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Baert M, Vandekerckhove M, Vanlommel J. Stress Fracture after Arthroscopic Lesser Trochanter Resection: Diagnosis and Therapy. Hip Pelvis 2024; 36:70-75. [PMID: 38420740 DOI: 10.5371/hp.2024.36.1.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 03/02/2024] Open
Abstract
We report on the case of a 52-year-old female who presented with a stress fracture after undergoing an endoscopic resection of the lesser trochanter in ischiofemoral impingement, which was resistant to maximal conservative treatment. To the best of our knowledge, this complication has not been previously described. Non-weight-bearing and intravenous alendronic acid were prescribed for management. No additional surgery was required. The patient was pain free with the ability to perform sports on the same level as before and had no complaints.
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Affiliation(s)
- Matthieu Baert
- Department of Orthopaedic Surgery, AZ Sint-Lucas, Brugge, Belgium
| | | | - Jan Vanlommel
- Department of Orthopaedic Surgery, AZ Sint-Lucas, Brugge, Belgium
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Jeyaraman M, Murugan J, Maffulli N, Jeyaraman N, Potty AG, Gupta A. Ischiofemoral impingement syndrome: a case report and review of literature. J Orthop Surg Res 2022; 17:393. [PMID: 35986379 PMCID: PMC9392291 DOI: 10.1186/s13018-022-03287-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/12/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction The etiology of ischiofemoral impingement (IFI) syndrome, an unusual and uncommon form of hip pain, remains uncertain. Some patients demonstrate narrowing of the space between the ischial tuberosity and lesser trochanter from trauma or abnormal morphology of the quadratus femoris muscle. Combined clinical and imaging aid in the diagnosis.
Case report A 32-year-old female presented with a 3 years history of pain over the lower aspect of the right buttock, aggravated by movements of the right hip, and partially relieved with rest and medications. The right hip showed extreme restriction of abduction and external rotation. MRI of the right hip showed reduced ischiofemoral space and quadratus femoris space when compared to the left hip. The patient underwent endoscopic resection of the right lesser trochanter, with no recurrence of pain at 2 years.
Conclusion An unusual cause of hip pain, IFI syndrome, should be suspected when hip pain at extremes of movement is associated with signal abnormality of quadratus femoris muscle. Management is tailored to address the inciting factors that precipitated the IFI syndrome.
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Fischer T, Stern C, Fritz B, Zingg PO, Pfirrmann CWA, Sutter R. MRI findings of ischiofemoral impingement after total hip arthroplasty are associated with increased femoral antetorsion. Acta Radiol 2022; 63:948-957. [PMID: 34098775 DOI: 10.1177/02841851211021044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Ischiofemoral impingement (IFI) is a known complication after total hip arthroplasty (THA). PURPOSE To assess if increased postoperative (FA) is associated with magnetic resonance imaging (MRI) findings of IFI. MATERIAL AND METHODS In 221 patients with THA, two independent readers measured FA, ischiofemoral space (IFS), quadratus femoris space (QFS), edema, and fatty infiltration of quadratus femoris muscle. Three sets of IFI-imaging features were defined: acute IFI (set 1): IFS ≤15 mm or QFS ≤10 mm and edema in the quadratus femoris muscle; chronic IFI (set 2): IFS ≤15 mm or QFS ≤10 mm and fatty infiltration of quadratus femoris muscle Goutallier grade ≥2; acute and chronic IFI (set 3) with both criteria applicable. For each set, FA angles were compared between positive findings of IFI and negative findings of IFI. The t-test for independent samples tested statistical significance. RESULTS In 7.2% (16/221) of patients, findings of IFI (IFS ≤15 mm or QFS ≤10 mm and edema, n = 1; fatty infiltration, n = 9; or both, n = 6) were observed. In women, 11.4% (14/123) exhibited findings of IFI compared to 2.0% (2/98) in men. Comparison in set 1 (n = 7): mean antetorsion of 23.9° ± 9.8° (findings of acute IFI) compared to 14.4° ± 9.7° (P = 0.01). Comparison in set 2 (n = 15): mean antetorsion of 16.2° ± 6.3° (findings of chronic IFI) compared to 14.5° ± 9.9° (P = 0.49). Comparison in set 3 (n = 6): mean antetorsion of 20.4° ± 3.8° (findings of acute and chronic IFI) compared to 14.5° ± 9.9° (P = 0.01). CONCLUSION After THA, high postoperative FA is associated with MRI findings of acute as well as acute and chronic IFI. Findings of IFI were commonly seen in women.
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Affiliation(s)
- Tim Fischer
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christoph Stern
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Benjamin Fritz
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Patrick O Zingg
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christian WA Pfirrmann
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Reto Sutter
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Konrads C, Ahrend MD, Beyer MR, Stöckle U, Ahmad SS. Rotation osteotomy of the distal femur influences coronal femoral alignment and the ischiofemoral space. Arch Orthop Trauma Surg 2022; 142:711-720. [PMID: 33355718 PMCID: PMC8994730 DOI: 10.1007/s00402-020-03704-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 12/03/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Despite the fact that osteotomies around the knee represent well-established treatment options for the redistribution of loads and forces within and around the knee joint, unforeseen effects of these osteotomies on the remaining planes and adjacent joints are still to be defined. It was, therefore, the aim of this study to determine the influence of a distal femoral rotation osteotomy on the coronal limb alignment and on the ischiofemoral space of the hip joint. MATERIALS AND METHODS Long-leg standing radiographs and CT-based torsional measurements of 27 patients undergoing supracondylar rotational osteotomies of the femur between 2012 and 2019 were obtained and utilized for the purpose of this study. Postoperative radiographs were obtained after union at the osteotomy site. The hip-knee-ankle angle (HKA), the mechanical lateral distal femur angle (mLDFA), and the ischiofemoral space were measured. Comparison between means was performed using the Wilcoxon-Mann-Whitney test. RESULTS Twenty-seven patients underwent isolated supracondylar external rotation osteotomy to reduce the overall antetorsion of the femur. The osteotomy resulted in a 2.4° ± 1.4° mean increase in HKA and 2.4 mm ± 1.7 mm increase in the ischiofemoral space (p < 0.001). CONCLUSION Supracondylar external rotation osteotomy of the femur leads to valgisation of the coronal limb alignment and increases the ischiofemoral space. This is resultant to the reorientation of the femoral antecurvature and the femoral neck. When planning a rotational osteotomy of the lower limb, this should be appreciated and may also aid in the decision regarding osteotomy site.
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Affiliation(s)
- Christian Konrads
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany.
| | - Marc-Daniel Ahrend
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
| | - Myriam Ruth Beyer
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
| | - Ulrich Stöckle
- Center for Musculoskeletal Surgery, Charité-University Medical Center Berlin, Berlin, Germany
| | - Sufian S Ahmad
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
- Center for Musculoskeletal Surgery, Charité-University Medical Center Berlin, Berlin, Germany
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Liu J, Cheng X, Tian C, Wang R, Chen J, Zhang X, Zeng X. Cinematic rendering for ischiofemoral impingement syndrome caused by osteochondroma: a case description. Quant Imaging Med Surg 2022; 12:1647-1651. [PMID: 35111656 DOI: 10.21037/qims-21-525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/31/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Jian Liu
- Department of Graduate School, Zunyi Medical University, Zunyi, China.,Department of Radiology, Guizhou Provincial People's Hospital, Key Laboratory of Intelligent Medical Imaging Analysis and Accurate Diagnosis of Guizhou Province, International Exemplary Cooperation Base of Precision Imaging for Diagnosis and Treatment, Guiyang, China
| | - Xinge Cheng
- Department of Graduate School, Zunyi Medical University, Zunyi, China.,Department of Radiology, Guizhou Provincial People's Hospital, Key Laboratory of Intelligent Medical Imaging Analysis and Accurate Diagnosis of Guizhou Province, International Exemplary Cooperation Base of Precision Imaging for Diagnosis and Treatment, Guiyang, China
| | - Chong Tian
- Department of Radiology, Guizhou Provincial People's Hospital, Key Laboratory of Intelligent Medical Imaging Analysis and Accurate Diagnosis of Guizhou Province, International Exemplary Cooperation Base of Precision Imaging for Diagnosis and Treatment, Guiyang, China
| | - Rongpin Wang
- Department of Radiology, Guizhou Provincial People's Hospital, Key Laboratory of Intelligent Medical Imaging Analysis and Accurate Diagnosis of Guizhou Province, International Exemplary Cooperation Base of Precision Imaging for Diagnosis and Treatment, Guiyang, China
| | - Jiaxiang Chen
- Guizhou University School of Medicine, Guiyang, China
| | - Xiaoyong Zhang
- Department of Radiology, Guizhou Provincial People's Hospital, Key Laboratory of Intelligent Medical Imaging Analysis and Accurate Diagnosis of Guizhou Province, International Exemplary Cooperation Base of Precision Imaging for Diagnosis and Treatment, Guiyang, China
| | - Xianchun Zeng
- Department of Radiology, Guizhou Provincial People's Hospital, Key Laboratory of Intelligent Medical Imaging Analysis and Accurate Diagnosis of Guizhou Province, International Exemplary Cooperation Base of Precision Imaging for Diagnosis and Treatment, Guiyang, China
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Volpi A, Matzko C, Feghhi D, Matheney T, Bharam S. Conservative Treatment of Avulsion Injuries of the Lesser Trochanter in Adolescent Athletes. Cureus 2021; 13:e15638. [PMID: 34306849 PMCID: PMC8278968 DOI: 10.7759/cureus.15638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Avulsion injuries of the lesser trochanter apophysis are relatively uncommon injuries and there have been no peer-reviewed case series dedicated to the evaluation and treatment of this injury. The purpose of this study is to characterize avulsion injuries of the lesser trochanter apophysis, review treatment protocols, and time to return to sport. Methods: We reviewed 30 confirmed avulsion fractures of the lesser trochanter. Clinical data were reviewed to evaluate treatment protocols, duration, and time to return to sport. Radiographs were reviewed to confirm lesser trochanter avulsion and fracture displacement. RESULTS There were 26 males and 4 females, with the average age at the time of injury being 14.2 years. Treatment modalities consisted of protective weight-bearing, discontinuation of the patient's sport in all cases, and formal physical therapy in 18 cases. The average treatment duration was 30.7 days. The mean follow-up time was 102 days. The radiographic assessment demonstrated an average fracture displacement of 5.1 mm. The average return to sport was 11 weeks. CONCLUSION This is the first large case series studying avulsion injuries of the lesser trochanter. We have shown that these athletes can be managed non-surgically and can successfully return back to sport within three months.
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Affiliation(s)
| | | | - Daniel Feghhi
- Orthopaedic Surgery, Lenox Hill Hospital, New York, USA
| | - Travis Matheney
- Orthopaedic Surgery, Boston Children's Hospital, Boston, USA
| | - Srino Bharam
- Orthopaedic Surgery, Lenox Hill Hospital, New York, USA
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Konrads C, Ahrend MD, Beyer MR, Stöckle U, Ahmad SS. Supracondylar rotation osteotomy of the femur influences the coronal alignment of the ankle. J Exp Orthop 2021; 8:32. [PMID: 33880687 PMCID: PMC8058125 DOI: 10.1186/s40634-021-00340-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/02/2021] [Indexed: 01/25/2023] Open
Abstract
Purpose Osteotomies represent well-established treatment-options for the redistribution of loads and forces within and around the knee-joint. Effects of these osteotomies on the remaining planes and adjacent joints are not fully understood. The aim of this study was to determine the influence of a distal-femoral-rotation-osteotomy on the coronal alignment of the ankle. It was hypothesized that supracondylar-external-rotation-osteotomy of the distal femur leads to a change in the coronal orientation of the ankle joint. Methods Long-leg standing radiographs and CT-based torsional measurements of 27 patients undergoing supracondylar-rotational-osteotomy of the femur between 2012 and 2019 were obtained and utilized for the purpose of this study. Postoperative radiographs were obtained after union at the osteotomy-site. The hip-knee-ankle-angle (HKA), the mechanical-lateral-distal-femur-angle (mLDFA), and Tibia-Plafond-Horizontal-Orientation-Angle (TPHA) around the ankle were measured. Comparison between means was performed using the Wilcoxon-Mann–Whitney test. Results Twenty-seven patients with high femoral antetorsion (31.3° ± 4.0°) underwent supracondylar-external-rotation-osteotomy. The osteotomy led to a reduced antetorsion (17.4 ± 5.1; p < 0.001) and to a valgisation of the overall limb-alignment. The HKA decreased by 2.4° ± 1.4° (p < 0.001). The TPHA decreased by 2.6° (p < 0.001). Conclusions Supracondylar external rotation osteotomy of the femur leads to lateralization of the weight bearing line at the knee and ankle due to valgisation of the coronal limb alignment. The mobile subtalar joint has to compensate (inversion) for the resulting valgus orientation of the ankle to ensure contact between the foot and the floor. When planning a rotational osteotomy of the lower limb, this should be appreciated – especially in patients with a preexisting valgus alignment of the lower extremities or restricted mobility in the subtalar joint.
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Affiliation(s)
- Christian Konrads
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany.
| | - Marc-Daniel Ahrend
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
| | - Myriam R Beyer
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
| | - Ulrich Stöckle
- Center for Musculoskeletal Surgery, Charité - University Medical Center Berlin, Berlin, Germany
| | - Sufian S Ahmad
- Department for Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany.,Center for Musculoskeletal Surgery, Charité - University Medical Center Berlin, Berlin, Germany
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8
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Ahmad SS, Kerber V, Konrads C, Ateschrang A, Hirschmann MT, Stöckle U, Ahrend MD. The ischiofemoral space of the hip is influenced by the frontal knee alignment. Knee Surg Sports Traumatol Arthrosc 2021; 29:2446-2452. [PMID: 33950346 PMCID: PMC8298225 DOI: 10.1007/s00167-021-06589-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 04/21/2021] [Indexed: 11/09/2022]
Abstract
PURPOSE The ischiofemoral distance (IFD), defined as the distance between the ischial tuberosity and the lesser trochanter of the femur, is gaining recognition as an extra-articular cause of hip pain. It is unknown whether the IFD is influenced by the frontal knee alignment. The aim of this study was to determine the influence of realignment surgery around the knee on the IFD. It was hypothesized that valgisation osteotomy around the knee is associated with reduction of the IFD. METHODS A consecutive series of 154 patients undergoing frontal realignment procedures around the knee in 2017 were included in this study. Long-leg standing radiographs were obtained before surgery and postoperatively. The IFD was measured between the ischium and the lesser trochanter at three different levels (proximal, middle and distal margins of the lesser trochanter parallel to the horizontal orientation of the pelvis) on standardized long-leg radiographs with the patient in upright standing position. The knee alignment was determined by measuring the hip knee ankle angle, mechanical lateral distal femur angle and the medial mechanical proximal tibia angle. Linear regression was performed to determine the influence of the change of frontal knee alignment on the IFD. RESULTS Linear regression showed a direct influence of the overall change in frontal knee alignment on the IFD of the hip, regardless of the site of the osteotomy (β-0.4, confidence-interval - 0.5 to - 0.3, p < 0.001). Valgisation osteotomy around the knee induced a significant reduction of the ipsilateral IFD (p < 0.001), while varisation osteotomy induced a significant increase (p < 0.001). The amount of ISD change was 0.4 mm per corresponding degree of change in frontal knee alignment. CONCLUSION These findings are relevant to both the hip and knee surgeons when planning an osteotomy or arthroplasty procedure. Correction of a malalignment of the knee may resolve an ischiofemoral conflict in the hip. The concept deserves inclusion in the diagnostic workup of both the hip and knee joints. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Sufian S. Ahmad
- grid.10392.390000 0001 2190 1447BG Center for Trauma and Reconstructive Surgery, Eberhard-Karls University of Tübingen, Tübingen, Germany ,grid.6363.00000 0001 2218 4662Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Vincent Kerber
- grid.10392.390000 0001 2190 1447BG Center for Trauma and Reconstructive Surgery, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Christian Konrads
- grid.10392.390000 0001 2190 1447BG Center for Trauma and Reconstructive Surgery, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Atesch Ateschrang
- grid.502406.5Evangelisches Stift St. Martin Gemeinschaftsklinikum Mittelrhein, Koblenz, Germany
| | - Michael T. Hirschmann
- grid.440128.b0000 0004 0457 2129Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101 Bruderholz, Switzerland
| | - Ulrich Stöckle
- grid.6363.00000 0001 2218 4662Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marc D. Ahrend
- grid.10392.390000 0001 2190 1447BG Center for Trauma and Reconstructive Surgery, Eberhard-Karls University of Tübingen, Tübingen, Germany
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Singaravadivelu V, Abraham AW. Ischiofemoral Impingement Syndrome Secondary to Arteriovenous Malformation of the Quadratus Femoris: A Case Report. JBJS Case Connect 2020; 10:e19.00326. [PMID: 33512926 DOI: 10.2106/jbjs.cc.19.00326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Ischiofemoral impingement syndrome (IFIS), an unusual presentation of hip pain, is frequently missed in clinical practice. We report a case of a 27-year-old man with complaints of gradual onset nonprogressive right gluteal pain with hip movement restriction for the past 5 years that was not relieved with conservative measures. Right hip magnetic resonance imaging revealed a vascular abnormality of the right quadratus femoris muscle suggestive of IFIS. This abnormal muscle was surgically excised, and its histologic evaluation was remarkable for an arteriovenous malformation. CONCLUSION The patient's longstanding symptomatic IFIS was ultimately attributed to a rare arteriovenous malformation of the quadratus femoris that resolved with surgical excision.
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Dukas AG, King TL, Adeyemi TF, Maak TG. Arthroscopic Reduction and Fixation of a Lesser Trochanter Avulsion Nonunion. Arthrosc Tech 2019; 8:e1525-e1531. [PMID: 31890533 PMCID: PMC6928366 DOI: 10.1016/j.eats.2019.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 08/12/2019] [Indexed: 02/03/2023] Open
Abstract
Identifying and treating avulsion fractures of the pelvis and proximal femur in adolescent athletes has become increasingly more important as the rate of competitive sports participation has grown. The majority of these fractures can be treated conservatively, with most returning to full activity. Surgical treatment of these injuries has been traditionally indicated for >2 cm displacement, painful nonunion, symptomatic exostosis formation, or persistent pain and symptoms. Lesser trochanter avulsion injuries are extremely rare and literature outlining their surgical treatment lacking. We present our method of arthroscopic reduction and fixation of lesser trochanter avulsion nonunions.
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Affiliation(s)
- Alex G. Dukas
- Department of Orthopaedic Surgery, University of Utah Orthopedic Center, Utah, U.S.A
| | - Taylor L. King
- School of Medicine, University of Utah, Salt Lake City, Utah, U.S.A
| | - Temitope F. Adeyemi
- Department of Orthopaedic Surgery, University of Utah Orthopedic Center, Utah, U.S.A
| | - Travis G. Maak
- Department of Orthopaedic Surgery, University of Utah Orthopedic Center, Utah, U.S.A,Address correspondence to Travis G. Maak, M.D., Associate Professor, Department of Orthopaedics, University of Utah Orthopaedic Center, 590 Wakara Way, Salt Lake City, UT 84108.
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Morris WZ, Fowers CA, Weinberg DS, Millis MB, Tu LA, Liu RW. Hip morphology predicts posterior hip impingement in a cadaveric model. Hip Int 2019; 29:322-327. [PMID: 29808721 DOI: 10.1177/1120700018779906] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Posterior hip impingement is a recently-identified cause of hip pain. The purpose of this study is to characterise posterior femoroacetabular and ischiofemoral impingement and identify its predisposing morphologic traits. METHODS Two hundred and six cadaveric hips were randomly selected and taken through controlled motion in two pure axes associated with posterior hip impingement: external rotation (through the mechanical axis) and adduction (coronal plane). The range of motion and location of impingement was noted for each specimen. Morphologic traits including femoral/acetabular version, and true neck-shaft angle (TNSA) were also measured. RESULTS External rotation impingement occurred between the femoral neck and acetabulum in 83.0% of hips, and between the lesser trochanter and ischial tuberosity in 17.0%. Adduction impingement occurred between the lesser trochanter and ischial tuberosity in 78.6% of hips, and between the femoral neck and acetabulum in 21.4%. Multiple regression revealed that increased femoral/acetabular version predicted earlier external rotation and adduction impingement. Unstandardised betas ranging from -0.39 to -0.64 reflect that each degree of increased femoral/acetabular version individually accounts for a loss of external rotation or adduction of approximately half a degree before impingement ( p < 0.001 for each). Increased TNSA was associated with earlier adduction impingement only (unstandardised beta -0.35, p = 0.005). DISCUSSION Relative femoral/acetabular anteversion was associated with earlier posterior hip impingement. Coxa valga was associated with earlier adduction impingement, but protective against external rotation impingement. These findings highlight the importance of monitoring correction during femoral/acetabular osteotomies, as overcorrection of retroversion may predispose to earlier posterior impingement.
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Affiliation(s)
- William Z Morris
- 1 Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals at Case Western Reserve University, Cleveland, OH, USA
| | - Cody A Fowers
- 1 Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals at Case Western Reserve University, Cleveland, OH, USA
| | - Douglas S Weinberg
- 1 Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals at Case Western Reserve University, Cleveland, OH, USA
| | - Michael B Millis
- 2 Department of Orthopaedic Surgery, Harvard Medical School, Children's Hospital Boston, Boston, MA, USA
| | - Leigh-Anne Tu
- 1 Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals at Case Western Reserve University, Cleveland, OH, USA
| | - Raymond W Liu
- 1 Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospitals at Case Western Reserve University, Cleveland, OH, USA
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DiSciullo AA, Stelzer JW, Martin SD. Dynamic Ischiofemoral Impingement: Case-Based Evidence of Progressive Pathophysiology from Hip Abductor Insufficiency: A Report of Two Cases. JBJS Case Connect 2018; 8:e107. [PMID: 30601277 DOI: 10.2106/jbjs.cc.18.00153] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
CASE We describe 2 patients with no historical, examination, or imaging evidence of ischiofemoral impingement; they both developed hip abductor insufficiency and subsequent ischiofemoral impingement with progression that was confirmed by examination and advanced imaging. CONCLUSION Hip abductor insufficiency may lead to dynamic progressive ischiofemoral impingement. Hemipelvic instability from hip abductor weakness results in a Trendelenburg gait, narrowing the ischiofemoral space and impinging the quadratus femoris muscle. Treatment options for dynamic ischiofemoral impingement potentially can focus on treatment of the underlying cause of the hemipelvic instability, preventing additional ischiofemoral-space narrowing and quadratus femoris damage by minimizing the Trendelenburg gait.
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Affiliation(s)
- Alexander A DiSciullo
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Abstract
In this review, we bring to the attention of the reader three relatively unknown types of hip impingement. We explain the concept of low anterior inferior iliac spine (AIIS) impingement, also known as sub-spine impingement, ischio-femoral impingement (IFI) and pelvi-trochanteric impingement. For each type of impingement, we performed a search of relevant literature.We searched the PubMed, Medline (Ovid) and Embase databases from 1960 to March 2016. For each different type of impingement, a different search strategy was conducted.In total, 19 studies were included and described. No data analysis was performed since there was not much comparable data between studies.An overview of symptoms, clinical tests and possible surgical treatment options for the three different types of extra-articular impingement is provided.Several disorders around the hip can cause similar complaints. Therefore, we plead for a standardized classification. In young and athletic patients, in particular, there is much to gain if hip impingement is diagnosed early. Cite this article: EFORT Open Rev 2018;3:30-38. DOI: 10.1302/2058-5241.3.160068.
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Corrales R, Mediavilla I, Margalet E, Aramberri M, Murillo-González JA, Matsuda D. Endoscopic Lesser Trochanter Resection With Refixation of the Iliopsoas Tendon for Treatment of Ischiofemoral Impingement. Arthrosc Tech 2018; 7:e321-e325. [PMID: 29868398 PMCID: PMC5981835 DOI: 10.1016/j.eats.2017.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 09/26/2017] [Indexed: 02/03/2023] Open
Abstract
Ischiofemoral impingement is a source of hip pain derived from impingement between the lesser trochanter and the ischium. Lesser trochanter excision has been recommended for recalcitrant ischiofemoral impingement through either an anterior or posterior approach. However, neither of these approaches involves refixation of the iliopsoas tendon. We describe an endoscopic procedure involving anterior trochanter-plasty, minimizing the risk of sciatic complications, with refixation of the partially detached iliopsoas tendinous insertion, potentially minimizing compromise to hip flexion strength and anterior hip stability.
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Affiliation(s)
| | | | | | | | - Jorge A. Murillo-González
- Department of Human Anatomy and Embryology, Faculty of Medicine, Madrid Complutense University, Madrid, Spain
| | - Dean Matsuda
- Kaiser West Los Angeles Medical Center, Los Angeles, California, U.S.A
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Suren C, Burgkart R, Banke IJ, Hertel G, Schauwecker J, von Eisenhart-Rothe R, Gollwitzer H. [Surgical therapy of ischiofemoral impingement by lateralizing intertrochanteric osteotomy]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2018; 30:98-110. [PMID: 29589046 DOI: 10.1007/s00064-018-0540-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/16/2017] [Accepted: 12/19/2017] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Lateralizing, derotating intertrochanteric varus osteotomy to increase the ischiofemoral space to counter painful impingement of the lesser trochanter and the os ischium with resulting entrapment of quadratus femoris muscle. INDICATIONS Symptomatic ischiofemoral impingement (IFI) caused by Coxa valga et antetorta, Coxa valga or Coxa antetorta, or a short femoral neck. CONTRAINDICATIONS Anatomic configuration suggestive of IFI in asymptomatic patients. Symptomatic IFI caused by another underlying pathology. Valgus deformity of the knee. SURGICAL TECHNIQUE Measurement of femoral antetorsion. Planning of the osteotomy, lateralization, varus angle for correction, rotation and offset correction, leg length change, and osteosynthesis plate. General or spinal anesthesia in supine or lateral position. Skin incision (15 cm) beginning lateral of the greater trochanter tip, distally along the axis of the femur. Preparation onto the femur by L‑shaped dissection of the vastus lateralis from the bone. A Kirschner(K-)wire is then positioned along the anterior femoral neck to designate the femoral neck antetorsion. A triangle set on the lateral femoral cortexis is used to determine the osteotomy angle. In the thus determined angle, a second K‑wire is shot centrally along the femoral neck axis just inferior to its cranial cortex. About 5 mm distal to the second wire, the entry for the blade is prepared using a drill. Using the blade setting instrument, the blade is introduced into the femoral neck, then slightly pulled back. The rotation is then marked on the anterior femoral cortex proximal and distal to the planned osteotomy and the osteotomy is performed. A blade plate without displacement is impacted. The osteotomy is then reduced, the distal fragment pulled laterally onto the plate, and the screws inserted after compression of the osteotomy with a tension device. POSTOPERATIVE MANAGEMENT Touch-toe bearing for 6 weeks, then radiological assessment of osteotomy healing before an increase in weight bearing (15 kg/week). Hip flexion limited to 90° for 6 weeks. Elective implant removal after 12-18 months. RESULTS Studies of this lateralizing varus osteotomy have not been published. The 25-year results of the conventional derotating intertrochanteric varus osteotomy technique show good functional results and low complication rates, with non-union being the most common. Arthroscopic resection of the lesser trochanter has been reported as a surgical alternative in the treatment of IFI in case reports and small series. Advantages of the osteotomy are the restoration of biomechanics and preservation of iliopsoas tendon insertion.
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Affiliation(s)
- C Suren
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - R Burgkart
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - I J Banke
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - G Hertel
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - J Schauwecker
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - R von Eisenhart-Rothe
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - H Gollwitzer
- ECOM - Excellent Center of Medicine, Arabellastr. 17, 81925, München, Deutschland. .,Chirurgische Klinik, München-Bogenhausen, Deutschland. .,ATOS Klinik München, München, Deutschland.
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17
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Short-term outcomes of open hip preservation surgery for symptomatic extraarticular femoroacetabular impingement. Hip Int 2017; 27:599-607. [PMID: 28605002 DOI: 10.5301/hipint.5000506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The purposes of this study were to describe: (i) short-term disease-specific patient-reported outcome scores (PROMs); and (ii) factors associated with reoperation or treatment failure in patients undergoing open hip preservation surgery for symptomatic extraarticular FAI. METHODS Patients undergoing open hip preservation surgery for symptomatic extraarticular FAI were identified from a prospective, single-centre hip preservation registry (n = 51 patients; median clinical follow-up 24 [range 11-49] months). Hip-specific PROMs were assessed preoperatively, 6 months, and each year subsequently. Patients undergoing reoperation or treatment failure (<10 point improvement in iHOT-33 postoperatively) over the study period were identified. Preoperative associated factors were explored on a univariate basis. RESULTS International Hip Outcome Tool-33 (iHOT-33) improved from 33 (standard deviation [SD] 18) to 62 (26) at most recent follow-up and 76% of patients improved by minimum clinically important difference (MCID). Harris Hip Score improved from 53 (15) to 75 (17) at most recent follow-up and 79% of patients improved by MCID. Hip Outcome Score (HOS) Sport improved from 45 (26) to 66 (28) at most recent follow-up and 60% of patients improved by MCID. Continued improvements in mean follow-up scores were seen from 1 year to 2 years. Overall, 7 patients underwent reoperation and 9 patients failed to improve by MCID. Preoperative HOS Sport was higher in patients experiencing reoperation or treatment failure (58 [SD 19] vs. 40 [SD 27] respectively; p = 0.03). No other associated demographic, physical examination, or radiographic factors were found. CONCLUSIONS Open treatment of extraarticular FAI results in short-term improvements in hip-specific PROMs in most patients. Higher HOS Sport scores were associated with reoperation or treatment failure. Longer-term follow-up is necessary to define maximum improvements in this challenging patient population.
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Chen YT, Jenkins KM. Ultrasound Finding of Ischiofemoral Impingement Syndrome and Novel Treatment With Botulinum Toxin Chemodenervation: A Case Report. PM R 2017; 10:665-670. [PMID: 29138040 DOI: 10.1016/j.pmrj.2017.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 10/12/2017] [Accepted: 11/05/2017] [Indexed: 10/18/2022]
Abstract
Ischiofemoral impingement syndrome (IFIS) is a rare and poorly understood condition that leads to deep gluteal pain, groin, and/or medial thigh pain. It has unique diagnostic challenges, with limited nonoperative treatment options. It is caused by the impingement of the quadratus femoris by the lesser trochanter and the ischium. Currently, there are no validated physical examination maneuvers for IFIS, and the value of ischiofemoral interval for establishing IFIS is also uncertain. Ultrasound-guided corticosteroid injections have been reported. Here, we present a case of novel treatment of IFIS with botulinum chemodenervation that led to long-term symptomatic and functional improvement in this patient, with the unique ultrasound findings of the "eruption sign." LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Yin-Ting Chen
- Department of Rehabilitation, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889; Department of Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, MD.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD
| | - Keyonna M Jenkins
- Department of Rehabilitation, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889; Department of Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, MD.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD
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Arévalo Galeano N, Santamaría Guinea N, Gredilla Molinero J, Grande Bárez M. Extra-articular hip impingement: a review of the literature. RADIOLOGIA 2017; 60:105-118. [PMID: 29110905 DOI: 10.1016/j.rx.2017.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/18/2017] [Accepted: 09/19/2017] [Indexed: 01/10/2023]
Abstract
Hip and groin pain is a common clinical problem. Multiple causes can generate hip or groin pain, often sharing clinical and demographic characteristics. Diagnostic imaging tests play an important role in the etiological diagnosis. New forms of extra-articular hip impingement have recently been recognized as a cause of hip pain and limited function especially in young active patients. These conditions include ischiofemoral impingement, anterior inferior iliac spine and subspine impingement, iliopsoas impingement and greater trochanteric-pelvic impingement. In general, they are caused by a mechanical conflict with an abnormal or excessive contact between the proximal femur and pelvis and/or soft tissue between them. In this manuscript we review the physiopathology, clinical presentation, the most common radiologic findings and treatment of these forms of extra-articular hip impingement.
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Affiliation(s)
- N Arévalo Galeano
- Servicio de Radiodiagnóstico, Hospital Universitario Clínico San Carlos, Madrid, España.
| | - N Santamaría Guinea
- Unidad Central de Radiodiagnóstico, Hospital Universitario Infanta Leonor, Madrid, España
| | - J Gredilla Molinero
- Servicio de Radiodiagnóstico, Hospital Universitario Ramón y Cajal, Madrid, España
| | - M Grande Bárez
- Unidad Central de Radiodiagnóstico, Hospital Universitario Infanta Leonor, Madrid, España
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20
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Gollwitzer H, Banke IJ, Schauwecker J, Gerdesmeyer L, Suren C. How to address ischiofemoral impingement? Treatment algorithm and review of the literature. J Hip Preserv Surg 2017; 4:289-298. [PMID: 29250337 PMCID: PMC5721376 DOI: 10.1093/jhps/hnx035] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 07/30/2017] [Indexed: 12/30/2022] Open
Abstract
Ischiofemoral impingement (IFI) is a rare cause of hip pain defined by a narrowing of the space between the lateral aspect of the os ischium and the lesser trochanter of the femur. Several underlying anatomic, functional and iatrogenic pathologies have been identified for symptomatic IFI in native hip joints and after total hip arthroplasty. Clinical symptoms vary but most commonly consist of pain of the lower buttock and groin including the inner thigh, and a snapping or clunking phenomenon is often reported. Symptoms may be provoked by a combined extension, adduction and external rotation during physical examination and during long-stride walking. Radiographs of the pelvis and an axial or false-profile-view of the hip as well as magnetic resonance imaging (MRI)-scans should be obtained to strengthen the diagnosis. On MRI, the quadratus femoris muscle signal and the space confined by the anatomic structures surrounding the muscle, the quadratus femoris space, are to be assessed. Targeted infiltration of the muscle can be helpful both diagnostically and therapeutically. The literature on differential diagnoses and treatment options for IFI is limited; therapeutic suggestions are offered only in case reports and series. With this work, we aim to give a systematic approach to the non-surgical and surgical treatment options for IFI based upon the current literature and the authors' personal experience.
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Affiliation(s)
- Hans Gollwitzer
- Technische Universität München, Klinik für Orthopädie und Sportorthopädie, Klinikum Rechts der Isar, Ismaninger Str. 22, DE 81925 Munich, Germany.,ATOS Klinik München, Effnerstr. 38, 81925 München, Germany
| | - Ingo J Banke
- Technische Universität München, Klinik für Orthopädie und Sportorthopädie, Klinikum Rechts der Isar, Ismaninger Str. 22, DE 81925 Munich, Germany
| | - Johannes Schauwecker
- Technische Universität München, Klinik für Orthopädie und Sportorthopädie, Klinikum Rechts der Isar, Ismaninger Str. 22, DE 81925 Munich, Germany
| | - Ludger Gerdesmeyer
- Universitätsklinikum Schleswig-Holstein Campus Kiel, Sektion für Onkologische und Rheumatologische Orthopädie, Arnold-Heller-Straße 3 DE 24105 Kiel, Germany
| | - Christian Suren
- Technische Universität München, Klinik für Orthopädie und Sportorthopädie, Klinikum Rechts der Isar, Ismaninger Str. 22, DE 81925 Munich, Germany
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Yan P, Zhu Y, Zhao H, Lu Y, Gao Y. Differential proteomic screening and identification for non-traumatic necrotic femoral osseous tissue. Exp Ther Med 2017; 13:2900-2904. [PMID: 28587357 PMCID: PMC5450605 DOI: 10.3892/etm.2017.4326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 02/13/2017] [Indexed: 01/12/2023] Open
Abstract
Currently, there is a lack of effective early screening and detection methods for femoral head necrosis. Current research on most orthopedic diseases focuses on proteomics in the preliminary stage. The recent fluorescence differential in gel electrophoresis (DIGE) has advantages such as a high reproducibility, high sensitivity, high throughput, and high dynamic range. It is currently one of the most widely used quantitative proteomic research means. We conducted this study to investigate the pathogenesis of non-traumatic femoral head necrosis using the fluorescence DIGE to screen non-traumatic femoral head necrosis based on proteomics and provide a theoretical basis for screening possible biomarkers and molecular targeted treatment. The DIGE technique was used to separate the protein. An electrophoretogram was established on the basis of scanning and analysis. Identification and a bioinformatics analysis were conducted for the differential protein. The protein with differential expression of over 2-fold was excavated and ionized by means of substrate assisted laser desorption. The flight time was identified with a mass spectrometer (matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, MALDI-TOF/TOF). The formation on sequences, structures and functions of these proteins were obtained through database retrieval. Western blot analysis was used to verify the differential protein expression and the reliability of the DIGE result was verified. DIGE was used to successfully separate 1,500±40 protein spots. There were 252 significant differential protein spots. The Ettan™ Spot Picker automatic work station was used to excavate 49 significant differential protein spots with expression difference over 2-fold. The MALDI-TOF/TOF mass spectrometer was used to identify these differential protein spots. Six proteins were identified in total, which include apolipoprotein A1 (APOA1), fibrous protein original chain, fibrous protein original chain, serum albumin, sulfur-oxygen protein peroxiredoxin 2 (PRDX2) and actin. APOA1 and PRDX2 were subject to western blot analysis detection; results were consistent with the DIGE result. Based on an analysis of the biological information, these proteins may be associated with the incidence and progression of femoral head necrosis.
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Affiliation(s)
- Peng Yan
- Department of Orthopedics, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning 121000, P.R. China
| | - Yeping Zhu
- Recovery Unit, Jinzhou Central Hospital, Jinzhou, Liaoning 121000, P.R. China
| | - Hui Zhao
- Department of Orthopedics, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning 121000, P.R. China
| | - Yanyan Lu
- Department of Orthopedics, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning 121000, P.R. China
| | - Yuzhong Gao
- Department of Orthopedics, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning 121000, P.R. China
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Nakano N, Yip G, Khanduja V. Current concepts in the diagnosis and management of extra-articular hip impingement syndromes. INTERNATIONAL ORTHOPAEDICS 2017; 41:1321-1328. [PMID: 28401279 DOI: 10.1007/s00264-017-3431-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/13/2017] [Indexed: 12/14/2022]
Abstract
PURPOSE Extra-articular hip impingement syndromes encompass a group of conditions that have previously been an unrecognised source of pain in the hip and on occasion been associated with intra-articular hip impingement as well. As arthroscopic techniques for the hip continue to evolve, the importance of these conditions has been recognised recently and now form an important part of the differential of an individual presenting with hip pain. The aim of this article, therefore, is to provide the reader with an evidence-based and comprehensive update of these syndromes. METHODS By reviewing past literature, the anatomy, pathophysiology, clinical features and the management of the five common extra-articular hip impingement syndromes were described. RESULTS The common extra-articular impingement syndromes are: 1) Ischiofemoral impingement: quadratus femoris muscle becomes compressed between the lesser trochanter and the ischial tuberosity. 2) Subspine impingement: mechanical conflict occurs between an enlarged or malorientated anterior inferior iliac spine and the distal anterior femoral neck. 3) Iliopsoas impingement: mechanical conflict occurs between the iliopsoas muscle and the labrum, resulting in distinct anterior labral pathology. 4) Deep gluteal syndrome: pain occurs in the buttock due to the entrapment of the sciatic nerve in the deep gluteal space. 5) Pectineofoveal impingement: pain occurs when the medial synovial fold impinges against overlying soft tissue, primarily the zona orbicularis. Knowledge for these syndromes still remains limited for reasons mostly relating to their low prevalence and their co-existence with typical femoro-acetabular impingement. CONCLUSIONS The knowledge of extra-articular hip impingement syndromes is essential and should form a part of the differential diagnoses alongside intra-articular pathology including femoro-acetabular impingement particularly in the younger patient with a non-arthritic hip.
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Affiliation(s)
- Naoki Nakano
- Consultant Orthopaedic Surgeon & Associate Lecturer, Department of Trauma and Orthopaedics, Addenbrooke's - Cambridge University Hospitals NHS Foundation Trust, Box 37, Hills Road, Cambridge, CB2 0QQ, UK
| | - Grace Yip
- Consultant Orthopaedic Surgeon & Associate Lecturer, Department of Trauma and Orthopaedics, Addenbrooke's - Cambridge University Hospitals NHS Foundation Trust, Box 37, Hills Road, Cambridge, CB2 0QQ, UK
| | - Vikas Khanduja
- Consultant Orthopaedic Surgeon & Associate Lecturer, Department of Trauma and Orthopaedics, Addenbrooke's - Cambridge University Hospitals NHS Foundation Trust, Box 37, Hills Road, Cambridge, CB2 0QQ, UK.
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Gómez-Hoyos J, Martin RL, Schröder R, Palmer IJ, Martin HD. Accuracy of 2 Clinical Tests for Ischiofemoral Impingement in Patients With Posterior Hip Pain and Endoscopically Confirmed Diagnosis. Arthroscopy 2016; 32:1279-84. [PMID: 27020393 DOI: 10.1016/j.arthro.2016.01.024] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 11/16/2015] [Accepted: 01/13/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To establish the accuracy of the long-stride walking (LSW) and ischiofemoral impingement (IFI) tests for diagnosing IFI in patients whose primary symptom is posterior hip pain. METHODS Confirmed IFI cases and cases in which IFI had been ruled out were identified considering imaging, injections, and endoscopic assessment, combined with pain relief and negative IFI-specific tests after treatment. Demographic data, duration of symptoms, pain location, ischiofemoral space, quadratus femoris space, quadratus femoris edema, surgical findings, and visual analog scale score for pain before and after treatment were computed for all patients included in this study. Sensitivity, specificity, predictive values, likelihood ratios, and diagnostic odds ratios were computed individually for the LSW test and IFI test. RESULTS Cases from 1,166 consecutive hip operations and charts from 564 consecutive outpatients were retrospectively reviewed to identify patients who underwent injection and/or endoscopic surgery because of posterior hip pain. Thirty individuals (21 women and 9 men) with a mean age of 49.8 years (range, 20 to 76 years; standard deviation, 13.0 years) were included for analysis. Of the 30 patients, 17 (56.6%) were confirmed as positive for IFI and 13 (43.4%) were confirmed as negative for IFI. The IFI test had a sensitivity of 0.82, specificity of 0.85, positive predictive value of 0.88, negative predictive value of 0.79, positive likelihood ratio of 5.35, negative likelihood ratio of 0.21, and diagnostic odds ratio of 25.6. The LSW test had a sensitivity of 0.94, specificity of 0.85, positive predictive value of 0.89, negative predictive value of 0.92, positive likelihood ratio of 6.12, negative likelihood ratio of 0.07, and diagnostic odds ratio of 88.8. CONCLUSIONS In patients with complaints of posterior hip pain and negative evaluation findings for lumbosacral spine involvement or static/dynamic mechanical axis malalignment, the IFI and LSW tests are highly accurate to help identify those with or without IFI. LEVEL OF EVIDENCE: Level III, diagnostic study.
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Affiliation(s)
- Juan Gómez-Hoyos
- Hip Preservation Center, Baylor University Medical Center, Dallas, Texas, U.S.A.; Orthopedic Unit, Clínica Las Américas, Medellín, Colombia; GRINMADE Research Group, Universidad de Antioquia, Medellín, Colombia.
| | | | - Ricardo Schröder
- Hip Preservation Center, Baylor University Medical Center, Dallas, Texas, U.S.A
| | - Ian James Palmer
- Hip Preservation Center, Baylor University Medical Center, Dallas, Texas, U.S.A
| | - Hal David Martin
- Hip Preservation Center, Baylor University Medical Center, Dallas, Texas, U.S.A
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Wilson MD, Keene JS. Treatment of ischiofemoral impingement: results of diagnostic injections and arthroscopic resection of the lesser trochanter. J Hip Preserv Surg 2016; 3:146-53. [PMID: 27583151 PMCID: PMC5005049 DOI: 10.1093/jhps/hnw006] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 12/02/2015] [Accepted: 01/11/2016] [Indexed: 11/14/2022] Open
Abstract
Ischiofemoral impingement (IFI) is an often unrecognized cause of hip pain caused by abnormal contact between the lesser trochanter and the ischium. To date, surgical treatment for those whose pain is not relieved by activity modification and steroid injections has not been defined. This study describes our imaging protocol and reports the results of arthroscopic, lesser trochanteric resections that were performed to treat this condition. Seven patients with symptomatic, MRI-documented IFI had ultrasound injections of ropivicaine and steroid into their ischiofemoral space. The injections provided complete but only transient relief of their groin and buttock pain and thus, all seven ultimately had an arthroscopic resection of their lesser trochanter. All hips were evaluated preoperatively and at 3, 6 and 12 months postoperatively with Byrd's modified Harris hip scoring system. Average age of the seven patients was 46 years and there were five females and one male. Preoperative scores averaged 43 points. After surgery, all patients used crutches for 4-6 weeks, and had 6-week scores that averaged 58 points. The patients and their scores continued to improve and at 6 and 12 months, their scores averaged 86 and 91 points, and none had chronic hip flexor weakness or recurrence of their hip pain or snapping. Arthroscopic iliopsoas tenotomies in combination with a resection of the lesser trochanter will provide complete relief of the painful snapping, groin and buttock pain caused by ischiofemoral impingement.
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Affiliation(s)
- Mark D. Wilson
- 1. Wilson Orthopaedics and Sports Medicine, 216 West Union Street, Suite a, Minden, LA 71055, USA
| | - James S. Keene
- 2. Division of Sports Medicine, Department of Orthopedic Surgery and Rehabilitation, 1685 Highland Avenue, Madison, WI 53705-2281, USA and
- 3. University of Wisconsin, Madison, WI, USA
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Abstract
Extrarticular causes of impingement have a current, interesting role in the complaint of groin pain in athletes. Subspine impingement is related to a prominent anterior inferior iliac spine (AIIS) and is actually described as a frequent cause of groin pain. Ischiofemoral impingement is described when the space between the lesser trochanter is decreased. Psoas impingement appears between the psoas tendon and the anterior labrum and anterior acetabular rim.
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Gómez-Hoyos J, Schröder R, Reddy M, Palmer IJ, Martin HD. Femoral Neck Anteversion and Lesser Trochanteric Retroversion in Patients With Ischiofemoral Impingement: A Case-Control Magnetic Resonance Imaging Study. Arthroscopy 2016; 32:13-8. [PMID: 26358634 DOI: 10.1016/j.arthro.2015.06.034] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 06/14/2015] [Accepted: 06/19/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the relationship between the femoral neck version (FNV) and lesser trochanteric version (LTV) in symptomatic patients with ischiofemoral impingement (IFI) as compared with asymptomatic hips. METHODS The FNV and LTV of patients with symptomatic IFI who underwent magnetic resonance imaging assessment including a standardized femoral version study protocol were compared with those of patients with asymptomatic hips in this retrospective, observational study. Patients with isolated intra-articular pathology, prior hip fracture, and lesser trochanter deformity were excluded. The FNV, LTV, ischiofemoral space, and quadratus femoris space were evaluated on axial magnetic resonance imaging, as well as the angle between the LTV and the FNV. Independent t-tests were used to determine differences between groups. RESULTS Data from 11 out 15 symptomatic patients and 250 out of 320 asymptomatic patients were analyzed. The mean ischiofemoral space (11.9 v 22.9 mm; P < .001; 95% confidence interval [CI], 6.9 to 15.2) and mean quadratus femoris space (7.2 mm v 14.9 mm; P < .001; 95% CI, 5.4 to 8.6) were significantly smaller in symptomatic patients versus asymptomatic patients. There was no difference in mean LTV between groups (-23.6° v -24.2°; P = .8; 95% CI, -7.5 to 6.4), however, the mean FNV (21.7° v 14.1°; P = .02; 95% CI, -14.2 to -1.1) and the angle between the FNV and LTV on average (45.4° v 38.3°; P = .01; 95% CI, -12.9 to -1.3) were higher in symptomatic than in asymptomatic patients, with statistical significance. CONCLUSIONS The femoral mean neck anteversion and the mean angle between the FNV and LTV are significantly higher in patients with symptomatic IFI. The mean LTV is not increased in patients with symptomatic ischiofemoral impingement as compared with those patients with asymptomatic hips. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Juan Gómez-Hoyos
- Hip Preservation Center, Baylor University Medical Center Dallas, Texas, U.S.A..
| | - Ricardo Schröder
- Hip Preservation Center, Baylor University Medical Center Dallas, Texas, U.S.A
| | - Manoj Reddy
- Hip Preservation Center, Baylor University Medical Center Dallas, Texas, U.S.A
| | - Ian James Palmer
- Hip Preservation Center, Baylor University Medical Center Dallas, Texas, U.S.A
| | - Hal David Martin
- Hip Preservation Center, Baylor University Medical Center Dallas, Texas, U.S.A
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Schröder RG, Reddy M, Hatem MA, Gómez-Hoyos J, Toye L, Khoury A, Martin HD. A MRI study of the lesser trochanteric version and its relationship to proximal femoral osseous anatomy. J Hip Preserv Surg 2015; 2:410-6. [PMID: 27011866 PMCID: PMC4732376 DOI: 10.1093/jhps/hnv067] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 08/21/2015] [Accepted: 09/28/2015] [Indexed: 11/14/2022] Open
Abstract
The purpose of this study is to quantify the lesser trochanteric version and determine the angle and the relationship between lesser trochanter and femoral neck version. Investigate the influence of the lesser trochanter version in the width of ischiofemoral space. Two hundred and fifty asymptomatic hips were evaluated with axial magnetic resonance image. The lesser trochanter version was calculated. The difference between the femoral neck version and the lesser trochanter version formed the angle between each structure. The width of ischiofemoral space was measured and its relationship with the lesser trochanter version was determined. The mean lesser trochanter version was -24° ± 11.5° (range, - 54° to + 17°) with a coefficient variation of 47.45%. The mean femoral neck version measured 14.0° ± 10.8° (range, -16° to 50°), with a coefficient variation of 81.32%. The lesser trochanter/femora neck angle was 38.4° ± 9.6° (range, 8° to 67°), coefficient variation of 30%, with a moderate correlation between the structures (r = 0.63, P < 0.01). The mean ischiofemoral space was 22.9.0 ± 7.0 mm (range, 10.3 to 55 mm), and a weak correlation was found between ischiofemoral space and lesser trochanteric version (r = -0.16, P < 0.05). The lesser trochanteric version showed a high variation with a moderate relationship with the femoral neck version. The lesser trochanteric version does not influence the width of the ischiofemoral space.
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Affiliation(s)
| | - Manoj Reddy
- 1. Hip Preservation Center at Baylor Scott&White Health Dallas, TX, USA
- 2. Texas A&M Health Science Center of College of Medicine, Dallas campus, TX, USA
| | - Munif Ahamad Hatem
- 1. Hip Preservation Center at Baylor Scott&White Health Dallas, TX, USA
- 3. Universidade Federal do Parana, Curitiba, PR, Brazil
| | - Juan Gómez-Hoyos
- 1. Hip Preservation Center at Baylor Scott&White Health Dallas, TX, USA
| | - Leon Toye
- 4. Department of Radiology, Baylor Scott&White Health Dallas, TX, USA
| | - Anthony Khoury
- 1. Hip Preservation Center at Baylor Scott&White Health Dallas, TX, USA
- 5. Bioengineering Department, University of Texas at Arlington. Arlington, TX, USA
| | - Hal David Martin
- 1. Hip Preservation Center at Baylor Scott&White Health Dallas, TX, USA
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Abstract
In the last 20 years, femoroacetabular impingement has been at the forefront of clinical practice as a cause of hip pain in young adults. As arthroscopic techniques for the hip continue to evolve, the possible presence of a new group of conditions creating mechanical conflict in and around the hip joint (ischiofemoral, subspine and iliopsoas impingement) has recently been elucidated whilst interest in already known 'impingement' syndromes (pelvic-trochanteric and pectineofoveal impingement) is now revived. This article attempts to increase awareness of these relatively uncommon clinical entities by describing their pathomorphology, contact mechanics, treatment and published results available to present. It is hoped that such knowledge will diversify therapeutic options for the clinician, thereby improving outcomes in a small but not negligible portion of patients with previously unexplained persistent symptoms.
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Gómez-Hoyos J, Schröder R, Palmer IJ, Reddy M, Khoury A, Martin HD. Iliopsoas tendon insertion footprint with surgical implications in lesser trochanterplasty for treating ischiofemoral impingement: an anatomic study. J Hip Preserv Surg 2015; 2:385-91. [PMID: 27011863 PMCID: PMC4732368 DOI: 10.1093/jhps/hnv060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 07/06/2015] [Accepted: 08/02/2015] [Indexed: 11/24/2022] Open
Abstract
The objective of this study was to describe the footprint location of the iliopsoas tendon on the lesser trochanter to clarify the surgical implications of the lesser trochanterplasty for treating ischiofemoral impingement. Ten non-matched, fresh-frozen, cadaveric hemipelvis specimens (average age, 62.4 years; range, 48–84 years; 7 male and 3 female) were included. Registered measures included bony parameters of the lesser trochanter (lesser trochanteric area, distances from the tip to the base in a coordinate system, height and area) and tendinous iliopsoas footprint descriptions (areas and detailed location). The mean height of the lesser trochanter was 13.1 (SD ± 1.8) mm, with female having a smaller lesser trochanter on average (11.3, SD ± 2.0). A double tendinous footprint was found in 7 (70%) specimens. The average area of the single- and double-footprint was 211.2 mm2 and 187.9 mm2, respectively. An anterior cortical area with no tendinous insertion on the anterior aspect of lesser trochanter was present in all specimens and measured 4.9 mm (SD ± 0.6) on average. The mean ratio between the bald anterior wall and the lesser trochanter height was 38% (SD ± 0.05). The iliopsoas tendon footprint is double (psoas and iliacus) in most cases and is located on the anteromedial tip of the lesser trochanter. A bald anterior wall on the bottom of the lesser trochanter indicates that a partial or total lesser trochanterplasty for increasing the ischiofemoral space without detaching partially or entirely the iliopsoas tendon is improbable.
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Affiliation(s)
- Juan Gómez-Hoyos
- 1. Hip Preservation Center, Baylor University Medical Center, Dallas, TX, USA ; 2. Department of Orthopaedic Surgery, University of Antioquia, Colombia
| | - Ricardo Schröder
- 1. Hip Preservation Center, Baylor University Medical Center, Dallas, TX, USA
| | - Ian J Palmer
- 1. Hip Preservation Center, Baylor University Medical Center, Dallas, TX, USA
| | - Manoj Reddy
- 3. Texas A&M Health Science Center, College of Medicine at Dallas, TX, USA
| | - Anthony Khoury
- 1. Hip Preservation Center, Baylor University Medical Center, Dallas, TX, USA ; 4. Department of Bioengineering, University of Texas at Arlington, TX, USA
| | - Hal David Martin
- 1. Hip Preservation Center, Baylor University Medical Center, Dallas, TX, USA
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Beck JJ, Giordano BD, Yen YM. Arthroscopic Treatments of Residual Pediatric Deformities. OPER TECHN SPORT MED 2015. [DOI: 10.1053/j.otsm.2015.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Beckmann JT, Safran MR, Abrams GD. Extra-Articular Impingement: Ischiofemoral Impingement and Trochanteric-Pelvic. OPER TECHN SPORT MED 2015. [DOI: 10.1053/j.otsm.2015.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ischiofemoral impingement syndrome: a meta-analysis. Skeletal Radiol 2015; 44:831-7. [PMID: 25672947 DOI: 10.1007/s00256-015-2111-y] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 12/19/2014] [Accepted: 01/26/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aims of this article are to review the imaging characteristics of ischiofemoral impingement (IFI), summarize measurement thresholds for radiologic diagnosis based on a meta-analysis of the literature and raise awareness among radiologists and clinicians of this entity. MATERIALS AND METHODS A PubMed search restricted to the English language containing the keywords "ischiofemoral impingement" and "quadratus femoris MRI" was performed, and citations in these articles were also used to identify a total of 27 studies discussing ischiofemoral impingement. After excluding case reports and non-representative studies, there were five remaining articles including 193 hip MRIs of IFI in 154 subjects (133 female, 21 male) and 135 asymptomatic control hip MRIs from 74 subjects (55 female, 19 male). Additionally, we performed a retrospective database search of pelvic and hip MRI reports from our institution including the terms "quadratus femoris" or "ischiofemoral impingement" from a 9-year period and 24 hip MRIs from 21 patients (18 female, 3 male) with IFI with 5 asymptomatic contralateral control hip MRIs identified. In all, 217 hip MRIs of IFI and 140 control cases were included. A meta-analysis of these hip MRIs was conducted to determine optimal thresholds of the ischiofemoral space (IFS) and quadratus femoris space (QFS) for identifying IFI. RESULTS Cases of IFI showed significantly smaller IFS and QFS compared to controls (14.91 ± 4.8 versus 26.01 ± 7.98 and 9.57 ± 3.7 versus 15.97 ± 6.07, measured in mm, respectively, p < 0.0001 for both). Pooled analysis revealed that for IFS, using a cutoff of ≤ 15 mm yielded a sensitivity of 76.9%, specificity of 81.0% and overall accuracy of 78.3%. For QFS, a cutoff of ≤ 10.0 mm resulted in 78.7% sensitivity, 74.1% specificity and 77.1% overall accuracy. CONCLUSION IFI is a potential cause of hip pain that can be accurately diagnosed with MRI in conjunction with clinical findings. Using the proposed measurement thresholds may better identify patients with this impingement syndrome so that optimal treatment options can be pursued.
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Relative femoral neck lengthening improves pain and hip function in proximal femoral deformities with a high-riding trochanter. Clin Orthop Relat Res 2015; 473:1378-87. [PMID: 25373936 PMCID: PMC4353530 DOI: 10.1007/s11999-014-4032-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Complex proximal femoral deformities, including an elevated greater trochanter, short femoral neck, and aspherical head-neck junction, often result in pain and impaired hip function resulting from intra-/extraarticular impingement. Relative femoral neck lengthening may address these deformities, but mid-term results of this approach have not been widely reported. QUESTIONS/PURPOSES Do patients who have undergone relative femoral neck lengthening show (1) less hip pain and greater function; (2) improved radiographic parameters; (3) significant complications requiring subsequent surgery; and (4) progression of osteoarthrosis (OA) or conversion to total hip arthroplasty (THA) at mid-term followup? METHODS We retrospectively reviewed 40 patients (41 hips) with isolated relative femoral neck lengthening between 1998 and 2006 with sequelae of Legg-Calvé-Perthes disease (38 hips [93%]), slipped capital femoral epiphysis (two hips [5%]), and postseptic arthritis (one hip [2%]). During this time, the general indications for this procedure included a high-riding greater trochanter with a short femoral neck with abductor weakness and symptomatic intra-/extraarticular impingement. Mean patient followup was 8 years (range, 5-13 years), and complete followup was available in 38 patients (39 hips [95%]). We evaluated pain and function with the impingement test, limp, abductor force, Merle d'Aubigné-Postel score, and range of motion. Radiographic parameters included trochanteric height, alpha angle, and progression of OA. Subsequent surgeries, complications, and conversion to THA were summarized. RESULTS The proportion of positive anterior impingement tests decreased from 93% (38 of 41 hips) preoperatively to 49% (17 of 35 hips) at latest followup (p = 0.002); the proportion of limp decreased from 76% (31 of 41 hips) to 9% (three of 35 hips; p < 0.001); the proportion of normal abductor strength increased from 17% (seven of 41 hips) to 91% (32 of 35 hips; p < 0.001); mean Merle d'Aubigné-Postel score increased from 14 ± 1.7 (range, 9-17) to 17 ± 1.5 (range, 13-18; p < 0.001); mean internal rotation increased to 25° ± 15° (range, 0°-60°; p = 0.045), external rotation to 32° ± 14° (range, 5°-70°; p = 0.013), and abduction to 37° ± 13° (range, 10°-50°; p = 0.004). Eighty percent of hips (33 of 41 hips) showed normal trochanteric height; alpha angle improved to 42° ± 10° (range, 27°-90°). Two hips (5%) had subsequent surgeries as a result of lack of containment; four of 41 hips (10%) had complications resulting in reoperation. Fourteen of 35 hips (40%) showed progression of OA; four of 40 hips (10%) converted to THA. CONCLUSIONS Relative femoral neck lengthening in hips with combined intra- and extraarticular impingement results in reduced pain, improved function, and improved radiographic parameters of the proximal femur. Although lack of long-term complications is gratifying, progression of OA was not prevented and remains an area for future research.
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Ricciardi BF, Fabricant PD, Fields KG, Poultsides L, Zaltz I, Sink EL. What are the demographic and radiographic characteristics of patients with symptomatic extraarticular femoroacetabular impingement? Clin Orthop Relat Res 2015; 473:1299-308. [PMID: 25344401 PMCID: PMC4353520 DOI: 10.1007/s11999-014-4001-3] [Citation(s) in RCA: 27] [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 Extraarticular femoroacetabular impingement (FAI) can result in symptomatic hip pain, but preoperative demographic, radiographic, and physical examination findings have not been well characterized. QUESTIONS/PURPOSES The purposes of this study were to (1) define the demographic characteristics of patients with symptomatic extraarticular FAI; and (2) identify relevant radiographic and physical examination findings that are associated with intraoperative locations of extraarticular FAI. METHODS For purposes of this study, we defined extraarticular FAI as abnormal contact between the extraarticular regions of the proximal femur (greater trochanter, lesser trochanter, extracapsular femoral neck) and the ilium or ischium. The diagnosis was suspected preoperatively, but it was confirmed at the time of surgery by direct visualization of extraarticular impingement after surgical hip dislocation. A prospective single-center hip preservation registry was used to retrospectively characterize patients presenting between October 2010 and November 2013 with symptomatic hip pain and intraoperative findings of extraarticular FAI (N = 75 patients, 86 hips). Detailed demographic data were recorded. Radiographs, CT, and MRI scans were reviewed for all patients by two of the authors (BFR, ELS). Outcome instruments including modified Harris hip score (mHHS), Hip Outcome Score (HOS), and International Hip Outcome Tool (iHOT-33) were assessed preoperatively. A comparison group of all patients (N = 1690 patients, 1989 hips) undergoing surgery for intraarticular FAI over the study period were included for demographic comparisons. Cases with extraarticular FAI accounted for 4% (75 of 1765 patients) of our cohort over the study time period. RESULTS Patients with extraarticular FAI were more likely to be younger (mean ± SD, 24 ± 7 years versus 30 ± 11 years; difference [95% confidence interval {CI}], -7 [-9 to -4]; p < 0.001), female (85% versus 49%; odds ratio [95% CI], 6 [3 to 12]; p < 0.001), to have undergone prior hip surgery (44% versus 10%; odds ratio [95% CI], 9 (6 to 15); p < 0.001), and have lower preoperative outcome scores after adjustment for age, sex, and revision status (mHHS 55 ± 15 versus 63 ± 15; adjusted difference [95% CI], -4 (-8 to -1); p = 0.017; HOS ADL 64 ± 19 versus 73 ± 18; adjusted difference [95% CI], -7 (-11 to -3); p = 0.002) than patients undergoing surgery for intraarticular FAI. Within the extraarticular FAI group, preoperative femoral version on CT was different among patients with anterior versus posterior extraarticular impingement (median [first quartile, third quartile], 8° [2, 18] versus 21° [20, 30], respectively; p = 0.005) and anterior versus complex extraarticular impingement (median [first quartile, third quartile], 8° [2, 18] versus 20° [10, 30], respectively; p = 0.007]. Preoperative external rotation in extension was increased in patients with anterior versus complex extraarticular FAI (median [first quartile, third quartile], 70° [55, 75] versus 40° [20, 60]; p < 0.001). CONCLUSIONS Extraarticular FAI is an uncommon source of impingement symptoms. We suspect the diagnosis often is missed, because many of these patients had prior hip surgery before the procedure that diagnosed the extraarticular impingement source. This diagnosis seems more common in younger, female patients. Radiographic and physical examination findings correspond to locations of intraoperative extraarticular impingement. Future studies will need to determine whether surgical treatment of extraarticular impingement pathology improves pain and function in this subset of patients.
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Affiliation(s)
- Benjamin F. Ricciardi
- />Center for Hip Pain and Preservation, Hospital for Special Surgery, 541 East 71th Street, New York, NY 10021 USA
| | - Peter D. Fabricant
- />Center for Hip Pain and Preservation, Hospital for Special Surgery, 541 East 71th Street, New York, NY 10021 USA
| | - Kara G. Fields
- />Healthcare Research Institute, Hospital for Special Surgery, New York, NY USA
| | - Lazaros Poultsides
- />Center for Hip Pain and Preservation, Hospital for Special Surgery, 541 East 71th Street, New York, NY 10021 USA
| | - Ira Zaltz
- />Department of Orthopedic Surgery, William Beaumont Hospital-Royal Oak, Royal Oak, MI USA
| | - Ernest L. Sink
- />Center for Hip Pain and Preservation, Hospital for Special Surgery, 541 East 71th Street, New York, NY 10021 USA
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Jo S, O'Donnell JM. Endoscopic lesser trochanter resection for treatment of ischiofemoral impingement. J Hip Preserv Surg 2015; 2:184-9. [PMID: 27011837 PMCID: PMC4718495 DOI: 10.1093/jhps/hnv019] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 02/09/2015] [Accepted: 02/10/2015] [Indexed: 11/13/2022] Open
Abstract
Ischiofemoral impingement (IFI) is an uncommon source of hip pain characterized by abnormal proximity of the lesser trochanter (LT) and the anterior border of ischium. The condition can be treated non-operatively but in severe cases, LT excision can provide beneficial results. Most previous descriptions for IFI operation use an open surgical approach but with the advancement of arthroscopic surgery, the LT can be approached less invasively. This study describes a simple endoscopic method to decompress the LT. Due to the posteromedial location of LT, this method requires careful positioning of the leg, and the use of curved type instruments is recommended. Also, it is helpful to assess the amount of resection with a properly oriented fluoroscopic view.
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Affiliation(s)
- Suenghwan Jo
- Hip Arthroscopy Australia, 21 Erin St Richmond, Victoria 3121, Australia
| | - John M O'Donnell
- Hip Arthroscopy Australia, 21 Erin St Richmond, Victoria 3121, Australia
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Diagnosis and 2-year outcomes of endoscopic treatment for ischiofemoral impingement. Arthroscopy 2015; 31:239-46. [PMID: 25278353 DOI: 10.1016/j.arthro.2014.07.031] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 07/23/2014] [Accepted: 07/25/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE The purposes of this study were to investigate the clinical and radiographic presentation of patients with ischiofemoral impingement (IFI) and to assess the outcomes of endoscopic treatment with partial resection of the lesser trochanter. METHODS Five patients with IFI who underwent endoscopic treatment with partial resection of the lesser trochanter were retrospectively reviewed. The outcomes were assessed at a mean follow-up of 2.3 years (range, 2 to 2.5 years) through the modified Harris Hip Score and a visual analog scale score for pain. Physical examination tests provoking the impingement between the lesser trochanter and ischium were used for the diagnosis of IFI, including the IFI test and reproducible pain lateral to the ischium with the long-stride walking test. The presence of quadratus femoris muscle edema and a decreased ischiofemoral space on magnetic resonance imaging was also necessary for the diagnosis. RESULTS The mean modified Harris Hip Score increased from 51.3 points (range, 34.1 to 73.7 points) preoperatively to 94.2 points (range, 78.1 to 100 points) at the final follow-up (P = .003). The mean visual analog scale score for pain decreased from 6.6 (range, 6 to 7.3) before surgery to 1 (range, 0 to 4) at the final follow-up (P = .001). The mean duration to return to sport after surgery was 4.4 months (range, 1 to 7 months) for the 5 patients in this study. No complication was observed. CONCLUSIONS The endoscopic treatment of IFI was effective at 2 years in 5 patients with consistent clinical and imaging diagnostic findings. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Khemka A, Raz G, Bosley B, Ludger G, Al Muderis M. Arthroscopically assisted fixation of the lesser trochanter fracture: a case series. J Hip Preserv Surg 2014; 1:27-32. [PMID: 27011799 PMCID: PMC4765264 DOI: 10.1093/jhps/hnu006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 06/13/2014] [Accepted: 07/13/2014] [Indexed: 11/28/2022] Open
Abstract
Avulsion fractures of the lesser trochanter in adolescents are uncommon. This injury is a result of a sudden forceful contraction of the iliopsoas tendon. It usually occurs during vigorous sport activity. Historically, these injuries were treated non-operatively, with guarded results, including weak hip flexor strength and non-union, hindering return to competitive sport. We report a series of three arthroscopically assisted fracture fixations performed by the senior author, using cannulated screw fixation in two cases and an anchor in one case. Mobilization was commenced immediately following surgery, allowing weight bearing as tolerated using crutches for 4 weeks, thereafter unaided walking was allowed. Patients were assessed at 2 weeks, 6 weeks, 3 months and 1-year post-operatively. Radiographs were utilized to confirm full union. All three patients were able to mobilize unaided by 4 weeks post-operatively and two of the three patients returned to competitive sport at 3 months. Near—anatomical union was achieved in all cases. No complications were noted during surgery and the peri-operative period in our series. The utilization of arthroscopic reduction and fixation of avulsion of the lesser trochanter results in good fixation and allows a faster recovery with a return to sports activity, and therefore, we suggest it as a viable treatment option for such injuries.
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Affiliation(s)
- Aditya Khemka
- 1. Norwest Private Hospital, Bella Vista 2153, Sydney, Australia 2. Department of Joint Arthroplasty and Clinical Science, Mare Clinic, Universitatsklinikum Schleswig-Holstein, Kiel, Germany 3. University Of Notre Dame, Australia School of Medicine, Sydney, Australia
| | - Guy Raz
- 1. Norwest Private Hospital, Bella Vista 2153, Sydney, Australia 2. Department of Joint Arthroplasty and Clinical Science, Mare Clinic, Universitatsklinikum Schleswig-Holstein, Kiel, Germany 3. University Of Notre Dame, Australia School of Medicine, Sydney, Australia
| | - Belinda Bosley
- 1. Norwest Private Hospital, Bella Vista 2153, Sydney, Australia 2. Department of Joint Arthroplasty and Clinical Science, Mare Clinic, Universitatsklinikum Schleswig-Holstein, Kiel, Germany 3. University Of Notre Dame, Australia School of Medicine, Sydney, Australia
| | - Gerdesmeyer Ludger
- 1. Norwest Private Hospital, Bella Vista 2153, Sydney, Australia 2. Department of Joint Arthroplasty and Clinical Science, Mare Clinic, Universitatsklinikum Schleswig-Holstein, Kiel, Germany 3. University Of Notre Dame, Australia School of Medicine, Sydney, Australia
| | - Munjed Al Muderis
- 1. Norwest Private Hospital, Bella Vista 2153, Sydney, Australia 2. Department of Joint Arthroplasty and Clinical Science, Mare Clinic, Universitatsklinikum Schleswig-Holstein, Kiel, Germany 3. University Of Notre Dame, Australia School of Medicine, Sydney, Australia
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de Sa D, Alradwan H, Cargnelli S, Thawer Z, Simunovic N, Cadet E, Bonin N, Larson C, Ayeni OR. Extra-articular hip impingement: a systematic review examining operative treatment of psoas, subspine, ischiofemoral, and greater trochanteric/pelvic impingement. Arthroscopy 2014; 30:1026-41. [PMID: 24793209 DOI: 10.1016/j.arthro.2014.02.042] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 02/24/2014] [Accepted: 02/26/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE Extra-articular hip impingement can be the result of psoas impingement (PI), subspine impingement (SSI), ischiofemoral impingement (IFI), and greater trochanteric/pelvic impingement (GTPI). Symptoms may be due to bony abutment or soft-tissue irritation, and often, it is a challenge to differentiate among symptoms preoperatively. Currently, the clinical picture and diagnostic criteria are still being refined for these conditions. This systematic review was conducted to examine each condition and elucidate the indications for, treatment options for, and clinical outcomes of surgical management. METHODS We searched online databases (Medline, Embase, and PubMed) for English-language clinical studies published from database inception through December 31, 2013, addressing the surgical treatment of PI, SSI, IFI, and GTPI. For each condition, 2 independent assessors reviewed eligible studies. Descriptive statistics are presented. RESULTS Overall, 9,521 studies were initially retrieved; ultimately, 14 studies were included examining 333 hips. For PI, arthroscopic surgery resulted in 88% of patients achieving good to excellent results, as well as significant improvements in the Harris Hip Score (P = .008), Hip Outcome Score-Activities of Daily Living (P = .02), and Hip Outcome Score-Sport (P = .04). For SSI, arthroscopic decompression, with no major complications, resulted in a mean 18.5° improvement in flexion range of motion, as well as improvements in pain (mean visual analog scale score of 5.9 points preoperatively and 1.2 points postoperatively) and the modified Harris Hip Score (mean of 64.97 points preoperatively and 91.3 points postoperatively). For both IFI and GTPI, open procedures anecdotally improved patient symptoms, with no formal objective outcomes data reported. CONCLUSIONS This review suggests that there is some evidence to support that surgical treatment, by arthroscopy for PI and SSI and by open surgery for IFI and GTPI, results in improved patient outcomes. LEVEL OF EVIDENCE Systematic review of Level IV and V (case report) studies.
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Affiliation(s)
- Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, McMaster University, Hamilton, Ontario, Canada
| | - Hussain Alradwan
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, McMaster University, Hamilton, Ontario, Canada; Ministry of Higher Education, Riyadh, Saudi Arabia
| | - Stephanie Cargnelli
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Zoyah Thawer
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Simunovic
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Edwin Cadet
- Raleigh Orthopaedic Clinic, Raleigh, North Carolina
| | | | - Christopher Larson
- Minnesota Orthopedic Sports Medicine Institute at Twin Cities Orthopedics, Edina, Minnesota, U.S.A
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, McMaster University, Hamilton, Ontario, Canada.
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