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      The pathoanatomy and arthroscopic management of femoroacetabular impingement

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          Abstract

          Femoroacetabular impingement (FAI) causes pain and chondrolabral damage via mechanical overload during movement of the hip. It is caused by many different types of pathoanatomy, including the cam ‘bump’, decreased head–neck offset, acetabular retroversion, global acetabular overcoverage, prominent anterior–inferior iliac spine, slipped capital femoral epiphysis, and the sequelae of childhood Perthes’ disease.

          Both evolutionary and developmental factors may cause FAI. Prevalence studies show that anatomic variations that cause FAI are common in the asymptomatic population. Young athletes may be predisposed to FAI because of the stress on the physis during development. Other factors, including the soft tissues, may also influence symptoms and chondrolabral damage.

          FAI and the resultant chondrolabral pathology are often treated arthroscopically. Although the results are favourable, morphologies can be complex, patient expectations are high and the surgery is challenging. The long-term outcomes of hip arthroscopy are still forthcoming and it is unknown if treatment of FAI will prevent arthrosis.

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          Femoroacetabular impingement: a cause for osteoarthritis of the hip.

          Reinhold Ganz, Javad Parvizi, Martin Beck … (2003)
          A multitude of factors including biochemical, genetic, and acquired abnormalities may contribute to osteoarthritis of the hip. Although the pathomechanism of degenerative process affecting the dysplastic hip is well understood, the exact pathogenesis for idiopathic osteoarthritis has not been established. Based on clinical experience, with more than 600 surgical dislocations of the hip, allowing in situ inspection of the damage pattern and the dynamic proof of its origin, we propose femoroacetabular impingement as a mechanism for the development of early osteoarthritis for most nondysplastic hips. The concept focuses more on motion than on axial loading of the hip. Distinct clinical, radiographic, and intraoperative parameters can be used to confirm the diagnosis of this entity with timely delivery of treatment. Surgical treatment of femoroacetabular impingement focuses on improving the clearance for hip motion and alleviation of femoral abutment against the acetabular rim. It is proposed that early surgical intervention for treatment of femoroacetabular impingement, besides providing relief of symptoms, may decelerate the progression of the degenerative process for this group of young patients.
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            Anteroposterior pelvic radiographs to assess acetabular retroversion: high validity of the "cross-over-sign".

            C. Meyer, Moulay A. Alaoui-Jamali, Alberto Martínez-Castelao … (2007)
            Acetabular retroversion has been proposed to contribute to the development of osteoarthritis of the hip. For the diagnosis of this condition, conventional AP pelvic radiographs may represent a reliable, easily available diagnostic modality as they can be obtained with a reproducible technique allowing the anterior and posterior acetabular rims to be visible for assessment. This study was designed to: (i) determine cranial, central, and caudal anatomic acetabular version (AV) from cadaveric specimens; (ii) establish the validity and reliability of the radiographic measurements of central acetabular anteversion; and (iii) determine the validity and reliability of the radiographic "cross-over-sign" to detect acetabular retroversion. Using 43 desiccated pelvises (86 acetabuli) the anatomic AVs were measured at three different transverse planes (cranially, centrally, and caudally). From these pelvises, standardized AP pelvic radiographs were obtained. To directly measure central AV, a modified radiographic method is introduced for the use of AP pelvic radiographs. The validity and reliability of this radiographic method and of the radiographic cross-over-sign to detect cranial acetabular retroversion were determined. The mean central and caudal anatomic AVs were approximately 20 degrees , and the mean cranial AV was 8 degrees . Cranial retroversion (AV < 0 degrees ) was present in 19 of 86 hips (22%). A linear correlation was found between the central and cranial AV. Below 10 degrees of central AV, all acetabuli were cranially retroverted. Between 10 degrees and 20 degrees , 30% of the acetabuli were cranially retroverted, and above 20 degrees , only 1 of 45 acetabuli was cranially retroverted. The radiographic measurement of the central AV (20.3 +/- 6.5 degrees ) correlated strongly with the anatomic AV (20.1 +/- 6.4 degrees ). The sensitivity of the cross-over-sign to detect a cranial acetabular anteversion of less than 4 degrees was 96%, its specificity 95%, and the positive predictive and negative predictive values 90% and 98%, respectively. Both the modified radiographic anteversion measurements and the cross-over-sign demonstrated substantial inter- and intraobserver reliability. Retroversion is almost exclusively a problem of the cranial acetabulum. The cranial AV is on average 12 degrees lower than the central AV, with the latter directly measurable from AP pelvic radiographs. A central AV of less than 10 degrees was associated with cranial retroversion. The presence of a positive cross-over-sign is a highly reliable indicator of cranial AV of <4 degrees. (c) 2007 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
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              Periacetabular osteotomy: a systematic literature review.

              John C Clohisy, Amanda Schutz, Lauren C St John … (2009)
              The Bernese periacetabular osteotomy is commonly used to treat symptomatic acetabular dysplasia. Although periacetabular osteotomy is becoming a more common surgical intervention to relieve pain and improve function, the strength of clinical evidence to support this procedure for these goals is not well defined in the literature. We therefore performed a systematic review of the literature to define the level of evidence for periacetabular osteotomy, to determine deformity correction, clinical results, and to determine complications associated with the procedure. Thirteen studies met our inclusion criteria. Eleven studies were Level IV, one was Level III, and one was Level II. Radiographic deformity correction was consistent and improvement in hip function was noted in all studies. Most studies did not correlate radiographic and clinic outcomes. Clinical failures were commonly associated with moderate to severe preoperative osteoarthritis and conversion to THA was reported in 0% to 17% of cases. Major complications were noted in 6% to 37% of the procedures. These data indicate periacetabular osteotomy provides pain relief and improved hip function in most patients over short- to midterm followup. The current evidence is primarily Level IV. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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                Author and article information

                Contributors
                Journal
                Journal ID (nlm-ta): Bone Joint Res
                Journal ID (iso-abbrev): Bone Joint Res
                Title: Bone & Joint Research
                Publisher: British Editorial Society of Bone and Joint Surgery
                ISSN (Print): 2046-3758
                ISSN (Electronic): 2046-3758
                Publication date Collection: October 2012
                Publication date (Electronic): 01 October 2012
                Volume: 1
                Issue: 10
                Pages: 245-257
                Affiliations
                [1 ]Center for Hip Preservation, Hospital for Special Surgery, 535 East 70th Street, New York, New York 10021, USA.
                [2 ]Schulthess Clinic, Department of Orthopaedic Surgery, Lengghalde 2 8008 Zurich, Switzerland.
                Author notes
                Correspondence should be sent to Dr M. Leunig; e-mail: michael.leunig@ 123456kws.ch
                Article
                Publisher ID: 2000105
                DOI: 10.1302/2046-3758.110.2000105
                PMC ID: 3626254
                PubMed ID: 23610655
                SO-VID: 4df1214a-e052-40d9-be3f-2e33c7edf207
                Copyright © ©2012 British Editorial Society of Bone and Joint Surgery
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attributions licence, which permits unrestricted use, distribution, and reproduction in any medium, but not for commercial gain, provided the original author and source are credited.

                History
                Date received : 23 May 2012
                Date accepted : 17 August 2012
                Funding
                This work received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
                Categories
                Subject: Hip
                Subject: 1
                Subject: Femoroacetabular Impingement
                Subject: Fai
                Subject: Hip Arthroscopy
                Subject: Hip Preservation
                Subject: Hip Development
                Subject: Hip Pain
                Custom metadata
                odf2nlm-version 1.0
                price $2.00
                principal-institution Hospital for Special Surgery, New York, United States, and Schulthess Clinic, Zurich, Switzerland
                article-type Instructional review
                coi-statement Dr. Leunig has the following potential conflicts of interest: consultant for Smith & Nephew and Biomet; stock options in Pivot Medical. No payment or benefit of any kind was received related to this work.

                Keywords: femoroacetabular impingement,fai,hip arthroscopy,hip preservation,hip development,hip pain
                Data availability:
                Keywords: femoroacetabular impingement, fai, hip arthroscopy, hip preservation, hip development, hip pain

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