Lisa M. Tibor

Two or More Impingement and/or Instability Deformities Are Often Present in Patients With Hip Pain

BackgroundDamage to the hip can occur due to impingement or instability caused by anatomic factors such as femoral and acetabular version, neck-shaft angle, alpha angle, and lateral center-edge angle (CEA). The associations between these anatomic factors and how often they occur in a painful hip are unclear but if unaddressed might explain failed hip preservation surgery.Questions/purposesWe determined (1) the influence of sex on the expression of impingement-related or instability-related factors, (2) the associations among these factors, and (3) how often both impingement and/or instability factors occur in the same hip.MethodsWe retrospectively reviewed a cohort of 170 hips (145 patients) undergoing MR arthrography of the hip for any reason. We excluded 58 hips with high-grade dysplasia, Perthes’ sequelae, previous surgery, or incomplete radiographic information, leaving 112 hips (96 patients). We measured femoral version and alpha angles on MR arthrograms. Acetabular anteversion, lateral CEA, and neck-shaft angle were measured on pelvic radiographs.ResultsWe observed a correlation between sex and alpha angle. Weak or no correlations were observed between the other five parameters. In 66% of hips, two or more (of five) impingement parameters, and in 51% of hips, two or more (of five) instability parameters were found.ConclusionsPatients with hip pain frequently have several anatomic factors potentially contributing to chondrolabral damage. To address pathologic hip loading due to impingement and/or instability, all of the anatomic influences should be known. As we found no associations between anatomic factors, we recommend an individualized assessment of each painful hip.Level of EvidenceLevel III, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

Case Reports: Anteroinferior Acetabular Rim Damage Due to Femoroacetabular Impingement

BackgroundThe most common location of labral tears and chondral damage in the hip is the anterosuperior region of the acetabulum, which is associated with pain in flexion and rotation. We describe a case series of patients with labral tears, ganglion formation, and chondromalacia isolated to the anteroinferior acetabulum. Clinically, patients had pain in extension and internal rotation.Case DescriptionsIsolated anteroinferior labral hypertrophy and ganglion were first observed in a patient with coxa valga. We retrospectively reviewed clinical and radiographic records and identified nine hips in seven patients with isolated anteroinferior damage. One patient with bilateral valgus femoral head tilt after slipped capital femoral epiphysis (SCFE) had impingement of the anteromedial metaphysis on the acetabulum from 3 to 6 o’clock. Five of seven had valgus neck-shaft angles and all had acetabular anteversion with damage isolated to the anteroinferior acetabular rim.Literature ReviewSeries on the diagnostic efficacy of MR arthrogram have noted anteroinferior damage adjacent to superior acetabular rim lesions. However, these do not describe isolated anteroinferior rim damage. In addition, available case series of patients with valgus SCFE do not describe a location of impingement or intraarticular damage.Purposes and Clinical RelevanceIn this small case series of patients with isolated anteroinferior chondrolabral damage, there are two potential causative mechanisms: (1) primary anteroinferior impingement with femoral extension and internal rotation and (2) posterior extraarticular ischiotrochanteric impingement causing secondary anterior instability of the femur. The pathoanatomy appears to be multifactorial, necessitating an individualized treatment approach.

The Hyperflexible Hip Managing Hip Pain in the Dancer and Gymnast

Context: Dance, gymnastics, figure skating, and competitive cheerleading require a high degree of hip range of motion. Athletes who participate in these sports use their hips in a mechanically complex manner. Evidence Acquisition: A search of the entire PubMed database (through December 2013) and additional searches of the reference lists of pertinent articles. Study Design: Systematic review. Level of Evidence: Level 3. Results: Whether innate or acquired, dancers and gymnasts have some hypermobility that allows their hips to be placed in potentially impinging or unstable positions required for their given activity. Such extremes of motion can result in both intra-articular and extra-articular impingement as well as compensatory osseous and muscular pathology. In addition, dancers and gymnasts are susceptible to impingement-induced instability. Dancers with innate generalized hyperlaxity are at increased risk of injury because of their activities and may require longer recovery times to return to play. Both nonoperative and operative treatments (arthroscopic and open) have an important role in returning flexibility athletes to their preoperative levels of sport and dance. Conclusion: Because of the extreme hip motion required and the compensatory soft tissue laxity in dancers and gymnasts, these athletes may develop instability, impingement, or combinations of both. This frequently occurs in the setting of subtle pathoanatomy or in patients with normal bony anatomy. With appropriate surgical indications and the correct operative technique, the treating surgeon can anticipate high levels of return to play for the gymnast and dancer with hip pain.

Not All Hip Pain Is Impingement: Femoral Neck Osteoid Osteoma in a Patient with a Coexisting Cam Deformity

To the best of our knowledge, the concept of femoroacetabular impingement (FAI) as a cause of hip pain in young adults was introduced in the last decade1. Since then, abnormal osseous morphology has been increasingly recognized as a cause of early primary hip arthrosis2. Approximately 90% of all patients with hip pain and labral pathology have underlying osseous abnormalities3,4. The prevalence of asymptomatic FAI morphology in young men, however, is approximately 25%5. Thus, other causes of hip pain should be considered, particularly when atypical features are present during the evaluation of a young patient with symptoms around the hip. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. An eighteen-year-old patient presented with steadily worsening right groin pain over the course of a year. Symptoms increased when he participated in sports and, progressively, occurred at night. Most pain medications, including nonsteroidal anti-inflammatories, had little effect. Prior to referral to our clinic, the patient had a standard anteroposterior pelvic radiograph, a pelvic magnetic resonance image (MRI), and an MR arthrogram, ostensibly demonstrating a decreased anterior femoral head-neck offset. Bone marrow edema in the femoral neck seen on the pelvic MRI was interpreted as reactive (Fig. 1). He was given the probable diagnosis of FAI and referred to our clinic for additional evaluation. Fig. 1 Pelvic MRI (coronal view) demonstrating bone marrow edema in the right femoral neck (arrowhead). On examination, the patient demonstrated a mild start-up limp that resolved quickly. Hip flexion, adduction, and internal rotation produced pain, as did palpation of the rectus femoris origin. Hip internal rotation was limited to 0° in 90° of flexion, as compared with 30° of internal rotation on the contralateral side. In all other planes, hip motion …

Introducing Arthroscopy to a Developing Nation: When and How to Make It Sustainable

The 2010 World Cup soccer tournament in South Africa was, by most accounts, the most-watched sporting event ever. The event highlighted the ability of sports, and soccer in particular, to serve as an important source of identity, collaboration, and international unity1-3. The World Cup showcased the improving infrastructure in South Africa, and the citizens were praised for being great hosts1,4. Several other African and Latin American teams, most notably those of Ghana and Uruguay, also received recognition for their impressive play. One factor contributing to the global popularity of the event was the improved telecommunications access brought about by general socioeconomic stability in much of the developing world. Over the course of the tournament, articles also noted the popularity of soccer in Africa and the impressive number of young soccer players determined to play despite meager conditions5-7. In the developed world, youth soccer is considered a high-risk sport for knee ligament and meniscal injuries5. A significant number of these patients undergo anterior cruciate ligament (ACL) reconstruction or arthroscopic meniscal repair in the hope of returning to soccer or at least preventing early-onset arthritis. To date, most of the literature and interventions related to orthopaedics in the developing world have focused on the care of musculoskeletal trauma8-11, with some additional attention to the treatment of congenital deformities12-14. In contrast, there has been little mention of the role of arthroscopy or the treatment of sports-related injuries within the scope of musculoskeletal care in a developing nation. We report here our experience of donating arthroscopy equipment to orthopaedic surgeons in Asmara, Eritrea (in East Africa), in November 2009. We do not pretend to be experts in this area. Our goal in …

Hip cartilage restoration: Overview

Treatment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1089 Nonoperative Management . . . . . . . . . . . . . . . . . . . . . . . . . 1089 Primary Repair Versus Arthroscopic Debridement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1089 Microfracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1092 Autologous Chondrocyte Implantation (ACI) and Matrix-Associated Chondrocyte Implantation (MACI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1092 Autologous Matrix-Induced Chondrogenesis (AMIC) . . . . . . . . . . . . . . . . . . . . . . . . . . . 1093 Osteochondral Autograft . . . . . . . . . . . . . . . . . . . . . . . . . . . 1093 Osteochondral Allograft . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1093 Allogenic Cartilage Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . 1094

Treatment of Labral Pathology: Reattachment and Replacement

The acetabular labrum has an important role in the structure and function of the hip. In young, active patients, painful labral tears can limit activities or sports. These may be the result of an acute hip injury but can also be the first indicators of subtle acetabular dysplasia, femoroacetabular impingement, or joint laxity. The biomechanical function of the labrum is complex and continues to be debated. Furthermore, although it is an area of intense interest and current research, it is not yet known if current joint-preserving strategies will ultimately prevent hip arthritis. Nonetheless, addressing labral pathology and contributing bony anomalies can resolve hip pain and allow patients to return to their activities.

The Management of Chondral Defects in the Hip

Prior to the description of the surgical hip dislocation, the results following treatment of focal cartilage lesions in the hip were generally poor and confounded by the risk of avascular necrosis associated with the surgical approach. The successful treatment of focal cartilage defects in the hip is relatively new and has been facilitated by advancements in open and arthroscopic surgical techniques. Some, but not all, of the cartilage basic science and treatments developed for the knee are applicable in the hip. The treatment goals for patients with focal defects are: resolution of pain, restoration of function, and return to activity. Although it has yet to be definitively proven, early treatment of a focal cartilage lesion may also help to prevent the progression of cartilage degeneration and osteoarthrosis. A better understanding of the cartilage biomechanics specific to the hip as well as more biomechanical and animal models of hip cartilage lesions will help to advance these treatments. In addition, all of the current clinical literature consists of case series and small case reports, so more prospectively collected data and longer follow up is necessary. Nonetheless, the recent experience in treating these lesions is encouraging and appears to be of significant benefit to young and active adults with cartilage defects.

Abnormal Osseous Anatomy

At present, there is a resurgence of interest in the relationship between hip deformity and osteoarthrosis (OA) due to advances in surgical techniques to correct the deformity and improved understanding of the role of deformity in the development of OA. Hip deformities that may cause either static or dynamic overload with mechanical damage to the joint and resultant OA include acetabular dysplasia and femoroacetabular impingement (FAI). The prevalence of FAI in the younger asymptomatic population is high. FAI is also likely responsible for the majority of what was formerly considered idiopathic arthrosis. The rates of FAI in younger patients are not, however, the same as the prevalence rates for hip arthrosis, indicating that additional factors play a role. The prevalence of dysplasia is variable, but like FAI, does not automatically cause hip arthrosis. This chapter will summarize the current understanding of the prevalence of hip deformity as it relates to the development of hip OA.

Slipped Capital Femoral Epiphysis and Its Variants

Although SCFE has been recognized and treated by orthopaedists for over a century, significant advances in the understanding and management have occurred in the past decade. Classically, the goals of treatment have been to stabilize the physis and prevent the iatrogenic complications of osteonecrosis and chondrolysis. This schema is currently undergoing re-evaluation due to the recognition that even mild stable SCFE can cause femoroacetabular impingement (FAI). Although the potential for impingement in SCFE has been recognized for some time, preventing impingement and the resultant damage to the cartilage and labrum is becoming a more important principle of SCFE treatment. Improved knowledge of the vascular anatomy responsible for femoral head perfusion allowed the development of a safe technique for open reduction and internal fixation of the displaced epiphysis. Although the surgical dislocation and open reduction are technically demanding, safe correction of the physis is now possible and the short to mid-term results are good. Long-term results should be similar, but may be influenced by the amount of cartilage and labral damage at the time of surgery.