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Stetzelberger VM, Zurmühle CA, Hanauer M, Laurençon J, Marti D, Meier MK, Popa V, Schwab JM, Tannast M. Reliability and Reproducibility of a Novel Grading System for Lesions of the Ligamentous-Fossa-Foveolar Complex in Young Patients Undergoing Open Hip Preservation Surgery. Orthop J Sports Med 2022; 10:23259671221098750. [PMID: 35706555 PMCID: PMC9189540 DOI: 10.1177/23259671221098750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Several classification systems based on arthroscopy have been used to describe lesions of the ligamentum teres (LT) in young active patients undergoing hip-preserving surgery. Inspection of the LT and associated lesions of the adjuvant fovea capitis and acetabular fossa is limited when done arthroscopically but is much more thorough during open surgical hip dislocation. Therefore, we propose a novel grading system based on our findings during surgical dislocation comprising the full spectrum of ligamentous-fossa-foveolar complex (LFFC) lesions. Purpose: To determine (1) intraobserver reliability and (2) interobserver reproducibility of our new grading system. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: We performed this validation study on 211 hips (633 images in total) with surgical hip dislocation (2013-2021). We randomly selected 5 images per grade for each LFFC item to achieve an equal representation of all grades (resulting in 75 images). The ligament, fossa, and fovea were subcategorized into normal, inflammation, degeneration, partial, and complete defects. All surgeries were performed in a standardized way by a single surgeon. The femur was disarticulated using a bone hook, the LT was inspected, documented and resected, then the fossa and fovea were documented with the femoral head in full dislocation using a 70° arthroscope. Six observers with different levels of expertise in hip-preserving surgery independently conducted the measurements twice, and intraclass correlation coefficients (ICC) were calculated to determine (1) intraobserver reliability and (2) interobserver reproducibility of the novel grading system. Results: For intraobserver reliability, excellent ICCs were found in both the junior and the experienced raters for grading the ligament, fossa, fovea, and total LFFC (ICCs ranged from 0.91 to 0.99 for the LFFC score). We found excellent interobserver reproducibility between raters for all items of the LFFC (all interobserver ICCs ≥ 0.76). Conclusion: Our new grading system for lesions of the LFFC is highly reliable and reproducible. It covers the full spectrum of damage more precisely than arthroscopic classifications do and offers a scientific basis for standardized intraoperative evaluation.
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Affiliation(s)
- Vera Maren Stetzelberger
- Department of Orthopaedic Surgery and Traumatology, Cantonal Hospital Fribourg HFR, University of Fribourg, Fribourg, Switzerland
| | - Corinne Andrea Zurmühle
- Department of Orthopaedic Surgery and Traumatology, Inselspital Bern, University of Bern, Bern, Switzerland
| | - Matthieu Hanauer
- Department of Orthopaedic Surgery and Traumatology, Inselspital Bern, University of Bern, Bern, Switzerland
| | - Jonathan Laurençon
- Department of Orthopaedic Surgery and Traumatology, Inselspital Bern, University of Bern, Bern, Switzerland
| | - Darius Marti
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Malin Kristin Meier
- Department of Orthopaedic Surgery and Traumatology, Inselspital Bern, University of Bern, Bern, Switzerland
| | - Vlad Popa
- Department of Orthopaedic Surgery and Traumatology, Cantonal Hospital Fribourg HFR, University of Fribourg, Fribourg, Switzerland
| | - Joseph Michael Schwab
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Moritz Tannast
- Department of Orthopaedic Surgery and Traumatology, Cantonal Hospital Fribourg HFR, University of Fribourg, Fribourg, Switzerland
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Amer MH, Dunlop DG. Recurrent Post-traumatic Posterior Hip Dislocation Treated Using a Bone Block Technique: Case Report and a Review of the Literature. JBJS Case Connect 2022; 12:01709767-202206000-00044. [PMID: 37440473 DOI: 10.2106/jbjs.cc.22.00113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
CASE A 26-year-old man presented with recurrent native hip dislocation after an initially traumatic posterior right hip dislocation. The combined soft-tissue and bony deficiency was addressed using an autologous bone block technique, as previously popularized for shoulder instability. Thirteen years postoperatively, no subsequent dislocations occurred, and the patient has an excellent functional outcome. CONCLUSION The bone block technique for hip stabilization can be used to address focal acetabular deficiencies with promising long-term follow-up.
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Affiliation(s)
- Mohammad H Amer
- University Hospital of Southampton NHS Trust, Southampton, United Kingdom
- Department of Trauma and Orthopaedics, Cairo University, Cairo, Egypt
| | - Douglas G Dunlop
- University Hospital of Southampton NHS Trust, Southampton, United Kingdom
- Department of Orthopaedics, Southampton University, Southampton, United Kingdom
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Christian RA, Butler BA, Weber TG, Stover MD. Novel Treatment for Recurrent Posttraumatic Hip Instability: A Case Report. JBJS Case Connect 2019; 9:e0272. [PMID: 31609750 DOI: 10.2106/jbjs.cc.18.00272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 26-year-old woman sustained a traumatic right hip dislocation with posterior wall component in a motor vehicle collision. Initial treatment consisted of open reduction internal fixation of her posterior wall fracture. Six years later, she developed low-energy recurrent hip instability. Imaging demonstrated posterior capsular insufficiency and femoral retrotorsion. The patient underwent intertrochanteric femoral rotational osteotomy. Nine years postoperatively, the patient has returned to activity without restriction or subsequent dislocations. CONCLUSIONS Recurrent posttraumatic hip instability requires careful identification of the etiology of instability. This case provides long-term follow-up after successful treatment with intertrochanteric femoral rotational osteotomy.
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Affiliation(s)
- Robert A Christian
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Bennet A Butler
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Timothy G Weber
- OrthoIndy Trauma, St. Vincent Trauma Center, St. Vincent Orthopedics and Spine Center, Indianapolis, Indiana
| | - Michael D Stover
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Acetabular Retroversion and Decreased Posterior Coverage Are Associated With Sports-related Posterior Hip Dislocation in Adolescents. Clin Orthop Relat Res 2019; 477:1101-1108. [PMID: 30272610 PMCID: PMC6494309 DOI: 10.1097/corr.0000000000000514] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Leverage of the femoral head against the acetabular rim may lead to posterior hip dislocation during sports activities in hips with femoroacetabular impingement (FAI) deformity. Abnormal concavity of the femoral head and neck junction has been well described in association with posterior hip dislocation. However, acetabular morphology variations are not fully understood. QUESTIONS/PURPOSES The purpose of this study was to compare the acetabular morphology in terms of acetabular version and coverage of the femoral head in adolescents who sustained a posterior hip dislocation during sports and recreational activities with a control group of patients without a history of hip disease matched by age and sex. METHODS In this case-control study, we identified 27 adolescents with posterior hip dislocation sustained during sports or recreational activities who underwent a CT scan of the hips (study group) and matched them to patients without a history of hip disease being evaluated with CT for possible appendicitis (control group). Between 2001 and 2017, we treated 71 adolescents (aged 10-19 years old) for posterior hip dislocations. During the period in question, we obtained CT scans or MR images after closed reduction of a posterior hip dislocation. One patient was excluded because of a diagnosis of Down syndrome. Twenty-one patients who were in motor vehicle-related accidents were also excluded. Twelve patients were excluded because MRI was obtained instead of CT. Finally, three patients with no imaging after reduction and seven patients with inadequate CT reformatting were excluded. Twenty-seven patients (38%) had CT scans of suitable quality for analysis, and these 27 patients constituted the study group. We compared those hips with 27 age- and sex-matched adolescents who had CT scans for appendicitis and who had no history of hip pain or symptoms (control group). One orthopaedic surgeon and one pediatric musculoskeletal radiologist, not invoved in the care of the patients included in the study, measured the lateral center-edge angle, acetabular index, acetabular depth/width ratio, acetabular anteversion angle (10 mm from the dome and at the level of the center of the femoral heads), and the anterior and posterior sector angles in the dislocated hip; the contralateral uninvolved hip of the patients with hip dislocations; and both hips in the matched control patients. Both the study and control groups had 25 (93%) males with a mean age of 13 (± 1.7) years. Inter- and intrarater reliability of measurements was assessed with intraclass correlation coefficient (ICC). There was excellent reliability (ICC > 0.90) for the acetabular anteversion angle measured at the center of the femoral head, the acetabular version 10 mm from the dome, and the posterior acetabular sector angle. RESULTS The mean acetabular anteversion angle (± SD) was lower in the study group at 10 mm from the acetabular dome (-0.4° ± 9° versus 4° ± 4°; mean difference -5°; 95% confidence interval [CI], -9 to -0.3; p = 0.015) and at the center of the femoral heads (10° ± 5° versus 14° ± 4°; mean difference -3°; 95% CI, -6 to -0.9; p = 0.003). A higher proportion of acetabula was severely retroverted in the study group (14 of 27 [52%]; 95% CI, 33%-71% versus four of 27 [15%]; 95% CI, 1%-28%; p = 0.006). The mean posterior acetabular sector angle was lower in the study group (82° ± 8° versus 90° ± 6°; mean difference -8°; 95% CI, -11 to -4; p < 0.001), whereas no difference was found for the anterior acetabular sector angle (65° ± 6° versus 65° ± 7°; mean difference 0.3°; 95% CI, -3 to 4; p = 0.944). There was no difference for the lateral center-edge angle (27° ± 6° versus 26° ± 5°; p = 0.299), acetabular index (5° ± 3° versus 6 ± 4°; p = 0.761), or acetabular depth/width ration (305 ± 30 versus 304 ± 31; p = 0.944) between groups. Acetabular anteversion angle at the center of the femoral heads (11° ± 4° versus 14° ± 4°; p = 0.006) and the posterior acetabular sector angle (86° ± 7 ° versus 91° ± 6°; p = 0.007) were lower in the contralateral uninvolved hips compared with control hips. CONCLUSIONS Decreased acetabular anteversion angle and posterior acetabular coverage of the femoral head were associated with posterior dislocation of the hip in adolescents with sports-related injury even in the absence of a high-energy mechanism. Further studies are necessary to clarify whether a causative effect exists between acetabular and femoral morphology and the dislocation of the hip in patients with sports-related injuries. LEVEL OF EVIDENCE Level III, prognostic study.
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Imai H, Takeba J, Maruishi A, Miyawaki J, Kamada T, Miura H. Computer-assisted anteverting eccentric rotational acetabular osteotomy for recurrent posterior dislocation associated with acetabular retroversion: a case report. J Med Case Rep 2019; 13:4. [PMID: 30630530 PMCID: PMC6329043 DOI: 10.1186/s13256-018-1949-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/12/2018] [Indexed: 11/10/2022] Open
Abstract
Background Acetabular retroversion is a rotatory abnormality of the entire hemipelvis that includes anterior over-coverage and posterior deficiency of the acetabulum, and is associated with pincer-type femoroacetabular impingement and posterior hip instability. Acetabular retroversion is thought to cause posterior dislocation of the hip in athletes due to both the pincer-type femoroacetabular impingement and posterior hip instability. Case presentation A 26-year-old Japanese man had acetabular retroversion that induced recurrent posterior dislocation of his hip due to excessive hip flexion while wakeboarding. We performed anteverting eccentric rotational acetabular osteotomy using preoperative three-dimensional planning and an intraoperative computerized navigation system. Our patient was able to return to sports activities 1 year postoperatively. Conclusions Both preoperative three-dimensional surgical planning software and an intraoperative navigation system can provide a highly accurate map for this complicated surgery that simultaneously improves the pincer-type femoroacetabular impingement and posterior deficiency of the acetabulum.
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Affiliation(s)
- Hiroshi Imai
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan.
| | - Jun Takeba
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Akira Maruishi
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Joji Miyawaki
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Tomomi Kamada
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Hiromasa Miura
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
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Leclerc JT, Belzile EL. Recurrent Posterior Hip Dislocations on a Cam-Type Femoroacetabular Impingement: A Case Report. Orthop J Sports Med 2018; 6:2325967118783671. [PMID: 30046629 PMCID: PMC6055318 DOI: 10.1177/2325967118783671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Jean-Thomas Leclerc
- Department of Orthopaedic Surgery, CHU de Québec-Université Laval, Québec, Québec, Canada
| | - Etienne L Belzile
- Department of Orthopaedic Surgery, CHU de Québec-Université Laval, Québec, Québec, Canada.,Centre de Recherche FRQS du CHU de Québec, Québec, Québec, Canada
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Carlson BC, Desy NM, Johnson JD, Trousdale RT, Leunig M, Ganz R, Sierra RJ. Modern Surgical Treatment of Recurrent Posterior Dislocation of the Native Hip. J Bone Joint Surg Am 2018; 100:1056-1063. [PMID: 29916934 DOI: 10.2106/jbjs.17.01170] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Redislocation of the native hip is rare. An anterior fulcrum between the proximal part of the femur and the pelvis must be present for a posterior dislocation to occur. The purpose of this study is to describe the cases of 9 patients with posterior redislocation or recurrent subluxation of the native hip that was treated with hip preservation surgery. METHODS We retrospectively identified the cases of 9 patients, from 2 institutions, who had undergone hip preservation surgery for the management of posterior redislocation or recurrent subluxation of the native hip after a dislocation. The mean number of dislocations prior to surgery was 3.2 (range, 1 to 7). Pelvic radiographs were used to classify the acetabular morphology, sufficiency of acetabular containment, and structural anatomy of the proximal part of the femur. Radiographic identification of impinging structures was used to guide surgical treatment, which involved either femoral correction alone or the combination of femoral correction and an anteverting periacetabular osteotomy. RESULTS At a mean follow-up of 73.8 months (range, 10 to 192 months), there had been no subsequent episodes of dislocation or subluxation in any of the hips treated with correction of the anatomic pivot point. An algorithmic approach is presented. CONCLUSIONS In patients who have episodes of redislocation or recurrent subluxation of the native hip, the identification of anatomic abnormalities that create a fulcrum between the proximal part of the femur and the pelvis is critical for making appropriate treatment decisions. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bayard C Carlson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nicholas M Desy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joshua D Johnson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Michael Leunig
- Orthopaedic Surgery, Schulthess Clinic, Zurich, Switzerland
| | - Reinhold Ganz
- Orthopaedic Surgery, Schulthess Clinic, Zurich, Switzerland
| | - Rafael J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Surgical Hip Dislocation for the Treatment of Intra-Articular Injuries and Hip Instability Following Traumatic Posterior Dislocation in Children and Adolescents. J Pediatr Orthop 2017; 36:673-9. [PMID: 25985375 DOI: 10.1097/bpo.0000000000000527] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Traumatic posterior hip dislocation in children is a rare injury that typically is treated with closed reduction. Surgical treatment is typically recommended for nonconcentric reduction with joint space asymmetry with entrapped labrum or an osteochondral fragment. The surgical hip dislocation (SHD) approach allows for full assessment of the acetabulum and femoral head and has been our preferred surgical strategy. The purpose of this study was to (1) describe the intra-articular pathologic findings seen at the time of SHD; and (2) to investigate hip pain, function, and activity level of a cohort of children and adolescents after open treatment of a posterior hip dislocation using the SHD approach. METHODS Following IRB approval, 23 patients who sustained a traumatic posterior hip dislocation between January 2009 and December 2013 were identified. In 8/23 (34.8%) patients there was evidence of nonconcentric reduction after closed treatment and surgical treatment was performed using the SHD approach. Seven male and 1 female (mean age, 11.2 y; range, 6 to 14.6 y) were followed for an average of 28 months (range, 13 to 67 mo). The modified Harris Hip Score (mHHS) and the University of California Los Angeles activity score assessed clinical hip outcome and activity level at minimum of 1 year after surgery. RESULTS Six patients were treated after an acute trauma, whereas 2 were treated after recurrent dislocations. Five patients were involved in motor vehicle accidents and 3 in sports-related injuries. Intraoperative findings include posterior labral avulsion in all patients, fracture of the cartilaginous posterior wall (n=3), and femoral head chondral injuries (n=5) and fracture (n=1). The labral root was repaired using suture anchor technique in 7/8 patients and resected in 1. In 2 patients, labral repair was complemented by screw fixation of the posterior wall. All but one patient (mHHS=94) reported maximum mHHS. The University of California Los Angeles activity score was 10 for 5/8 patients and 7 in 3 patients. No case of femoral head osteonecrosis was noted. One patient developed an asymptomatic heterotopic ossification. CONCLUSIONS When open reduction is recommended for the treatment of intra-articular pathologies and hip instability following traumatic dislocation of the hip in children and adolescents, the SHD is an excellent approach that allows surgical correction of the damaged bony and soft-tissue structures including repair of the capsule-labral complex, and reduction and internal fixation of the cartilaginous posterior wall and femoral head fractures. LEVEL OF EVIDENCE Level IV.
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Mayer SW, Abdo JCM, Hill MK, Kestel LA, Pan Z, Novais EN. Femoroacetabular Impingement Is Associated With Sports-Related Posterior Hip Instability in Adolescents: A Matched-Cohort Study. Am J Sports Med 2016; 44:2299-303. [PMID: 27311413 DOI: 10.1177/0363546516651119] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Femoroacetabular impingement (FAI) deformity has been associated with posterior hip instability in adult athletes. PURPOSE To determine if FAI deformity is associated with posterior hip instability in adolescents, the femoral head-neck junction or acetabular structure in a cohort of adolescent patients who sustained a low-energy, sports-related posterior hip dislocation was compared with that in a group of healthy age- and sex-matched controls with no history of hip injury or pain. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS We identified 12 male patients (mean age, 13.9 years; range, 12-16 years) who sustained a sports-related posterior hip dislocation and underwent a computed tomography (CT) scan after closed reduction. For each patient, 3 age- and sex-matched healthy controls were identified. Femoral head-neck type was assessed by measurement of the alpha angle on the radially oriented CT images at the 12-, 1-, 2-, and 3-o'clock positions. Age, body mass index (BMI), alpha angle at each position, acetabular version, Tönnis angle, and lateral center-edge angle (LCEA) on the involved hip in the dislocation group were compared with those of the matched controls using a mixed-effects model. A logistic regression analysis using a generalized estimating equation was used to compare the percentage of subjects with cam-type FAI deformity (alpha angle >55°) in each group. RESULTS The dislocation and control groups were similar in age distribution and BMI (P > .05). The mean alpha angles were statistically significantly higher in the dislocation group compared with the control group at the superior (46.3° ± 1.1° vs 42.7° ± 0.6°; P = .0213), superior-anterior (55.5° ± 1.9° vs 46.0° ± 1.3°; P = .0005), and anterior-superior (54.9° ± 1.5° vs 48.9° ± 1.0°; P = .0045) regions. Cam deformity was present in a larger proportion of patients in the dislocation group than in the control group (P < .0035). An alpha angle greater than 55° was present in 16.7% of the dislocation group and 0% of the control group at the 12-o'clock position (P = .1213), 41.7% versus 0% at the 1-o'clock position (P = .0034), 58% versus 6% at the 2-o'clock position (P = .0004), and 25% versus 2.8% at the 3-o'clock position (P = .0929). Acetabular anteversion was lower in the dislocation group (9.6° ± 1.4°) compared with the control group (15.1° ± 0.8°) (P = .0068). Mean acetabular LCEA was within a normal range in both groups. CONCLUSION A significantly higher mean alpha angle from the superior to the anterior-superior regions of the femoral head-neck junction and lower acetabular version were found in adolescents who sustained low-energy, sports-related posterior hip dislocations.
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Affiliation(s)
- Stephanie W Mayer
- Sports Medicine Center and Department of Orthopaedic Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Mary K Hill
- Musculoskeletal Research Center and Department of Orthopaedic Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Lauryn A Kestel
- Musculoskeletal Research Center and Department of Orthopaedic Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Zhaoxing Pan
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Eduardo N Novais
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
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Harris JD, Gerrie BJ, Lintner DM, Varner KE, McCulloch PC. Microinstability of the Hip and the Splits Radiograph. Orthopedics 2016; 39:e169-75. [PMID: 26730687 DOI: 10.3928/01477447-20151228-08] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 05/27/2015] [Indexed: 02/03/2023]
Abstract
A normal hip has a natural tendency toward stability because of both osseous and soft tissue structures. Hip motion is primarily rotational around a center of rotation. When the femoral head and its center of rotation translate, with or without rotation, the inherent stability of the femoroacetabular articulation may be lost. The spectrum of hip instability ranges from subtle microinstability to traumatic dislocation. Microinstability may be the cause or the effect of several other hip pathologies. Soft tissue contributions to stability include the static capsule, dynamic musculotendinous units, and underlying generalized connective tissue (eg, Ehlers-Danlos). Osseous contributions include multiple femoral and acetabular radiographic coverage parameters. Iatrogenic contributions include an unrepaired capsulotomy, overresection of the acetabular rim (iatrogenic dysplasia), overresection of cam osteochondroplasty, iliopsoas tenotomy, labral debridement, and ligamentum teres debridement. Patients with hip microinstability often have deep groin pain, exhibited by a C sign. These patients frequently participate in flexibility sports and activities, such as ballet, gymnastics, figure skating, and martial arts. On physical examination, generalized hypermobility syndromes should be assessed, as should loss of log-roll external rotation recoil, excessive abduction, trochanteric-pelvic impingement, and abductor fatigue. Standard imaging, including plain radiographs, magnetic resonance imaging, and computed tomography, should be analyzed for all causes of hip pain. A new plain radiograph, the splits radiograph is introduced here, consistently showing lateral femoral head translation and creation of a vacuum sign, showing hip microinstability. The splits radiograph is illustrated in a 22-year-old female dancer who presented with bilateral deep anterolateral groin pain.
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Canham CD, Yen YM, Giordano BD. Does Femoroacetabular Impingement Cause Hip Instability? A Systematic Review. Arthroscopy 2016; 32:203-8. [PMID: 26427629 DOI: 10.1016/j.arthro.2015.07.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 06/22/2015] [Accepted: 07/24/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether femoroacetabular impingement (FAI) is associated with hip instability. METHODS A systematic search examining FAI and hip instability was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Clinical and basic science studies were included. Instability had to be documented with either a clinical or imaging examination. Studies were excluded if they did not define diagnostic criteria for FAI, involved prosthetic hips, were not in English, were review articles, or reported Level V evidence (case reports, expert opinion). Rates of FAI morphologic features in patients with documented hip instability were determined. Mechanisms and rates of FAI-induced hip subluxation were examined in basic science studies. RESULTS The search yielded 1,630 relevant studies. Seven studies (4 clinical and 3 basic science) met inclusion criteria. Four studies investigated an association between FAI and hip instability in 92 patients with an average age of 31 years. Seventy-six patients experienced frank dislocations and 16 experienced posterior subluxation events. The prevalence of FAI was documented in 89 patients with hip instability. The rates of cam and pincer morphologic characteristics were 74% and 64%, respectively. The average lateral center edge angle and prevalence of acetabular retroversion were 30° and 70%, respectively (n = 76 patients). All 3 basic science studies had real-time visualization of FAI-induced hip subluxations. CONCLUSIONS High rates of FAI morphologic characteristics are present in patients with hip instability. FAI morphologic characteristics may predispose the hip to instability through anatomic conflict caused by pincer or cam lesions (or both) levering the femoral head posteriorly. LEVEL OF EVIDENCE Level IV, systematic review of Level III, Level IV, and non-clinical studies.
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Affiliation(s)
- Colin D Canham
- Division of Sports Medicine, Department of Orthopaedics and Rehabilitation, Hip Preservation Program, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Yi-Meng Yen
- Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Brian D Giordano
- Division of Sports Medicine, Department of Orthopaedics and Rehabilitation, Hip Preservation Program, University of Rochester Medical Center, Rochester, New York, U.S.A..
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Surgical Hip Dislocation is Safe and Effective Following Acute Traumatic Hip Instability in the Adolescent. J Pediatr Orthop 2015; 35:435-42. [PMID: 25197945 DOI: 10.1097/bpo.0000000000000316] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND A traumatic hip dislocation in the pediatric patient is a rare but potentially catastrophic injury. The purpose of this study was to review our early clinical results and radiographic morphology of hips treated with a surgical hip dislocation (SHD) approach for intra-articular hip pathology resulting from traumatic instability in pediatric and adolescent patients. METHODS This is a retrospective analysis of a consecutive series of patients presenting with nonconcentric reduction after traumatic hip instability. All patients were treated with a transtrochanteric SHD with concomitant procedures based on intra-articular findings. Radiographic evaluations and Harris Hip Scores were completed at final follow-up. RESULTS Eleven male patients, mean age of 12.3 years (range, 9.3 to 16.1 y) and mean body mass index 19.6 kg/m (range, 15.4 to 28.0 kg/m). Intraoperative findings included: labral tear (8), femoral cartilage injury (5), acetabular rim fracture (4), acetabular cartilage delamination (3), loose body (2), and femoral head osteochondral fracture (1). Postoperatively, 1 patient developed a transient peroneal nerve palsy. At a mean 24.5 months (range, 12.0 to 48.1 mo) postoperatively, no hips have radiographic evidence of osteonecrosis. The mean lateral center edge angle was 20 degrees (range, 9 to 38 degrees) with 6 hips of <20 degrees; mean acetabular index 9 degrees (range, -2 to 23 degrees) with 5 hips of >10 degrees; mean α-angle 56 degrees (range, 48 to 62 degrees) with 6 hips of >55 degrees; mean acetabular version 12 degrees (range, 8 to 16 degrees) with 8 hips of <15 degrees. At 1-year follow-up, the mean Harris Hip Score was 95.8 (range, 84.7 to 100). CONCLUSIONS Early results suggest that SHD is a safe approach to treat an incomplete reduction following posterior hip instability and is effective for identification and treatment of acute intra-articular pathology. Acetabular dysplasia, relative acetabular retroversion, and/or decreased femoral offset may be risk factors for posterior hip instability in adolescents. LEVEL OF EVIDENCE Level IV.
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Mayer SW, Stewart JR, Fadell MF, Kestel L, Novais EN. MRI as a reliable and accurate method for assessment of posterior hip dislocation in children and adolescents without the risk of radiation exposure. Pediatr Radiol 2015; 45:1355-62. [PMID: 25801904 DOI: 10.1007/s00247-015-3317-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/18/2015] [Accepted: 02/10/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Posterior hip dislocation in children and adolescents may involve the non-ossified posterior acetabular wall. Plain radiographs and computed tomography (CT) have been shown to underestimate injury to the unossified acetabulum as well as associated soft-tissue structures. OBJECTIVE The purpose of this study was to describe findings on radiographs, CT and magnetic resonance imaging (MRI) after posterior hip dislocation in a series of adolescents and to report the intraoperative findings, which are considered the gold standard. Measurements of the posterior wall length using MRI and CT scans were also performed. MATERIAL AND METHODS After institutional review board approval, 40 patients who sustained a traumatic posterior dislocation of the hip between September 2007 and April 2014 were identified. Inclusion criteria were (1) age younger than 16 years old and (2) availability of MRI obtained following closed reduction of the hip. Eight male patients and one female patient with an average age of 13.2 years (range: 10.1-16.2 years) underwent hip MRI following posterior dislocation. Seven of the nine patients also underwent evaluation by CT. Plain radiographs, CT scans and MRI were evaluated in all patients by a single pediatric radiologist blinded to surgical findings for joint space asymmetry, posterior wall fracture, femoral head fracture, labrum tear, complete or partial ligamentum teres rupture and presence of intra-articular fragments. Six patients underwent surgical treatment and the intraoperative findings were compared with the imaging findings. RESULTS CT identified all bone injuries but underestimated the involvement of posterior wall fractures. Assessment of the posterior wall size and fracture displacement was possible with MRI. All surgically confirmed soft-tissue injuries, including avulsion of the posterior labrum, were identified preoperatively on MRI. The measurement of posterior wall length was not statistically different using CT and MRI. CONCLUSION Intraoperative pathological findings at the time of open surgical treatment were universally recognized on MRI but not on CT scans. MRI should be considered for evaluation of the hip following closed reduction for the treatment of a posterior dislocation in children and adolescents as it reliably allows assessment of intra-articular pathology without the risk of radiation exposure.
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Affiliation(s)
- Stephanie W Mayer
- Department of Orthopaedic Surgery, Children's Hospital Colorado and University of Colorado School of Medicine, 13123 East 16th Ave., B060, Aurora, CO, 80045, USA
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O'Donnell JM, Pritchard M, Salas AP, Singh PJ. The ligamentum teres-its increasing importance. J Hip Preserv Surg 2014; 1:3-11. [PMID: 27011796 PMCID: PMC4765261 DOI: 10.1093/jhps/hnu003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 05/04/2014] [Accepted: 05/06/2014] [Indexed: 12/19/2022] Open
Abstract
The ligamentum teres (LT) has attracted much greater interest over recent years due to the increased use of hip arthroscopy. There have been advancements in our understanding of the LT's biomechanical function and its role in hip and groin pain. Our ability to suspect LT tears by clinical examination and imaging has improved. Publications by many authors concerning LT tear treatment and outcomes continue to increase. This manuscript is a review of the function, mechanism of injury, clinical assessment, imaging, arthroscopic assessment, treatment, outcomes, reconstruction, and unusual conditions of the LT.
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Affiliation(s)
- John M. O'Donnell
- 1. 21 Erin Street, Richmond, Victoria 3121, Australia
- 2. Hip Arthroscopy Australia, 21Erin St Richmond, Australia
| | - Michael Pritchard
- 3. Hip Arthroscopy Australia, 30 Cascade Rd South Hobart, Hobart, Australia
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Steppacher SD, Albers CE, Siebenrock KA, Tannast M, Ganz R. Reply to the Letter to the editor: Femoroacetabular impingement predisposes to traumatic posterior hip dislocation. Clin Orthop Relat Res 2013; 471:3720-1. [PMID: 24014272 PMCID: PMC3792271 DOI: 10.1007/s11999-013-3276-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 08/29/2013] [Indexed: 01/31/2023]
Affiliation(s)
- Simon Damian Steppacher
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Christoph Emanuel Albers
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Klaus Arno Siebenrock
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Reinhold Ganz
- Faculty of Medicine, University of Bern, Walchstrasse 10, 3073 Guemligen, Switzerland
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Larson CM, Stone RM. Current concepts and trends for operative treatment of FAI: hip arthroscopy. Curr Rev Musculoskelet Med 2013; 6:242-9. [PMID: 23728614 DOI: 10.1007/s12178-013-9170-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There has been an increasing body of literature regarding arthroscopic management of femoroacetabular impingement (FAI). Refinement of arthroscopic techniques has allowed for more complete management of FAI, and meta-analysis and systematic reviews have shown comparable outcomes to surgical hip dislocation with appropriate indications. There are still, however, pathomorphologies that are not accessible or much more challenging to address arthroscopically, and open corrective procedures should be considered in these situations. Extra-articular FAI is receiving increased attention and can be secondary to anterior inferior iliac spine/subspine impingement, trochanteric-pelvic impingement, and ischio-femoral impingement. Femoral and acetabular version and their impact on hip stability as well as the concept of impingement induced instability are being increasingly recognized. Acetabular labral and capsular management and repair techniques have also received increased attention. Finally, 3-dimensional imaging and dynamic software analysis are beginning to emerge as potential tools to better evaluate hip pathomorphology.
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Affiliation(s)
- Christopher M Larson
- Minnesota Orthopedic Sports Medicine Institute at Twin Cities Orthopedics, 4010 West 65th St, Edina, MN, 55435, USA,
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CORR Insights™: Femoroacetabular impingement predisposes to traumatic posterior hip dislocation. Clin Orthop Relat Res 2013; 471:1944-5. [PMID: 23471554 PMCID: PMC3706662 DOI: 10.1007/s11999-013-2910-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 03/01/2013] [Indexed: 01/31/2023]
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