pressure ulcers. This pilot study compared the functionality of a traditional design high support chair to a new design of motorised high support chair: 1) a motion laboratory study compared joint angles and pressure at the hip, knee, ankle, elbow and spine when pushing each chair, and 2) a pressure mapping study compared the interface pressure when older people with limited mobility used the chairs. Significant reduction in joint angles for the person pushing the chair (degree difference range -3.6 to 14.2) and decreased seated pressure (w/kg difference range -0.2 to 2.1) for the seated user were identified for the motorised chair. Longitudinal investigations are required to determine if the significant differences identified in this pilot study result in less manual handling injuries and pressure areas.

Hip muscle activity in male football players with hip-related pain; a comparison with asymptomatic controls during walking

OBJECTIVES

Compare muscle activity between male football players with and without hip-related pain. Morphological and intra-articular features of hip-related pain are proposed pre-cursors to hip osteoarthritis. Altered muscle activity is a feature of severe hip osteoarthritis, but it is not known whether differences exist earlier in the pathological spectrum.

DESIGN

Cross-sectional; SETTING: University laboratory; PARTICIPANTS: Forty-two male football players with hip-related pain; and 19 asymptomatic controls.

MAIN OUTCOME MEASURES

Hip muscle activity (Gluteus maximus, gluteus medius, tensor facia latae, adductor longus and rectus femoris) was recorded during walking using surface electromyography (EMG).

RESULTS

Men with hip-related pain had sustained rectus femoris activity prior to toe-off (47-51% of the gait cycle) (p = 0.01, ES = 0.51) unlike controls who had reduced activity. In men with severe hip-related pain, gluteus maximus EMG was sustained into mid-stance (12-20% of the gait cycle) (F = 6.15, p < 0.01) compared to controls.

CONCLUSIONS

Differences in rectus femoris and gluteus maximus activity were identified between male footballers with and without hip-related pain. The pattern of gluteus maximus EMG relative to peak, approaching mid-stance in severe hip-related pain, is consistent with observations in severe hip osteoarthritis. This supports the hypothesis that symptom severity may influence muscle activity across the spectrum of hip degeneration.

The in vivo location of edge-wear in hip arthroplasties : combining pre-revision 3D CT imaging with retrieval analysis

Aims

Acetabular edge-loading was a cause of increased wear rates in metal-on-metal hip arthroplasties, ultimately contributing to their failure. Although such wear patterns have been regularly reported in retrieval analyses, this study aimed to determine their in vivo location and investigate their relationship with acetabular component positioning.

Methods

3D CT imaging was combined with a recently validated method of mapping bearing surface wear in retrieved hip implants. The asymmetrical stabilizing fins of Birmingham hip replacements (BHRs) allowed the co-registration of their acetabular wear maps and their computational models, segmented from CT scans. The in vivo location of edge-wear was measured within a standardized coordinate system, defined using the anterior pelvic plane.

Results

Edge-wear was found predominantly along the superior acetabular edge in all cases, while its median location was 8° (interquartile range (IQR) -59° to 25°) within the anterosuperior quadrant. The deepest point of these scars had a median location of 16° (IQR -58° to 26°), which was statistically comparable to their centres (p = 0.496). Edge-wear was in closer proximity to the superior apex of the cups with greater angles of acetabular inclination, while a greater degree of anteversion influenced a more anteriorly centred scar.

Conclusion

The anterosuperior location of edge-wear was comparable to the degradation patterns observed in acetabular cartilage, supporting previous findings that hip joint forces are directed anteriorly during a greater portion of walking gait. The further application of this novel method could improve the current definition of optimal and safe acetabular component positioning.

Cite this article: Bone Joint Res 2021;10(10):639–649.

Acetabular Edge Loading During Gait Is Elevated by the Anatomical Deformities of Hip Dysplasia

Developmental dysplasia of the hip (DDH) is a known risk factor for articular tissue damage and secondary hip osteoarthritis. Acetabular labral tears are prevalent in hips with DDH and may result from excessive loading at the edge of the shallow acetabulum. Location-specific risks for labral tears may also depend on neuromuscular factors such as movement patterns and muscle-induced hip joint reaction forces (JRFs). To evaluate such mechanically-induced risks, we used subject-specific musculoskeletal models to compare acetabular edge loading (AEL) during gait between individuals with DDH (N = 15) and healthy controls (N = 15), and determined the associations between AEL and radiographic measures of DDH acetabular anatomy. The three-dimensional pelvis and femur anatomy of each DDH and control subject were reconstructed from magnetic resonance images and used to personalize hip joint center locations and muscle paths in each model. Model-estimated hip JRFs were projected onto the three-dimensional acetabular rim to predict instantaneous AEL forces and their accumulative impulses throughout a gait cycle. Compared to controls, subjects with DDH demonstrated significantly higher AEL in the antero-superior acetabulum during early stance (3.6 vs. 2.8 × BW, p ≤ 0.01), late stance (4.3 vs. 3.3 × BW, p ≤ 0.05), and throughout the gait cycle (1.8 vs. 1.4 × BW^*s, p ≤ 0.02), despite having similar hip movement patterns. Elevated AEL primarily occurred in regions where the shallow acetabular edge was in close proximity to the hip JRF direction, and was strongly correlated with the radiographic severity of acetabular deformities. The results suggest AEL is highly dependent on movement and muscle-induced joint loading, and significantly elevated by the DDH acetabular deformities.

Does femoral morphology and stem alignment influence outcomes of cementless total hip arthroplasty with proximally coated double-tapered titanium stems?

INTRODUCTION

Stem subsidence and thigh pain can cause significant patient dissatisfaction after cementless THA. The purpose of this study was to examine the effect of proximal-femoral morphology and stem alignment on clinical outcomes using a double-tapered, cementless titanium femoral component.

METHODS

We retrospectively reviewed 281 consecutive, primary THAs from 2012 to 2014 with a mean follow-up of 4 years. Preoperative radiographs were used to assess femoral neck shaft angle (FNS), canal flare index (CFI), Dorr classification, and greater trochanter (GT) overhang. Postoperative radiographs were used to determine stem alignment and 6-week follow-up radiographs were used to determine subsidence. Clinical outcomes included thigh pain, leg-length discrepancy (LLD), patient-reported outcome measures (PROMs) and revision surgeries.

RESULTS

271 stems (96%) did not subside (<4 mm) and 10 (4%) showed evidence of subsidence (>4 mm). Subsidence was significantly associated with subsequent revision surgery (p < 0.01). 278 stems (99%) were in neutral alignment and 3 in varus (1%). Alignment did not significantly influence subsidence, thigh pain, LLD, revisions, or PROMs. Femoral morphology measures (FNS, CFI, Dorr classification, and GT overhang) were not significantly associated with stem alignment, subsidence, LLD, or revisions. CFI was significantly associated with intraoperative calcar fractures (p = 0.02). GT overhang was associated with thigh pain (p = 0.03) and FNS was inversely associated with postoperative HOOS scores.

CONCLUSIONS

Subsidence and proximal-femoral morphology are potential sources of postoperative morbidity in certain cementless THA patients. In accordance with prior studies, CFI was identified as a potential risk factor for intraoperative calcar fractures. More research into preoperative femoral morphologies, such as GT overhang and FNS, is warranted as these may contribute to unsatisfactory results related to cementless THA.

Multi-joint biomechanics during sloped walking in patients with developmental dysplasia of the hip

BACKGROUND

Developmental dysplasia of the hip is characterized by abnormal acetabular and femoral geometries that alter joint loading and increase the risk of hip osteoarthritis. Current understanding of biomechanics in this population remains isolated to the hip and largely focused on level-ground walking, which may not capture the variable loading conditions that contribute to symptoms and intra-articular damage.

METHODS

Thirty young adult females (15 with dysplasia) underwent gait analysis during level, 10° incline, and 10° decline walking while whole-body kinematics, ground reaction forces, and electromyography (EMG) were recorded. Low back, hip, and knee joint kinematics and internal joint moments were calculated using a 15-segment model and integrated EMG was calculated within the functional phases of gait. Dependent variables (peak joint kinematics, moments, and integrated EMG) were compared across groups with a one-way ANOVA with multiple comparisons controlled for using the Benjamini-Hochberg method (α = 0.05).

FINDINGS

During level and incline walking, patients with developmental dysplasia of the hip had significantly lower trunk flexion angles, lumbar and knee extensor moments, and erector spinae activity than controls. Patients with developmental dysplasia of the hip also demonstrated reduced rectus femoris activity during loading of level walking and increased gluteus maximus activity during mid-stance of decline walking.

INTERPRETATION

Patients with developmental dysplasia of the hip adopt compensations both proximal and distal to the hip, which vary depending on the slope of walking. Furthering the understanding of multi-joint biomechanical compensations is important for understanding the mechanism of osteoarthritis development as well as secondary conditions.

Distal locking of short cephalomedullary nails decreases varus collapse in unstable intertrochanteric fractures - a biomechanical analysis

INTRODUCTION

Peritrochanteric fractures are a growing problem and complications relating to operative fixation of these fracture, including varus collapse and screw cutout, are common in elderly osteoporotic patients. We hypothesize that unlocked nails will demonstrate increased varus collapse and inferior construct stiffness in specimens with increased diaphyseal medullary diameter.

MATERIALS AND METHODS

Sixteen non-cadaveric osteoporotic biomechanical femur specimens were utilized in this study, with eight specimens having an artificially large femoral canal to represent Dorr C femurs. All femurs were instrumented with a short cephalomedullary nail with and without distal cross-lock screw fixation and had an unstable intertrochanteric fracture created in a repeatable pattern. Specimens underwent cyclic compression to a maximal load of 1000N with segmental motion quantified through the use of visual tracking markers. Statistical comparisons were performed using one-way ANOVA with Tukey post-hoc analysis to determine differences between specific groups. Significance was defined as p<0.05.

RESULTS

Unlocked short cephalomedullary nails showed increased varus collapse due to motion of the nail within the femoral canal in capacious femoral canals compared with narrow femoral canals and distally cross-locked nails. The coronal deformation of the wide canal unlocked group (17.9 ^o±2.6^o) was significantly greater in the varus direction than any other fixation under compressive load of 1000N. There was no significant difference in varus angulation between the wide canal or narrow canal locked groups (11.1^o±8.7^o vs. 8.2^o±1.7^o respectively, p=0.267). The narrow canal unlocked group (13.7^o±2.4^o) showed significantly greater varus angulation than the narrow canal locked (p=0.015). The wide canal unlocked group showed significantly greater varus angulation than the wide canal locked group (p=0.003). Motion between the femoral shaft and the cephalomedullary nail (toggling of the nail within the shaft) was significantly greater in narrow or wide canal unlocked specimens, 7.94^o±2.13^o and 10.2^o±1.7^o respectively, than in the narrow or wide canal locked specimens, 2.4^o±0.2^o and 4.2^o±0.5^o respectively (p<0.05) CONCLUSION: Unlocked short intramedullary fixation for unstable peritrochanteric fractures results in increased varus collapse under axial compression. This study supports the use of distal cross-locking of short intramedullary fixation for unstable peritrochanteric fractures in patients with capacious femoral canals secondary to osteoporosis who might otherwise be as risk for varus collapse, device failure, and malunion.

Influence of loading direction due to physical activity on proximal femoral growth tendency

Longitudinal bone growth is regulated by mechanical forces arising from physical activity, whose directions and magnitudes depend on activity kinematics and intensity. This study aims to investigate the influence of common physical activities on proximal femoral morphological tendency due to growth at the femoral head growth plate. A subject-specific femur model based on magnetic resonance images of one able-bodied 6-year old child was developed, and the directions of hip contact force were described as load samples at a constant magnitude. Finite element analysis was performed to predict growth rate and growth direction, and expected changes in neck-shaft angle and femoral anteversion were computed corresponding to circa 4 months of growth. For most loading conditions, neck-shaft angle and femoral anteversion decreased during growth, corresponding to the femur's natural course during normal growth. The largest reduction in neck-shaft angle and femoral anteversion was approximately 0.25° and 0.15°. Our results suggest that most common physical activities induce the expected morphological changes in normal growth in able-bodied children. Understanding the influence of contact forces during less common activities on proximal femoral development might provide improved guidelines and treatment planning for children who have or are at risk of developing a femoral deformity.

Discrete element and finite element methods provide similar estimations for hip joint contact mechanics during walking gait

Finite element analysis (FEA) provides a powerful approach for estimating the in-vivo loading characteristics of the hip joint during various locomotory and functional activities. However, time-consuming procedures, such as the generation of high-quality FE meshes and setup of FE simulation, typically make the method impractical for rapid applications which could be used in clinical routine. Alternatively, discrete element analysis (DEA) has been developed to quantify mechanical conditions of the hip joint in a fraction of time compared to FEA. Although DEA has proven effective in the estimation of contact stresses and areas in various complex applications, it has not yet been well characterised by its ability to evaluate contact mechanics for the hip joint during gait cycle loading using data from several individuals. The objective of this work was to compare DEA modelling against well-established FEA for analysing contact mechanics of the hip joint during walking gait. Subject-specific models were generated from magnetic resonance images of the hip joints in five asymptomatic subjects. The DEA and FEA models were then simulated for 13 loading time-points extracted from a full gait cycle. Computationally, DEA was substantially more efficient compared to FEA (simulation times of seconds vs. hours). The DEA and FEA methods had similar predictions for contact pressure distribution for the hip joint during normal walking. In all 13 simulated loading time-points across five subjects, the maximum difference in average contact pressures between DEA and FEA was within ±0.06 MPa. Furthermore, the difference in contact area ratio computed using DEA and FEA was less than ±6%.

Sex-specific sagittal and frontal plane gait mechanics in persons post-hip arthroscopy for femoroacetabular impingement syndrome

Postoperative gait mechanics in persons with femoroacetabular impingement syndrome (FAIS) remain understudied as a treatment outcome despite observed, yet inconclusive, preoperative gait abnormalities. Females with FAIS demonstrate worse preoperative patient-reported hip function and altered hip mechanics when compared with males; it is unknown whether these sex differences persist postarthroscopy. The purpose of this study was to compare sex-specific gait kinematics between persons at least 1 year postarthroscopy for FAIS and healthy comparisons. General linear models with estimating equations were used to evaluate the effect of (a) limb and sex within each group, and (b) limb and group within each sex for peak sagittal and frontal plane trunk, pelvis, and hip kinematics during stance phase of gait. Analyses were covaried by gait speed. Seventeen females and eight males an average 2.5 years postarthroscopy (1.1-7.2 year) for FAIS were compared with healthy females (n = 7) and males (n = 5). Females in the FAIS group presented with an average of 4.6° more anterior pelvic tilt, and 4.8° less hip extension compared with healthy females (P ≤ .03) and 8.6° less trunk flexion, 4.8° more anterior pelvic tilt, 3.1° more pelvic drop, and 7.5° more hip flexion than males with FAIS (P ≤ .03). Males in the FAIS group presented with 2.9° less pelvic drop, and 3.2° less hip adduction than healthy males. Preoperative gait mechanics were not collected and thus changes in mechanics could not be evaluated. This study is significant to clinicians who treat patients postarthroscopy to consider sex-specific gait impairments.

Femoroacetabular Impingement and Acetabular Labral Tears - Part 2: Clinical Diagnosis, Physical Examination and Imaging

The clinical diagnosis of femoral acetabular impingement (FAI) continues to evolve as the understanding of normal and pathological hips progresses. Femoral acetabular impingement is currently defined as a syndrome in which the diagnosis consists of the combination of a previously-obtained comprehensive clinical history, followed by a consistent and standardized physical examination with specific orthopedic maneuvers. Additionally, radiographic and tomographic examinations are used for the morphological evaluation of the hip, and to ascertain the existence of sequelae of childhood hip diseases and the presence of osteoarthritis. The understanding of the femoral and acetabular morphologies and versions associated with images of labral and osteochondral lesions obtained through magnetic resonance imaging (MRI) contributes to the confirmation of this syndrome in symptomatic patients, and helps in the exclusion of differential diagnoses such as iliopsoas tendon snaps, subspine impingement, ischiofemoral impingement, and other hip joint pathologies.

Effects of strengthening the hip flexor muscles on walking ability and the locomotive syndrome rank test: An intervention study

BACKGROUND

Locomotive syndrome is a state in which locomotive function is decreased due to musculoskeletal diseases. To extend a healthy lifespan, it is important to prevent falls and locomotive syndrome development accompanying aging by slowing the decline in walking ability. However, it is unclear whether hip flexor muscle strengthening improves walking ability and locomotive syndrome. This study aimed to examine the effect of hip flexor muscle strengthening on walking ability and the locomotive syndrome rank test.

METHODS

Forty participants were enrolled. Before hip flexor muscle strengthening, maximum muscle strength on the exercised side was measured, and gait analysis and the two-step test were performed simultaneously. Participants were divided into a healthy group and a locomotive syndrome group based on the two-step test and were given hip flexor muscle training at least three days a week for six weeks. After completing the training, maximum muscle strength was measured and gait analysis was performed for all participants. The difference between the two-step test conducted pre- and post-training in the locomotive syndrome group was statistically analyzed.

RESULTS

Twenty-two and 14 participants were included in the healthy and the locomotive syndrome groups, respectively. Hip flexion strength on the exercised side increased from 1.68 to 1.95 Nm/kg (p < 0.0001) and 1.04 to 1.21 Nm/kg (p = 0.0031) in the healthy and the locomotive syndrome groups, respectively. Step length, stride length and walking speed measured by gait analysis also increased in both groups. Consequently, the two-step test score improved from 1.17 to 1.30 (p = 0.0002) and the stage of locomotive syndrome improved in 9 participants (p = 0.041).

CONCLUSIONS

Strengthening of the hip flexor muscles improved walking ability and the stage of locomotive syndrome. Therefore, strengthening of the hip flexor muscles is important for the prevention and improvement of locomotive syndrome.

Pericapsular hip muscle activity in people with and without femoroacetabular impingement. A comparison in dynamic tasks

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.

Individual muscle contributions to hip joint-contact forces during walking in unilateral transfemoral amputees with osseointegrated prostheses

Direct skeletal attachment of prostheses in transfemoral amputees circumvents skin-interface complications associated with conventional sockets; however, joint pain and musculoskeletal disease is known to occur postoperatively. This study quantified hip contact forces and the roles of individual muscles in producing hip contact forces during walking in transfemoral amputees with osseointegrated prostheses. Musculoskeletal models were developed for four transfemoral amputees. Gluteus maximus and gluteus medius were the major contributors to the hip contact forces, and the intact limb hip muscles demonstrated greater contributions to hip contact forces than those of the residual limb. The findings may be useful for mitigating walking asymmetry.

Gait compensatory mechanisms in unilateral transfemoral amputees

Individuals with unilateral transfemoral amputation depend on compensatory muscle and joint function to generate motion of the lower limbs, which can produce gait asymmetry; however, the functional role of the intact and residual limb muscles of transfemoral amputees in generating progression, support, and mediolateral balance of the body during walking is not well understood. The aim of this study was to quantify the contributions of the intact and the residual limb's contralateral muscles to body center of mass (COM) acceleration during walking in transfemoral amputees. Three-dimensional subject-specific musculoskeletal models of 6 transfemoral amputees fitted with a socket-type prosthesis were developed and used to quantify muscle forces and muscle contributions to the fore-aft, vertical, and mediolateral body COM acceleration using a pseudo-inverse ground reaction force decomposition method during over-ground walking. Anterior pelvic tilt and hip range of motion in the sagittal and frontal planes of the intact limb was significantly larger than those in the residual limb (p<0.05). The mean contributions of the intact limb hip muscles to body COM support, forward propulsion and mediolateral balance were significantly greater than those in the residual limb (p<0.05). Gluteus maximus contributed more to propulsion and support, while gluteus medius contributed more to balance than other muscles in the intact limb than the residual limb. The findings demonstrate the role of the intact limb hip musculature in compensating for reduced or absent muscles and joint function in the residual limb of transfemoral amputees during walking. The results may be useful in developing rehabilitation programs and design of prostheses to improve gait symmetry and mitigate post-operative musculoskeletal pathology.

Current trends in sport and exercise hip conditions: Intra-articular and extra-articular hip pain, with detailed focus on femoroacetabular impingement (FAI) syndrome

Musculoskeletal conditions, such as hip pain are leading causes of pain and disability. Hip pain is the second most common cause of lower limb musculoskeletal pain, and is commonly seen in active individuals. Hip and groin pain may have intra-articular and extra-articular causes. Femoroacetabular impingement (FAI) syndrome and the associated pathologies are common intra-articular causes of hip and groin pain in active individuals. There are also a number of extra-articular causes of pain, which include musculotendinous conditions, extra-articular impingements and the clinical entities of groin pain described in the Doha agreement. This chapter will describe these, with a detailed focus on FAI syndrome. Specifically, it addresses: 1. What is and what causes FAI syndrome; 2. How do I diagnose FAI syndrome; and 3. What is the evidence-based approach to managing FAI syndrome?

Hip Function 6 to 10 Months After Arthroscopic Surgery: A Cross-sectional Comparison of Subjective and Objective Hip Function, Including Performance-Based Measures, in Patients Versus Controls

Background:

Little is known about hip-related function, mobility, and performance in patients after hip arthroscopic surgery (HA) during the time that return to sports can be expected.

Purpose:

To evaluate measures of subjective and objective hip function 6 to 10 months after HA in patients compared with healthy controls and to compare objective function in the HA group between the operated and nonoperated hips.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 33 patients who had undergone HA (mean, 8.1 ± 2.6 months postoperatively) and 33 healthy participants matched on sex, age, and activity level were compared regarding subjective hip function (Copenhagen Hip and Groin Outcome Score [HAGOS]) and objective function including hip range of motion (ROM; flexion, internal rotation, and external rotation), isometric hip muscle strength (adduction, abduction, flexion, internal rotation, and external rotation), and performance-based measures: the Y Balance Test (YBT), medial and lateral triple-hop test, and Illinois agility test. Group differences were analyzed using independent-samples t tests. Paired-samples t tests were used for a comparison of the operated and nonoperated hips. Standard effect sizes (Cohen d) were provided for all outcomes.

Results:

The HA group reported worse subjective hip function than the control group (HAGOS subscores: d = –0.7 to –2.1; P ≤ .004). Objective measures of hip ROM (d = –0.5 to –1.1; P ≤ .048), hip flexion strength (d = –0.5; P = .043), and posteromedial reach of the YBT (d = –0.5; P = .043) were also reduced in the HA group, although there were no significant differences between groups regarding the remaining objective measures (d = –0.1 to –0.4; P ≥ .102 to .534). The only significant difference between the operated and nonoperated hips in the HA group was reduced passive hip flexion (d = –0.4; P = .045).

Conclusion:

Patients who had undergone HA demonstrated reduced subjective hip function compared with controls 6 to 10 months after surgery, when return to sports can be expected. While most objective strength and performance test results were comparable between the HA and control groups at 6 to 10 months after surgery, the HA group presented with impairments related to hip mobility and hip flexion strength. No consistent pattern of impairments was found in operated hips compared with nonoperated hips.

The effect of altered stride length on iliocapsularis and pericapsular muscles of the anterior hip: An electromyography investigation during asymptomatic gait

BACKGROUND

Anterior pericapsular muscles potentially contribute to active hip joint stability in walking by controlling anterior femoral translation in peak extension. Alternatively, these muscles could flex the hip and tension the anterior capsule to aid initiation of swing. Although never investigated, the location of Iliocapsularis and its extensive anterior hip capsule attachment imply a potential role in these functions. We hypothesised if these muscles contribute to control of femoral head translation (rather than hip flexion), their activation would decrease when peak hip extension is reduced during shorter stride walking.

RESEARCH QUESTIONS

To provide the first description of iliocapsularis activity during walking and challenge the hypothesised roles of the anterior pericapsular hip muscles in gait by walking with shortened strides.

METHODS

Fifteen healthy volunteers walked with self-selected and shortened stride lengths. Electromyographic recordings were made from iliocapsularis, iliacus and anterior gluteus minimus with intramuscular electrodes, and rectus femoris with surface electrodes. Stride characteristics were measured using force sensors and 3D motion capture. Ensembles of burst activity profiles for each stride length were compared.

RESULTS

Iliocapsularis displayed a consistent EMG burst around toe-off (terminal hip extension) that peaked during early swing phase with self-selected strides. In shortened strides, iliocapsularis EMG increased during mid to late stance (p = 0.03), with no difference in other muscles. Iliocapsularis, iliacus and rectus femoris activity decreased during early stance (p < 0.01) in short strides, whereas gluteus minimus EMG increased (p = 0.03).

SIGNIFICANCE

Iliocapsularis displayed an EMG burst around toe-off during walking, and greater EMG during mid-late stance in short stride walking, which was not seen in other pericapsular muscles. Shortened strides increase the demand for active tensioning of the hip joint capsule in initial swing, and suggests a role for iliocapsularis during active hip flexion in pain free young individuals.

Hip Radiograph Findings in Patients Aged 40 Years and Under with Posterior Pelvic Pain

BACKGROUND

Several sacroiliac joint (SIJ) provocative tests used to assess posterior pelvic pain involve moving and stressing the hip. It is unknown if there is a subgroup of patients with posterior pelvic pain who have underlying hip deformity that could potentially influence performance and interpretation of these tests.

OBJECTIVE

To describe the prevalence of radiographic hip deformity and hip osteoarthritis in a group of adults 40 years old and under who met the clinical diagnostic criteria for treatment of posterior pelvic pain with an image guided intra-articular SIJ injection.

DESIGN

Retrospective cohort study.

SETTING

Tertiary university orthopedic department PATIENTS (OR PARTICIPANTS): One hundred and forty-eight patients were evaluated (83% (123/148) female; mean age 31.3 ± 6.2 years). All had completed a trial of comprehensive noninvasive treatment for posterior pelvic pain and had a minimum of three positive SIJ provocative tests on physical examination.

METHODS

Retrospective review identified patients undergoing SIJ injection for pain recommended and performed by seven physiatrists between 2011 and 2017. Hip radiographs were read by a physician with expertise in hip measurements with previously demonstrated excellent intrarater reliability.

MAIN OUTCOME MEASUREMENTS

Percentage of patients with hip deformity findings.

RESULTS

No patients meeting the inclusion criteria had significant radiographic hip osteoarthritis (Tonnis ≥2 indicating moderate or greater radiographic hip osteoarthritis) and 4/148 (3%) were found to have mild radiographic hip osteoarthritis. Prearthritic hip disorders were identified in 123 (83%, 95% CI: 76, 89%) patients. For those patients with prearthritic hip disorders, measurements consistent with femoroacetabular impingement (FAI) were seen in 61 (41%) patients, acetabular dysplasia in 49 (33%) patients, and acetabular retroversion in 85 (57%) patients. Acetabular retroversion was identified in 43% (crossover sign) and 39% (prominent ischial spine) of patients.

CONCLUSIONS

Approximately 57% of adult patients under the age of 40 years with the clinical symptom complex of SIJ pain were found to have radiographic acetabular retroversion. This is a higher percentage than the 5%-15% found in asymptomatic people in the current literature. Further study is needed to assess links between hip structure, hip motion, and links to pelvic pain including peri and intra-articular SIJ pain.

LEVEL OF EVIDENCE

III.

Capsular plication in the non-deformity hip: impact on post-operative joint stability

Purpose and hypothesis

The aim of this study was to evaluate the hip joint range of motion after different capsular plication. The study hypothesis proposed that capsular plication after hip arthroscopy may reduce hip external rotation and thus prevent the hip joint instability created by arthroscopic capsulotomies.

Methods

Six fresh frozen human cadavers were studied in the intact state (5 males, 1 females) for a total of 12 non-deformity hips tested. They were fixed to the operating room table using a custom-made apparatus. Three Steinman pins were inserted, the first into ASIS, a parallel pin into the distal femur proximal to inter-epicondylar axis and the third pin into the lateral epicondyle. Simulation of arthroscopic capsulotomies was done progressively with simulation of three capsular plication techniques. The first plication technique consisted of a primary plication shift of the antero-lateral capsule. The distal-medial arm of the iliofemoral ligament was shifted toward the proximal-lateral arm. The second plication technique consisted in adding a longitudinal arm to the capsulotomy, between the lateral arm and the medial arm of the iliofemoral ligament, to create a T-shaped capsulotomy. The resulting two triangular capsular flaps were overlaid onto each other by approximately 5 mm, plicated fully and tighly sutured in a double-breast manner. The third plication technique, called redrapping, consisted in excising the inferior capsular triangular flap (previously made in the second technique), and suturing the latero-anterior superior capsular flap to the medial arm of the iliofemoral ligament, superimposing the capsular edges for closure. External rotation of the hip at 0°, 15° and 30° of flexion were obtained after the capsulotomy and each capsular plication technique to quantify the increase in hip stability after plication. Data were assessed using a two-way repeated measure analysis of variance (ANOVAs) and Student’s T-test when necessary to determine if the change in external rotation was significantly different.

Results

After capsulotomy, external rotation averaged 26.3°, 29.1° and 31.1° at 0°, 15° and 30° of flexion. With the primary plication shift, external rotation averaged 24.9°, 30.3° and 34.0°. With the two-triangle technique, external rotation averaged 26.1°, 31.9° and 33.3°. With the re-draping technique, external rotation averaged 25.8°, 30.9° and 32.0°. A significant relationship was found between «Plication Technique» and «Angle of flexion» factors for the measured angle of external rotation (P = 0.04).

A decomposition of the interaction showed that external rotation decreased at 0° of hip flexion and increased as the hip flexion angle increased. The only significant difference found corresponded to the two triangles technique at 15° flexion (mean difference compared to the non-repaired state = 2.8° ± 3.8° or 8.8% increase in external rotation; P = 0.03).

Conclusions

Different techniques of capsular plication result in a non-significant increase in hip external rotation when compared to unrepaired capsulotomies. Therefore, special attention should be paid at the time of capsular plication, which could be disadvantageous when done overzealously aiming to increase postoperative stability.

Musculoskeletal models with generic and subject-specific geometry estimate different joint biomechanics in dysplastic hips

Optimizing the geometric complexity of musculoskeletal models is important for reliable yet feasible estimation of joint biomechanics. This study investigated the effects of subject-specific model geometry on hip joint reaction forces (JRFs) and muscle forces in patients with developmental dysplasia of the hip (DDH) and healthy controls. For nine DDH and nine control subjects, three models were created with increasingly subject-specific pelvis geometry, hip joint center locations and muscle attachments. Hip JRFs and muscle forces during a gait cycle were compared among the models. For DDH subjects, resultant JRFs from highly specific models including subject-specific pelvis geometry, joint locations and muscle attachments were not significantly different compared to models using generic geometry in early stance, but were significantly higher in late stance (p = 0.03). Estimates from moderately specific models using CT-informed scaling of generic pelvis geometry were not significantly different from low specificity models using generic geometry scaled with skin markers. For controls, resultant JRFs in early stance from highly specific models were significantly lower than moderate and low specificity models (p ≤ 0.02) with no significant differences in late stance. Inter-model JRF differences were larger for DDH subjects than controls. Inter-model differences for JRF components and muscle forces were similar to resultant JRFs. Incorporating subject-specific pelvis geometry significantly affects JRF and muscle force estimates in both DDH and control groups, which may be especially important for reliable estimation of pathomechanics in dysplastic hips.

Hip joint muscle forces during gait in patients with femoroacetabular impingement syndrome are associated with patient reported outcomes and cartilage composition

Femoroacetabular impingement syndrome (FAIS) consists of abnormal hip joint morphology and pain during activities of daily living. Abnormal gait mechanics and potentially abnormal muscle forces within FAI patients leads to articular cartilage damage. Therefore, there is a necessity to understand the effects of FAI on hip joint muscle forces during gait and the link between muscle forces, patient reported outcomes (PRO) and articular cartilage health. The purposes of this study were to assess: (1) hip muscle forces between FAI patients and healthy controls and (2) the associations between hip muscle forces with PRO and cartilage composition (T_1ρ/T₂ mapping) within FAI patients. Musculoskeletal simulations were used to estimate peak muscle forces during the stance phase of gait in 24 FAI patients and 24 healthy controls. Compared to controls, FAI patients ambulated with lower vasti (30% body-weight, p = 0.01) and higher sartorius (4.0% body-weight, p < 0.01) forces. Within FAI patients, lower peak gluteus medius, gluteus minimus, sartorius and iliopsoas forces were associated with worse hip joint pain and function (R = 0.43-0.70, p = 0-0.04), while lower muscle forces were associated with increased T_1ρ and T₂ values (i.e. altered cartilage composition) within the hip joint cartilage (R = -0.44 to -0.58, p = 0.006-0.05). Although FAI patients demonstrate abnormal muscle forces, it is unknown whether or not these altered muscle force patterns are associated with pain avoidance or weak musculature. Further investigation is required in order to better understand the effects of FAI on hip joint muscle forces and the associations with hip joint cartilage degeneration.

Gait Alterations in Femoroacetabular Impingement Syndrome Differ by Sex

Background Femoroacetabular impingement (FAI) syndrome may affect gait kinematics differently between males and females. Objectives To investigate whether individuals with FAI syndrome have different hip and pelvic motion during gait, at their preferred speed and a prescribed speed, compared to individuals of the same sex without pain. Methods Twenty-one participants (11 males and 10 females) with FAI syndrome and 41 participants (19 males and 22 females) without hip pain were included in this case-control laboratory study. There were no differences between the 2 groups in age, body mass index, and activity score. Kinematic data for all participants were collected while walking at a preferred speed and at 1.25 m/s. For sex and walking speed, linear regression analyses were used to examine the effect of group and the interaction of group by limb. Results At both speeds, males with FAI syndrome walked with more than 6° less peak hip extension (P≤.018), 5° greater anterior pelvic tilt (P≤.020), and 5° less posterior pelvic tilt (P≤.018) compared to males without hip pain. Females with FAI syndrome walked with 2° less hip extension (P≤.012) and at least 3° more hip adduction (P<.001) in the more painful hip than in the less painful hip at both speeds. Conclusion Males and females with FAI syndrome have different gait alterations when compared to a same-sex comparison group. In males, differences were between groups. In females with FAI syndrome, differences were between the more painful and the less painful limb. J Orthop Sports Phys Ther 2018;48(8):649-658. Epub 22 May 2018. doi:10.2519/jospt.2018.7913.

Sub-elite Football Players With Hip-Related Groin Pain and a Positive Flexion, Adduction, and Internal Rotation Test Exhibit Distinct Biomechanical Differences Compared With the Asymptomatic Side

Background Hip-related groin pain is common in sub-elite football players and may be associated with altered hip biomechanics. Objectives To compare the hip biomechanics, bony hip morphology associated with femoroacetabular impingement (FAI) syndrome, and hip strength and range of motion (ROM) between the symptomatic and asymptomatic limbs of sub-elite football players with unilateral hip-related groin pain and a positive flexion, adduction, and internal rotation (FADIR) test. Methods Fifteen sub-elite football (soccer) players with unilateral hip-related groin pain and a positive FADIR test were recruited for this observational cross-sectional study. Three-dimensional motion analysis and ground reaction force data were recorded for walking and a single-leg drop-jump (SLDJ) task. Participants also underwent a standard anterior-posterior hip radiograph and hip strength and ROM assessment. Between-limb differences were assessed using paired t tests or Wilcoxon signed-rank tests. Results The symptomatic limb displayed a smaller peak hip extension angle (P = .01) and a lower peak hip adduction moment (P = .03) compared with the asymptomatic limb during the stance phase of walking. Additionally, during the SLDJ, the symptomatic limb demonstrated less total sagittal plane ROM (P = .04). The symptomatic limb also demonstrated less external rotation ROM (P = .03). However, no differences were found between limbs for bony hip morphology associated with FAI syndrome or hip strength. Conclusion This study found between-limb asymmetries in low- and high-impact functional tasks, such as walking and an SLDJ, in football players with unilateral hip-related groin pain. Despite unilateral pain, bony morphology associated with FAI syndrome did not differ between limbs. J Orthop Sports Phys Ther 2018;48(7):584-593. Epub 8 May 2018. doi:10.2519/jospt.2018.7910.

Editorial Commentary: Caveat Flexor-To Release or Not to Release the Iliopsoas, That Is the Question

In nonarthritic patients with femoroacetabular impingement syndrome, borderline dysplasia, and symptomatic iliopsoas snapping, arthroscopic iliopsoas fractional lengthening carries a significant risk of postarthroscopic instability. The iliopsoas is a dynamic stabilizer of the anterior hip. Thus, although statistically significant and clinically important improvements in hip function have the potential to be achieved with iliopsoas fractional lengthening, surgeons must be supremely confident in their ability to perform a secure capsular plication, labral preservation (not debridement), comprehensive cam correction, avoidance of intra-abdominal fluid extravasation, release of all iliopsoas tendon bands (if bifid or trifid), and ensure that femoral version is normal or low, neck-shaft angle is not excessively valgus, the dysplasia magnitude is no more than mild, and that there is no excessive soft tissue hypermobility. If these goals can be met, then excellent outcomes can be achieved. If not, then an iliopsoas fractional lengthening should not be performed.

Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients

Background

Clinical assessments and rehabilitation in athletic groin pain (AGP) have focused on specific anatomical structures and uniplanar impairments rather than whole body movement.

Objective

To examine the effectiveness of rehabilitation that targeted intersegmental control in patients with AGP and to investigate post rehabilitation changes in cutting biomechanics.

Methods

Two hundred and five patients with AGP were rehabilitated focusing on clinical assessment of intersegmental control, linear running and change of direction mechanics in this prospective case series. Hip and Groin Outcome Score (HAGOS) was the primary outcome measure. Secondary measures included pain-free return to play rates and times, pain provocation on squeeze tests and three-dimensional (3D) biomechanical analysis during a 110° cutting manoeuvre.

Results

Following rehabilitation, patients demonstrated clinically relevant improvements in HAGOS scores (effect size (ES): 0.6–1.7). 73% of patients returned to play pain-free at a mean of 9.9 weeks (±3.5). Squeeze test values also improved (ES: 0.49–0.68). Repeat 3D analysis of the cutting movement demonstrated reductions in ipsilateral trunk side flexion (ES: 0.79) and increased pelvic rotation in the direction of travel (ES: 0.76). Changes to variables associated with improved cutting performance: greater centre of mass translation in the direction of travel relative to centre of pressure (ES: 0.4), reduced knee flexion angle (ES: 0.3) and increased ankle plantar flexor moment (ES: 0.48) were also noted.

Conclusions

Rehabilitation focused on intersegmental control was associated with improved HAGOS scores, high rates of pain-free return to sporting participation and biomechanical changes associated with improved cutting performance across a range of anatomical diagnoses seen in AGP.

Gluteal tendinopathy and hip osteoarthritis: Different pathologies, different hip biomechanics

BACKGROUND

Gluteal tendinopathy (GT) and hip osteoarthritis (OA) are the most common causes of hip pain and associated disability in older adults. Pain and altered walking biomechanics are common to both conditions. This study aimed to compare three-dimensional walking biomechanics between individuals with unilateral, symptomatic GT and HOA.

METHODS

Sixty individuals with symptomatic unilateral GT confirmed by magnetic-resonance-imaging and 73 individuals with symptomatic unilateral HOA (Kellgren-Lawrence Grade ≥ 2) underwent three-dimensional gait analysis. Maximum and minimum values of the external sagittal hip moment, the first peak, second peak and mid-stance minimum of the hip adduction moment (HAM), sagittal plane hip excursion and hip joint angles, pelvic obliquity and trunk lean, at the three HAM time points during stance phase of walking were compared between groups.

RESULTS

Compared to individuals with HOA, those with GT exhibited a greater hip peak extension moment (P < 0.001) and greater HAM throughout the stance phase of walking (P = 0.01-P < 0.001), greater hip adduction (P < 0.001) and internal rotation (P < 0.01-P < 0.001) angles and lower hip flexion angles and excursion (P = 0.02 - P < 0.001). Individuals with HOA exhibited a greater forward trunk lean (P ≤ 0.001) throughout stance, and greater ipsilateral trunk lean in the frontal plane (P < 0.001) than those with GT.

CONCLUSION

Despite presence of pain in both conditions, hip kinematics and kinetics differ between individuals with symptomatic unilateral GT and those with symptomatic unilateral HOA. These condition-specific impairments may be targets for optimization of management of HOA and GT.

Lower limb biomechanics in femoroacetabular impingement syndrome: a systematic review and meta-analysis

Objective

(1) Identify differences in hip and pelvic biomechanics in patients with femoroacetabular impingement syndrome (FAIS) compared with controls during everyday activities (eg, walking, squatting); and (2) evaluate the effects of interventions on hip and pelvic biomechanics during everyday activities.

Design

Systematic review.

Data sources

Medline, CINAHL, EMBASE, Scopus and SPORTDiscus until February 2017.

Methods

Primary aim: studies that investigated hip or pelvic kinematics and/or joint torques of everyday activities in patients with FAIS compared with the asymptomatic contralateral limb or a control group. Secondary aim: studies that evaluated effects of conservative or surgical interventions on patients with FAIS using pre-post or controlled clinical trial designs. Biomechanical data must have been collected using three-dimensional motion capture devices. Reporting quality was assessed using the Epidemiological Appraisal Instrument and data were pooled (standardised mean difference (SMD), 95% CI) where populations and primary outcomes were similar.

Results

Fourteen studies were included (11 cross-sectional and three pre/post intervention), varying between low and moderate reporting quality. Patients with FAIS walked with a lower: peak hip extension angle (SMD −0.40, 95% CI −0.71 to −0.09), peak internal rotation angle (−0.67, 95% CI −1.19 to −0.16) and external rotation joint torque (−0.71, 95% CI −1.07 to −0.35), and squatted to a lesser depth with no difference in hip flexion range. Pre/post intervention data were limited in number and quality, and to surgical cohorts.

Conclusion

This review suggests that patients with FAIS may demonstrate hip biomechanical impairments during walking and squatting, with minimal literature available to comment on other tasks.

Clinical relevance

The information presented in the review provides insight into the biomechanical differences associated with FAIS; however, the between-group differences were small to moderate. This information may aid in the development of management strategies for people with the condition.

PROSPEROregistration number

CRD42016038677.

Biomechanical Analysis of the Proximal Femoral Locking Compression Plate: Do Quality of Reduction and Screw Orientation Influence Construct Stability?

OBJECTIVES

To investigate biomechanically in a human cadaveric model the failure modes of the proximal femoral locking compression plate and explore the underlying mechanism.

METHODS

Twenty-four fresh-frozen paired human cadaveric femora with simulated unstable intertrochanteric fractures (AO/OTA 31-A3.3) were assigned to 4 groups with 6 specimens each for plating with proximal femoral locking compression plate. The groups differed in the quality of fracture reduction and plating fashion of the first and second proximal screws as follows: (1) anatomic reduction with on-axis screw placement; (2) anatomic reduction with off-axis screw placement; (3) malreduction with on-axis screw placement; (4) malreduction with off-axis screw placement. The specimens were tested until failure using a protocol with combined axial and torsional loading. Mechanical failure was defined as abrupt change in machine load-displacement data. Clinical failure was defined as 5 degrees varus tilting of the femoral head as captured with optical motion tracking.

RESULTS

Initial axial stiffness (in N/mm) in groups 1 to 4 was 213.6 ± 65.0, 209.5 ± 134.0, 128.3 ± 16.6, and 106.3 ± 47.4, respectively. Numbers of cycles to clinical and mechanical failure were 16,642 ± 10,468 and 8695 ± 1462 in group 1, 14,076 ± 3032 and 7449 ± 5663 in group 2, 8800 ± 8584 and 4497 ± 2336 in group 3, and 9709 ± 3894 and 5279 ± 4119 in group 4. Significantly higher stiffness and numbers of cycles to both clinical and mechanical failure were detected in group 1 in comparison with group 3, P ≤ 0.044.

CONCLUSIONS

Generally, malreduction led to significantly earlier construct failure. The observed failures were cut-out of the proximal screws in the femoral head, followed by either screw bending, screw loosening, or screw fracture. Proper placement of the proximal screws in anatomically reduced fractures led to significantly higher construct stability. Our data also indicate that once the screws are placed off-axis (>5 degrees), the benefit of an anatomic reduction is lost.

Increased Hip Stresses Resulting From a Cam Deformity and Decreased Femoral Neck-Shaft Angle During Level Walking

BACKGROUND

It is still unclear why many individuals with a cam morphology of the hip do not experience pain. It was recently reported that a decreased femoral neck-shaft angle may also be associated with hip symptoms. However, the effects that different femoral neck-shaft angles have on hip stresses in symptomatic and asymptomatic individuals with cam morphology remain unclear.

QUESTIONS/PURPOSES

We examined the effects of the cam morphology and femoral neck-shaft angle on hip stresses during walking by asking: (1) Are there differences in hip stress characteristics among symptomatic patients with cam morphology, asymptomatic individuals with cam morphology, and individuals without cam morphology? (2) What are the effects of high and low femoral neck-shaft angles on hip stresses?

METHODS

Six participants were selected, from a larger cohort, and their cam morphology and femoral neck-shaft angle parameters were measured from CT data. Two participants were included in one of three groups: (1) symptomatic with cam morphology; (2) asymptomatic with a cam morphology; and (3) asymptomatic control with no cam morphology with one participant having the highest femoral neck-shaft angle and the other participant having the lowest in each subgroup. Subject-specific finite element models were reconstructed and simulated during the stance phase, near pushoff, to examine maximum shear stresses on the acetabular cartilage and labrum.

RESULTS

The symptomatic group with cam morphology indicated high peak stresses (6.3-9.5 MPa) compared with the asymptomatic (5.9-7.0 MPa) and control groups (3.8-4.0 MPa). Differences in femoral neck-shaft angle influenced both symptomatic and asymptomatic groups; participants with the lowest femoral neck-shaft angles had higher peak stresses in their respective subgroups. There were no differences among control models.

CONCLUSIONS

Our study suggests that the hips of individuals with a cam morphology and varus femoral neck angle may be subjected to higher mechanical stresses than those with a normal femoral neck angle.

CLINICAL RELEVANCE

Individuals with a cam morphology and decreased femoral neck-shaft angle are likely to experience severe hip stresses. Although asymptomatic participants with cam morphology had elevated stresses, a higher femoral neck-shaft angle was associated with lower stresses. Future research should examine larger amplitudes of motion to assess adverse subchondral bone stresses.

Higher medially-directed joint reaction forces are a characteristic of dysplastic hips: A comparative study using subject-specific musculoskeletal models

Acetabular dysplasia is a known cause of hip osteoarthritis. In addition to abnormal anatomy, changes in kinematics, joint reaction forces (JRFs), and muscle forces could cause tissue damage to the cartilage and labrum, and may contribute to pain and fatigue. The objective of this study was to compare lower extremity joint angles, moments, hip JRFs and muscle forces during gait between patients with symptomatic acetabular dysplasia and healthy controls. Marker trajectories and ground reaction forces were measured in 10 dysplasia patients and 10 typically developing control subjects. A musculoskeletal model was scaled in OpenSim to each subject and subject-specific hip joint centers were determined using reconstructions from CT images. Joint kinematics and moments were calculated using inverse kinematics and inverse dynamics, respectively. Muscle forces and hip JRFs were estimated with static optimization. Inter-group differences were tested for statistical significance (p≤0.05) and large effect sizes (d≥0.8). Results demonstrated that dysplasia patients had higher medially directed JRFs. Joint angles and moments were mostly similar between the groups, but large inter-group effect sizes suggested some restriction in range of motion by patients at the hip and ankle. Higher medially-directed JRFs and inter-group differences in hip muscle forces likely stem from lateralization of the hip joint center in dysplastic patients. Joint force differences, combined with reductions in range of motion at the hip and ankle may also indicate compensatory strategies by patients with dysplasia to maintain joint stability.

Athletic groin pain (part 2): a prospective cohort study on the biomechanical evaluation of change of direction identifies three clusters of movement patterns

Background

Athletic groin pain (AGP) is prevalent in sports involving repeated accelerations, decelerations, kicking and change-of-direction movements. Clinical and radiological examinations lack the ability to assess pathomechanics of AGP, but three-dimensional biomechanical movement analysis may be an important innovation.

Aim

The primary aim was to describe and analyse movements used by patients with AGP during a maximum effort change-of-direction task. The secondary aim was to determine if specific anatomical diagnoses were related to a distinct movement strategy.

Methods

322 athletes with a current symptom of chronic AGP participated. Structured and standardised clinical assessments and radiological examinations were performed on all participants. Additionally, each participant performed multiple repetitions of a planned maximum effort change-of-direction task during which whole body kinematics were recorded. Kinematic and kinetic data were examined using continuous waveform analysis techniques in combination with a subgroup design that used gap statistic and hierarchical clustering.

Results

Three subgroups (clusters) were identified. Kinematic and kinetic measures of the clusters differed strongly in patterns observed in thorax, pelvis, hip, knee and ankle. Cluster 1 (40%) was characterised by increased ankle eversion, external rotation and knee internal rotation and greater knee work. Cluster 2 (15%) was characterised by increased hip flexion, pelvis contralateral drop, thorax tilt and increased hip work. Cluster 3 (45%) was characterised by high ankle dorsiflexion, thorax contralateral drop, ankle work and prolonged ground contact time. No correlation was observed between movement clusters and clinically palpated location of the participant's pain.

Conclusions

We identified three distinct movement strategies among athletes with long-standing groin pain during a maximum effort change-of-direction task These movement strategies were not related to clinical assessment findings but highlighted targets for rehabilitation in response to possible propagative mechanisms.

Trial registration number

NCT02437942, pre results.

Walking patterns and hip contact forces in patients with hip dysplasia

INTRODUCTION

Several studies have investigated walking characteristics in hip dysplasia patients, but so far none have described all hip rotational degrees of freedom during the whole gait cycle. This descriptive study reports 3D joint angles and torques, and furthermore extends previous studies with muscle and joint contact forces in 32 hip dysplasia patients and 32 matching controls.

METHODS

3D motion capture data from walking and standing trials were analysed. Hip, knee, ankle and pelvis angles were calculated with inverse kinematics for both standing and walking trials. Hip, knee and ankle torques were calculated with inverse dynamics, while hip muscle and joint contact forces were calculated with static optimisation for the walking trials.

RESULTS

No differences were found between the two groups while standing. While walking, patients showed decreased hip extension, increased ankle pronation and increased hip abduction and external rotation torques. Furthermore, hip muscle forces were generally lower and shifted to more posteriorly situated muscles, while the hip joint contact force was lower and directed more superiorly.

CONCLUSION

During walking, patients showed lower and more superiorly directed hip joint contact force, which might alleviate pain from an antero-superiorly degenerated joint.

What is the underlying mechanism for the failure mode observed in the proximal femoral locking compression plate? A biomechanical study

PURPOSE

Recently, several cases of clinical failure have been reported for the Proximal Femoral Locking Compression Plate (PF-LCP). The current study was designed to explore biomechanically the underlying mechanism and to determine whether the observed failure was due to technical error on insertion or to implant design.

METHODS

A foam block model simulating an unstable intertrochanteric fracture was created for 3 study groups with 6 specimens each. Group C was correctly instrumented according to the manufacturer's guidelines. In Group P and Group A, the first or second proximal screw was placed with a posterior or anterior off-axis orientation by 2° measured in the transversal plane, respectively. Each construct was cyclically tested until failure using a test setup and protocol simulating complex axial and torsional loading. Radiographs were taken prior to and after the tests. Force, number of cycles to failure and failure mode were compared.

RESULTS

A screw deviation of 2° from the nominal axis led to significantly earlier construct failure in Group P and Group A in comparison to Group C. The failure mode was characterised by loosening of the off-axis screw due to disengagement with the plate, resulting in loss of construct stiffness and varus collapse of the fracture.

CONCLUSIONS

In our biomechanical test setup, the clinical failure modes observed with the PF-LCP were reproducible. A screw deviation of 2° from the nominal axis consistently led to the failure. This highlights how crucial is the accurate placement of locking screws in the proximal femur.

REHABILITATION AFTER HIP ARTHROSCOPY AND LABRAL REPAIR IN A HIGH SCHOOL FOOTBALL ATHLETE: A 3.6 YEAR FOLLOW-UP WITH INSIGHT INTO POTENTIAL RISK FACTORS

BACKGROUND

Hip arthroscopy is a common surgical technique for the correction of intraarticular pathology. While surgical success is often determined by anatomical correction, post-operative rehabilitation serves an essential role in restoring pre-morbid activity levels. A paucity of long-term post-operative rehabilitation outcomes exists in the literature lending uncertainty to the long-standing efficacy of interventions and associated risk for future injury.

CASE DESCRIPTION

This case report describes the progress of a male subject 3.6 years after left hip arthroscopy with labral repair. Detailed clinical measures and insight into potential risk factors are presented as a follow-up to a previously published case report.

OUTCOME

A 3.6-year follow-up assessment revealed potential risk factors that may have predisposed the subject to future pathology. The most profound finding was the subject's complaint of contralateral right hip pain and examination findings suggesting intraarticular pathology. His left surgical hip presented with no reported problems or significant findings. The examination also revealed an anterior tilted pelvis, muscle length deficits, and hip muscle weakness which may have contributed to his right hip pain or may be risk factors for future pathology in both hips. It appeared that these impairments affected his gait and performance on functional tests.

DISCUSSION

This case report describes the 3.6 year follow-up for a young adult male subject after unilateral left hip arthroscopy and acetabular labral repair. The re-examination findings and risk factors identified at the follow-up may provide insight into the need for long-term surveillance among post-surgical individuals. Detailed reporting of the long-term effects of a post-operative program after hip arthroscopy is non-existent in the literature and the current findings suggest the potential need for mitigating risk in the non-surgical hip. Future longitudinal studies are needed to develop a consensus on the best interventions for these patients.

LEVEL OF EVIDENCE

4-Case Report.